Chris Ham on GP commissioning

In a recent speech to the BMA, Andrew Lansley argued that separating the management of care from the management of resources was a fundamental weakness, adding “examples in America of physician-led, more integrated services, demonstrate how differently – and effectively – they can deliver care.”

As someone who has studied integrated delivery systems in the United States (US), I strongly support the Health Secretary’s comments. The challenge facing the government is to use the opportunities presented by the white paper to move the NHS in the direction of these integrated systems and to emulate their achievements in delivering high quality and responsive care at reasonable cost. GP commissioning provides a basis for doing this provided that four key lessons from US experience are heeded.

First, GP commissioners must be allowed to take the “make or buy” decisions that will help to improve performance in the NHS. Only if GPs are able to use their control of resources to provide more services directly will it be possible to offer real alternatives to hospitals and to stem the rise in emergency admissions. Of course, commissioners must be held to account for their use of budgets, but simplistic arguments about conflicts of interest should not be used to prevent primary care teams from doing more to manage demand in the community.

Second, commissioning should be used to achieve closer integration between GPs and specialists. In the US, multispecialty groups of doctors are at the heart of integrated delivery systems and are able to provide many forms of diagnosis and treatment without recourse to hospitals. GP consortia will be operating on a sufficient scale to bridge the historic division in British medicine if the government is willing to let this happen.

Third, multispecialty medical groups work hand in hand with health insurers to redesign care pathways and to ensure resources are used efficiently. Health insurers provide infrastructure and support to medical groups as well as assistance with contract negotiation, claims processing, and data analysis. GP commissioners must be able to access similar support if they are to realise their potential, although where this will come from following the proposed abolition of PCTs is not clear.

Fourth, as Andrew Lansley indicated in his speech to the BMA, a cadre of GP leaders will be needed to take forward commissioning and to achieve closer integration of care. I would add that GP leaders will need support from top class managers, while also being able to call on technical expertise in developing new models of care. GP commissioners must have adequate resources for this purpose, even if management costs are being cut back.

The reform programme set out in the white paper offers a radical vision of the future, and its potential will only be realised if policy makers are willing to heed these lessons as their plans are worked up in more detail.

Chris Ham is the chief executive of the King’s Fund.

This blog also appears on the King’s Fund website at

  • Steve Ford

    I dissent from this view.

    The present proposals arise within the context of a specific narrow political world view – the neo-liberal free market hegemony. Consequently, these reforms will and must fail – just as all previous reforms have failed.

    Reform is essential and never finished but success can only arise when reform builds from the prosaic actualité of healthcare.

    The politics has to fit around reality, not the other way round. Its no use saying here's my political position, now mould the facts around me.

    The NHS can be brilliant, it should take as its cornerstone the consultation and build up from there. The NHS does not have to do everything for everyone all the time and it will only really succeed when this need for boundaries is accepted.

    Assessment and advice for anything, anywhere, any time is the portal to the system. The pathways from that point can be engineered to be uniformly excellent but do not all have to involve the NHS.

  • Melvyn Jones

    ok so how is it going to work exactly? Our PBC group manages to meet for 1 hour a month and we struggle to get through the pressing stuff such as “why has the health visitors service been cut”. I know of a very good PBC group that has managed to commission just 1 new service in 4 years, by the time they had complied with tendering, EU competition law, patient involvement and consultation etc. If the clinician deciding on resources genuinely is to shape the system, how will they actually have time to see patients? An accountable system directing how hundreds of millions of pounds of public money are spent can not be done in a 1 hour meeting. If it is more than that, the role necessarily becomes that of medical bureaucrat largely absent from clinical care- we are then back to PCGs, that then become PCTs, that then become health authorities and mindless merry go round of health service reform continues.

    We have to accept that dealing with sick people is time consuming and very costly. We therefore have to decide if or how we pay for this. This current reform will achieve no more than the previous four I have worked through. It will sap the good will of countless more clinicians and health service managers and prevent them from providing good clinical services.

  • Chris Timmis

    Melvyn Jones describes two contrasting scenarios. One the on hand GPs devoted to their clinical work and able to meet only one hour a month, and on the other a 'bureaucracy largely devolved from patient care'. Neither seems likely to work. All the more reason therefor to seek a middle way: A substantial proportion of GPs releasing some of their time…maybe a day or two a week…but still involved in clinical care, and supported by a management team. One of the problems of PBC has been that the PCTs, mindful of having financial responsibility, have been reluctant to give GP Commissioning Groups real authority. Now the tables are turned and the GPs. Will have the authority, but also the financial responsibility. There are tough times ahead and priorities need to be set. I believe that the best people to set these priorities are clinicians…GPs in cooperation with Specialist colleagues, Community staff, and patients. These reforms may offer an opportunity of real clinical power in the management of the NHS. The devil may be in the detail, but so far so good.