Abstract
The government's White Paper Equity and Excellence: Liberating the NHS 1 introduces the most radical changes to the English NHS since its inception in 1948. These reforms include abolition of Primary Care Trusts, the current bodies that purchase healthcare, and Strategic Health Authorities, the regional management outposts of the Department of Health. Up to 70% of the NHS budget (£80bn) will instead be routed directly from a National Commissioning Board to consortia of GPs who will have responsibility for scoping and purchasing the majority of health services for their populations. An important caveat is that these changes only affect England: the divergence of the NHS between the four countries of the UK will increase, with Scotland in particular set against market-style reforms.
How will the financial responsibility and new-found power bestowed on GPs affect the health service in England? There are a number of important points to consider: There will be an increased focus on value for money; an over-emphasis on creating a market risks fragmenting healthcare; new conflicts of interest will emerge; the influence of patients in the new system is uncertain; and improvements in care will take several years to be realized. We consider each of these points in turn.
The recent government Spending Review confirms that restrictions on NHS funding will continue through to 2014, with real increases amounting to little more than 1% per year – nothing close to the 6.7% average annual increases the health service has seen over the past decade. 2, 3 The creation of hundreds of smaller purchasing organizations will cause an increase in transaction costs (time and resources for commissioning and contracting) especially in large urban areas where hospitals may have to contract with several different GP commissioning consortia. In addition, the NHS needs to make £20bn in savings over the next five years to accommodate medical cost inflation. 4, 5
All of this means that the purchasing decisions GP consortia make will be under close public scrutiny, and their leaders will be under tremendous pressure to contain costs. One consequence is likely to be increased involvement of the private sector: GPs will increasingly commission from the private sector as they seek to obtain better value for money, and they will also involve the private sector in providing management support for their new commissioning roles. This is in line with government thinking which sees a market in healthcare as a key way of improving value for money. But there are risks in this approach, too. First, competition for the first time in the NHS will be on price, which risks reducing quality. Secondly, Monitor, the new NHS economic regulator, will try to create a level playing field on which ‘any willing provider’ can bid to provide NHS care, and as a result may set regulations that actually prevent GPs from developing close relationships with consultants in their local trust. This would cut straight across the pressing need for GPs to work more closely with local consultants to provide better integrated care, and could result in further fragmentation. The risk will be reduced if Monitor and the National Commissioning Board actively promote the benefits of building long-term relationships between and purchasers and providers, as seen in other industries. 6
Under the proposed reforms, GPs will take on new responsibilities, including that for rationing care. Commissioning consortia will have to decide what and how many services to purchase within their budgets, and this will force them to make uncomfortable decisions. Both the British Medical Association and Royal College of General Practitioners have expressed concern at the conflicts of interest this will bring in relation to GPs' roles as providers of care for individual patients. The Secretary of State's view is that hard decisions have to be made, and the best people to make them are the clinicians who have best knowledge of their local populations.
The reforms will affect GPs' relationships with patients in other ways, too. Patients can never have everything they want in a system where the budget is capped, and GPs' new responsibility for choosing what care is available may negatively impact patients' views of their doctors. However, patients will also have a stronger voice, developed though the more active patient role envisaged in the White Paper. Local and national public involvement organizations (HealthWatch) will be established and given greater responsibility, and patients will be supported by better information on the range and quality of services available. However, expectations of the impact of patient involvement should probably be low: past attempts to involve patients and the public in NHS decision-making have had little effect. 7 Indeed, where GP commissioning consortia want to reconfigure services in a way that involves loss of local facilities, local patient voices are more likely to inhibit than promote innovation.
The idea of clinicians being more closely involved in commissioning healthcare is probably a good one. However, the impact of previous experiments with primary care commissioning was far from dramatic. When GP fundholding was introduced in 1991, waiting lists were reduced and some enthusiasts improved care for their patients. However, the overall effect was modest 8 and GPs were not strategic in their purchasing decisions. Subsequently, primary care trusts proved to be risk averse and ineffective commissioners. 9 This led the government to revert to giving GPs notional budgets under ‘practice-based commissioning’ in 2004 but this reform, too, was slow to get off the ground.
One potential obstacle to success has been that governments in the past have consistently underestimated the disruptive effects of system reform. 10 Some things are bound to look worse three to four years from now as the NHS loses two major tiers of administration and new GP-led organizations take on budgets with only modest preparation and support. It will probably be seven or eight years before we can really judge whether these reforms have been successful, and the risk of another major change during that time is high. Politicians will need uncharacteristic patience to see the reforms through.
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