Lots of ways to get it wrong and very few ways to get it right – worrying words from US doctor/academic Dr Lawrence Casalino writing about GP Commissioning. The article in the Nuffield Trust Viewpoint series is mercifully free of political axe-grinding and makes some good points based on his US experience of doctor-led groups coming together as independent practice associations (IPAs) as well as his research in the UK. IPAs collectively hold budgets from insurance companies but are independent of them. This is a model where insurers step back from micro-managing decisions by primary care people and in return asks them to accept some risks. The first sobering statistic is that while 1500 IPAs were set up in the US, only 150 have made a good go at this form of ‘risk-contracting’ (to be differentiated from the ‘fee for service’ approach). There were a number of high profile bankruptcies with considerable disruption for patients and the professional prospects of the doctors themselves.
Failure without investment
The reason for the high failure rate is clear – lack of investment in leadership, management and infrastructure. Dr Casalino’s explanation mirrors our experience of GPs here – “(they) focus on their current income and dislike reducing their current income to pay for things they do not value, that is leadership, management and infrastructure”.
If this investment is not made, Casalino goes on to say “many if not most consortia will fail.” He supplies a useful yardstick – a consortium with 100,000 patients/ 50 GPs ( the minimum size in his and others’ view) will need at least two physicians spending most of their time leading the consortium plus a Board with people on it spending a lot of time on running the show. Outside administrative and management help is not the answer since to make the best use of such help, the consortia will need … see above..leadership, management etc.
Risk and loss of income
This prospect helps explain the cries of protest and pain about ‘privatisation’ – used as a code word for the prospect of risk and loss of income. Withdrawal of contracts by the NHS Commissioning Board will carry a real financial penalty. Life for the GP practice has been largely risk free. There were no financial sanctions that could be applied in the GP fundholding schemes of the 1990’s. To avoid the penalties and earn the extra income, GPs will have to acknowledge their weaknesses in these areas of management and get some help.
So hooray for Casalino’s suggestion 3 “Provide training for GP leaders”. One of the most important outcomes from the pause for reflection, is the abandonment of tight timetables. Now GPs need not form consortia till they are ready and able to do so.So they have time for training and development of the skills needed. They have to move on from using their practice manager as a sort of surgery butler left to manage life behind the green baize door – dealing with importunate and impertinent callers (aka patients) and the underlings who receive them out there at the reception desk. They have to take a grip themselves, understand how their business runs and how it links to other providers. Leaders take responsibility and GP commissioning extends that responsibility well beyond the surgery door – a big ask when many GPs have become used to life as salarymen when in theory at least, they are supposed to be independent contractors selling their services – a private business indeed. Higher risk will be a worry for them but one they can manage if they learn how.
Patient Satisfaction: Key Incentive
Given our patient focus, we have also to applaud suggestion 4 to balance quality, patient experience and cost incentives. If it is all cost related, the cries of privatisation will rise again. If there are incentives and penalties, they have to be based on more than controlling costs. The patient experience and the quality of care have to have equal weight. We have said in a past blog that we see achievement of a high level of patient satisfaction as being a core criterion when evaluating a practice’s readiness to be a GP commissioner.
The Moore Adamson Craig Partnership supports user and public participation, trains lay representatives and develops responsive health, care and education organisations. We are ready to work with and support all those who want to make sense and a success of the new structures of patient and public engagement within the new arrangements for health and social care commissioning and providing. Feel free to contact us to discuss the opportunities.