 Market-style
mechanisms remain central to Government policy in England, making strong
commissioning an essential element of NHS modernisation.
This week, ‘Is the treatment working? Progress with the NHS reform
programme’, a verdict on NHS reforms so far, was published.1
Community
pharmacy organisations, however, have their own ideas about the progress
of the internal market, so the verdict of an independent review is worth
reading.
The review, from the Audit and Health Care Commissions, examines the
impact of new commissioning policies: patient choice, payment by results
and diversity of supply in secondary care. It uses field work, existing
data sets and qualitative interview techniques to quantify the effect
of the estimated £1bn spent on these reforms to date. The report
is clear and primary care trusts concur: local commissioning capacity
remains underdeveloped.
The World Class Commissioning programme promises to get PCTs up to speed
so they focus on improving health outcomes (which means providers will
need to measure them), reduce health inequalities and take a medium-
to long-term focus, unfettered by short-term thinking. It sounds like
nirvana to anyone working with the NHS, but assessments are being set
against these competencies, so there will be nowhere to hide.
Practice based commissioning (PBC) also comes under scrutiny. Introduced
in 2005 because their leaders argued PCT commissioning is remote from
patients and clinicians, PBC should be engaging GPs in the process. There
were incentive payments and, at a cost of £98m in 2006/07, 96 per
cent of practices received one. But PCTs report that this high uptake
does not reflect real life engagement at grass roots level.
More damning
still, despite the fact it has had three years to bed down, PBC has yet
to deliver any measurable improvements in patient care. Feedback from
NHS trusts reinforces this. Most report that PBC is not influencing the
activity in their organisations either.
This may be because GPs’ focus is elsewhere. An Audit Commission
report, “Putting commissioning into practice”2 found that
many practices were more interested in directly providing new services
rather than commissioning them. PCTs are frustrated that GPs want to
focus on providing profitable services, rather than on service redesign
and health inequalities. But given that they are independent businesses,
is it any wonder?
So what would incentivise the majority of GPs to engage? The Audit and
Health Care Commissions task PCTs with that thorny challenge. But, ironically,
its own report may hold the key.
Experience of introducing diversity of supply through centrally commissioned
independent sector treatment centres (ISCTs) in competition with NHS
trusts parallels the parachuting in of “super surgeries” and
plans for polyclinics that are currently being condemned daily in the
national press by the British Medical Association.
If the experience
of ISTCs is repeated in primary care, the threat of competition and fear
of the impact of patient choice may prove a positive force for change
among doctors, enabling PCT commissioners to open up meaningful dialogue
about efficiency and service redesign beyond the surgery.
Government wants service users to have greater choice and control over
services. One day, the patient could be the commissioner. That could
be great for community pharmacy, but the report highlights the biggest
barrier to patient choice as lack of relevant information. Again, GPs
have become central here. In 2006/07 they were offered an incentive,
paid as a directed enhanced service, to offer all eligible patients a
choice of provider for elective surgery.
A second payment was made, on
the basis that at least 60 per cent of patients confirmed that their
GP had honoured this promise through a GP-issued survey. The total amount
paid to GPs across England is estimated at £19.25m.
However, once
again, this high level of engagement on paper is out of sync with other
data, which suggest the number of patients offered choice is significantly
lower. The report concludes that these incentive payments are delivering
little value for money.
To further address the information deficit, the Department of Health
has spent £3.6m on the NHS Choices website. There are a couple
of problems however. The information it contains is incomplete. Not all
organisations list the same information, making true comparisons difficult;
although this is not, of course, an insurmountable problem.
An even bigger fly in the ointment is the fact that over 37 per cent
of NHS elective patients are over 65 years, and more than 75 per cent
of them have never accessed the internet. This transforms a potentially
powerful tool into a rather blunt instrument for communicating with the
highest users of NHS services.
Commissioners also appear to be in denial about the power of patient
choice. The report unveils a widely held view that there will never be
a large amount of patient movement due to choice — because patients
will simply not exercise their right to choose. This is despite strong
evidence that a significant proportion of patients will change provider.3
Perhaps
it is only the commissioners who feel this way. The report says that
providers are clearly positioning themselves for the future and
the impact that they feel choice could have. The authors conclude that
it may even be that the fear of choice rather than choice itself proves
to be the most powerful force for change.
Most worrying for those trying to break into the market, PCTs admit
that if staff did not support certain choice options, they consequently
presented
these in a different way to patients. Given that GPs could increasingly
be acting as both commercial service providers and patient choice advocates,
conflict of interest and the temptation to refer to the home side is
unavoidable.
For those operating in a commercial environment, all this is a bit
of an anathema. Suppliers ignoring the requirements of their customers;
paying people to do a job, and three years later when they clearly
have
not delivered results, sticking with it anyway; introducing a major
change in business process without monitoring the impact on the bottom
line;
and targeting communications at high users of services through a medium
they do not use. It just would not happen. But in the NHS, excuses
are made. Change takes time.
Is it not time to ask difficult questions about the validity of spending
millions on services and incentives that are delivering no value? The
pharmacy
White Paper is a mandate to deliver but significant new funding
needs to be found. In an NHS that commissions on the basis of evidence,
it looks like it is time for a bit of disinvestment.
References
1. Audit Commission and Healthcare Commission. Is
the treatment working? Audit commission, June 2008
2. Audit Commission. Putting
commissioning into practice. Implementing
practice based commissioning through good financial management. Audit
Commission, November 2007.
3. Coulter A, Le Maistre N, Henderson L. Patients’ experience of
choosing where to undergo surgical treatment, evaluation of the London
patient choice scheme.
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