Developing Practice-Based Commissioning

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 7/8

Abstract

As detailed in report 5(2005), since April 2005 GP practices in England have been allowed to hold a practice-based 'indicative' commissioning budget from their primary care trust (PCT). The GP practices can use this budget to manage directly the delivery of care for their patients, and are allowed to keep at least 70% of any savings they make. The GPs are required to invest these savings into their premises or capital equipment to broaden the range of primary care services they offer.

Purpose of health policy or idea

As also detailed in report 5(2005), the introduction of practice-based budgeting appears to be a return to a slightly 'weaker' version of GP fundholding that the New Labour Government abandoned in the late 1990s due to the concern at that time that the voluntary take-up of fundholding was creating a 'two-tiered' national health service. Other than stimulating a relatively short term increase in inefficiency (through, for example, GP fundholders demanding shorter hospital stays and more day case surgery, and taking greater care in their pharmaceutical prescribing practices etc) , there is little evidence that GP fundholding had long-term positive positive effects, but the current Government clearly believes that by entrusting GPs with the financial incentives embedded in holding their own indicative budgets, they will commission better quality care for their patients with the resources that are available to them. As far as I know, there has not yet been any assessment of whether the indicative budget leads GPs to skimp on some care, mindful that they are allowed to invest any savings into their practices, although skimping may be difficult, because the PCTs and the Healthcare Commissioning are presumably monitoring (or at least, pose the threat of monitoring) the GPs' activities. Moreover, related to the notion of skimping, there is little or no evidence that GP fundholders in the 1990s 'cream-skimmed' those patients that would offer them the best opportunities to 'underspend' their budgets, so it is possible that GPs, when given budgets to work within, generally resist the temptation for underhand behaviours.     

Main points

Main objectives

To offer GPs the chance to hold indicative budgets to commission health care with the objective that this will improve the care offered to local populations.

Type of incentives

Practice-based commissioning is undertaken voluntarily, but GPs are offered an incentive payment for uptaking the scheme. The financial incentives of holding a budget in the knowledge that at least 70% of the savings that one makes can be used to invest in one's practice are clear.

Groups affected

GPs, PCTs, Patients

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

There is plenty to be skeptical about motivation for this policy, the degree to which policy makers are able and willing to learn from the past, and whether this policy will be successul in the future. However, given that the NHS seems to be undergoing almost constant (if, in most cases, rather marginal) change, it might be wise for all parties to accept the policy and do everything that they can to try to make it work to improve patient care, rather than to re-backtrack on this policy direction once again, which would almost certainly serve to further undermine the morale of those working in the NHS.  

Political and economic background

This is an on-going policy, developed by a Government that became enamored with the potential benefits of financial incentive mechanisms from around the turn of the century onwards (see report 5(2005)). In developments, they were encouraged by a few influential policy entrepreneurs, even though a large number of experts have been at best skeptical of the direction that the Government has taken NHS policy over the past several years. 

Change based on an overall national health policy statement

See report 5(2005)

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

This has been explained also in 5(2005). The main driving force behind the policy has been the New Labour leadership, that often operates in a historical vacuum, and a few influential policy experts.

Stakeholder positions

Again the Government is usually successful in implementing its policy ideas, and the Minister for Health has expressed strong support for practice-based commissioning. Many people working within (and indeed outside) the NHS are tired of the almost constant re-organisations of the health care system, and it is easy to be somewhat skeptical when a Government reimplements a (not, in the past, too successful) policy direction that it had abandoned several years previously (and which the Labour Party had heavily criticised the Conservative Government for originally implementing in the early 1990s). Some think that GP practices are too small to effectively commission services from large, powerful hospitals. Others believe that there is insufficient capacity in the NHS to create substantial efficiency improvements through selective commissioning at the GP level. Still others believe that the NHS does not have the institutional framework for market-type incentives to work. Nonetheless, as of May 2006, 3,500 GP practices had agreed to participate in practice-based commissioning, and this number has further increased substantially over recent months (attracted in part, no doubt, by the incentive payment to participate).

Influences in policy making and legislation

Practice-based commissioning is part of an ongoing policy direction.

Adoption and implementation

Through the participation incentive payment and the promise of retaining savings for investment purposes, the Government is seemingly proving successful in getting the PCTs and the GPs to sign up in rapidly increasing numbers to practice-based commissioning. Whether the policy will improve efficiency in the NHS and the range of services available in primary care in the long-term, remains to be seen.   

Monitoring and evaluation

The Government, through the Department of Health, regularly reports the uptake on practice-based commissioning, and issues press releases of developments and resource savings reportedly enjoyed by practices and PCTs as a consequence of the policy. These press releases, however, usually only report 'good news'. Official reports and academic articles on the success or otherwise of practice-based commissioning will probably take a few more years to reach any definitive, or even semi-definitive, conclusions. PCTs and presumably the Healthcare Commission monitor the GPs for their activities in order to make sure that patient care is not suffering as a consequence of the policy. 

Review mechanisms

Halbzeitevaluation

Dimensions of evaluation

Struktur, Prozess

Results of evaluation

As of May 2006, 3,454 GP practices out of 8,433 in England had accepted the incentive payment to participate in practice-based commissioning. This represented 41% of all practices. By August 2006, this percentage had increased to 74%, up from 65% in July 2006. In July 2006, it was reported that a number of PCTs each had projected savings of about one million pounds sterling as a result of savings made by pratices adopting practice-based commissioning. These savings are being used to invest in a variety of new services, including new community-based dermatology, diabetes, orthopaedics and chronic disease management clinics, specialist community-based glaucoma care equipment, and telephone and email advice services from hospital consultants to serve the PCT's facilities. 

Expected outcome

It is too early to assess the real benefits to patients that this policy will have. GPs are clearly increasingly taking up the opportunity to work within their own indicative budgets, but then more than 50% of GPs became fundholders in the 1990s, and there is not much evidence to suggest that the policy then had significant, sustained benefits. Only time will tell if substantial benefits flow from the policy this time.

This has already been commented upon above.

References

Sources of Information

www.primarycarecontracting.nhs.uk

www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/Commissioning/PracticeBasedCommissioning/fs/en

www.gnn.gov.uk/environment/fullDetail.asp?ReleaseID=212418&NewsAreaID=2&NavigatedFromDepartment=False

Reform formerly reported in

Empowering GPs: a return to fundholding Process Stages: Umsetzung

Author/s and/or contributors to this survey

Adam Oliver

Empfohlene Zitierweise für diesen Online-Artikel:

Adam Oliver. "Developing Practice-Based Commissioning". Health Policy Monitor, October 2006. Available at http://www.hpm.org/survey/gb/a8/2