Abstract
The regular ‘re-disorganizations’ of NHS structures over the last 30 years have largely marginalized the reform of primary care provision by focusing on the development of commissioning and improving the performance of hospitals. The Thatcher reforms created the purchaser-provider split and instituted the notion of ‘trust’ hospitals. The Blair reforms saw changes in commissioners (health authorities to primary care trusts) and efforts to improve their performance e.g. ‘World Class Commissioning’, as well as greater autonomy for hospitals with foundation trusts and continuous efforts to improve safety and productivity in secondary care.
In contrast to this focus on commissioning and improved provision of hospital care, the purchasing and provision of primary care has been largely ignored. For instance, GP fund holding was introduced as an afterthought by the Thatcher government. During the Blair administration the quality outcomes framework (QOF) for general practitioners whilst radical and expensive, did not alter primary care fundamentally.
The failure of NHS reforms to focus thoroughly on the role of primary care as a provider means that practice variations and fundamental issues about the efficient delivery of primary care have been side-lined. This makes it imperative that in the current period of financial austerity, policy makers must seek to improve primary care productivity with a programme of radical reform inherent in the NHS reform documentation. 1 How can this reform improve transparency, accountability and efficiency, and thereby contribute to the saving of £20bn required to maintain NHS services for an ageing population in the next 4 years?
In the new NHS structure primary care will be commissioned by the national commissioning board (NCB). Their apparent intention is to set national standards of process and outcome, and rigorously manage the performance of practices and practitioners.
The authors of the McKinsey report, 2 using simplistic arguments, concluded that ‘5–10% of GPs are very weak performers and 15–25% are weak performers in the number of appointments offered per week’ They asserted that considerable savings could be made by ensuring that ‘weak and very weak GP performers achieve the standard performance’.
McKinsey's report offered neither robust evidence to support their assertions nor did they identify demonstrably efficient incentive mechanisms to remedy these performance deficits. However, their approach was accepted uncritically by naive policy makers who appeared to concur with the consultancy firm that general practice performance had a normal distribution, that lower deciles were ‘inadequate’ performers and average practice was desirable and ‘good’.
However, this material is indicative of the recognition of large clinical practice variations in primary care 3 and an ambition in Whitehall to generate efficiency savings by standardizing processes and outcomes. This approach has evolved in principle over more than a decade, with a focus on process performance indicators, 4 the introduction of the QOF in 2004, and the recent publication of the 60 item NHS Outcomes Framework. 5 Some of these variations may be indicative of good, bad or uncertain clinical practice. However, until now they have largely been ignored, and when altered will produce significant efficiency gains.
Changing clinical practice
The agenda for change in the provision of primary care involves improved activity analysis, complementing activity data with outcome measurement, competitive tendering and changes in skill mix. All these measures have a common purpose of incentivizing change and producing productivity increases that free resources to fund increasing patient demand.
Interventions to reduce practice variations are unlikely to use financial incentives using bonuses primarily due to funding constraints. Instead there will be more focus on policies which create threats to income and reputational incentives i.e. identifying outliers in activity and outcomes, and relying on peer pressure and professional pride to motivate change. In addition to obvious candidates for incentivization of reductions in variations such as hospital referrals and prescribing, feeding back comparative bio-chemical and X-ray data to GPs, may induce change and greater economy. Such activity data if complemented by cost data may also induce greater economy.
However, what is the impact of such management on patient outcomes, in terms of their duration and quality of life? The focus on activity data and the ambition to reduce variation will be complemented by the use of outcome data in primary care in an effort to further enhance transparency, productivity and the quality of patient care. The development of patient reported outcomes measurement (PROMs) has been focused on hospital care. Since 2009, disease specific and generic quality of life questionnaires have been completed by NHS patients before and after four elective procedures: hips and knee replacements, hernia repairs and varicose vein surgery (e.g.EQ5D
An obvious reform of PROMs is to include it in the GP-QOF and integrate it into routine primary care practice. This will enable GPs to use outcome data to improve primary care, particularly their management of chronic conditions, but also give them greater insight into the efficiency of competing secondary care providers. Patients can complete PROMs before each consultation to provide continuing diagnostic intelligence for GPs and to ensure, for instance ‘health related quality of life for people with long term conditions’ (5, target 2). GPs can assess the comparative performance of consultants and secondary care, and inform CCG commissioning. 7
Using activity and PROMs data enables the NCB to set standards, and they and their partners, Clinical Commissioning Groups, can monitor compliance in primary care. If McKinsey's are correct in their assertions of poor performance amongst some GPs and after assistance to improve poor clinical performance, contracts for failing group practices may be put out to competitive tender. The threat of tendering when practices failed to deliver good patient care, as measured by activity and PROMs data, will further engender improved efficiency in primary care.
In the past, opposition to rigorous and transparent competitive contracting has been opposed with a focus not just on the appropriateness of activity and outcome and the provision of good practice indicators, but with concerns about premises owned by partnerships. These facilities will be taken over (or not) by successful competing public and private providers, with any losses being regarded as inevitable aspects of market trading. The threat of losses may further induce productivity changes. The eighteenth century political economist Adam Smith and behaviourist economists today assert that the threat of income losses motivate change more efficiently than the prospect of gains through bonus payments. 8
If competitive tendering led to provision by new organizations, redundancy payments might be avoided by transfer of undertakings (protection of employment) regulations (TUPE, 2006) processes if the new provider had the same objectives and used the same skill mix. However, this may not be the case. Whilst practice objectives may be the same, the skill mix used to deliver primary care may alter radically.
Much of primary care can be provided effectively by nurses. With austerity and constrained NHS budgets there will be an incentive to use nurses not as complements but as substitutes for medically qualified practitioners. However, nurses refer more, prescribe more and are slower than GPs. 9 Competitive tendering can incentivize changes in skill mix but its cost effectiveness needs careful evaluation. There is no evidence that ‘innovating’ private firms are able to deliver primary care more efficiently than their NHS rivals.
The pursuit of increased productivity will increase policy makers' focus on the need to reform the GP contract. The GMS contract introduced in 1948 lacks transparency and masks variations in activity and outcomes. Creating a remuneration system which merges GMS and salaried GPs is challenging, as practitioners have experienced income reduction for four years as policy makers sought to claw back the ‘excesses’ of the QOF. Budget constraints, workload inflation and proposed pension changes are affecting GP recruitment. This complex mix, together with resource constraints and skill mix pressures, will make for keen negotiations as the NCB seeks to improve productivity and maintain patient services.
Conclusions
As with the Thatcher and Blair reforms of the NHS, the provision of primary care might appear to some to be a marginal issue in the Coalition's reforms, with GPs as commissioners being the apparent primary focus of change. However, this appearance masks the true intent of a parsimonious and radical government, and its agent, the NHS Commissioning Board. It is time to reform primary care with the vigour and persistence shown in reforming secondary care in recent decades. Radical attempts to reform the provision of primary care should be expected as the commissioning board pursues improved productivity throughout the NHS in order to achieve the saving and recycling of £20 billion over 4 years. Defining targets and improving incentives will be the focus of the NCB as it uses the clinical commissioning groups to enforce its will locally. Whilst reforms are inevitable, it is essential that they are developed with care and a focus on evidence of the cost effectiveness of competing policy options, rather than the rhetoric of politicians and the superficial analysis of consulting firms.
DECLARATIONS
Competing interests
AM is Chair, Vale of York Clinical Commissioning Group
Funding
None
Ethical approval
Not applicable
Guarantor
AM
Contributorship
AM is the sole contributor
Acknowledgements
None