I became interested in commissioning through Fundholding. Like the majority of GP practices that got involved we did so because we wanted to improve the experience and the services our patients received. We used the influence which holding a budget gave us to address quality. For example, we improved the safety of anticoagulation management, we accessed investigations without having to send people to hospital so we could deliver more effective care, and we reduced waiting times for planned care. Fundholding made me realise that getting involved, as a doctor, in how the system was managed could improve quality for patients. The advent of PCTs drew me into the more complex and difficult agenda of large-scale change and whole-system improvement. I realised that if I didn’t want to disadvantage my own practice, because of the obvious conflict of interest I had in being able to influence funding flows across the whole system, then I needed to leave general practice and commit to commissioning.
I was thinking about all of this as I sat in a meeting, recently, where we were discussing the quality premium. This is part of the proposed reforms. Superficially it seems like a good idea. We are used to providers having incentives. It is intended that clinical commissioning groups (CCGs) will have an incentive, the quality premium, for commissioning. The problems start to accumulate once you begin to consider this idea in any depth.
Where will the money for the quality premium come from—presumably the commissioning budget? Does that mean it is a personal reward or money to be used to improve patient care? Clinical commissioning groups are supposed to embrace the Nolan principles. The first of these states: “..holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.”
Even if that principle is ignored, then who should the payment be made to? The original intention of the white paper, to liberate local GPs to respond to the needs of their patients and to commission services with an assumed autonomy from central control, has changed considerably. CCGs will be composed of member practices but also have lay members, a nurse and a secondary care specialist on their governing bodies. Should it be the practices or the governing body membership that receives the incentive payment?
Putting that to one side let’s move onto what the quality premium should be paid for. It is a quality premium, so presumably it is not for balancing the budget; but if a CCG doesn’t balance its budget (or generate a surplus) where will the money for a quality premium come from? Maybe it should be a value premium based on Porter and Teisberg’s theory that commissioning should focus on value (quality/cost). That then begs the question, what is quality in commissioning? Will it be the same quality indicators which we use for the Quality and Outcome Framework (QOF) or the Commissioning for Quality and Innovation (CQUIN) payment framework? We already allocate not insubstantial sums of money within commissioning budgets to incentivise quality with providers and one of those providers is general practice. Therefore, if we incentivise member practices of a CCG to commission and also incentivise them to deliver quality, will we end up paying twice for, basically, the same thing?
The question, it seems to me, is why does an NHS commissioner need a quality incentive? Commissioning is about working in the public good, in accordance with the Nolan principles, to extract the best value from the resources the government has invested to improve health and health services on behalf of the population served. Providers have incentives to deliver. The logic that therefore a commissioner needs an incentive is perhaps an error of logic in that it may cause more problems than it solves.
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.