J Health Serv Res Policy OnlineFirst, published on July 8, 2015 as doi:10.1177/1355819615594825
Review Article
What happens when GPs engage in commissioning? Two decades of experience in the English NHS
Journal of Health Services Research & Policy 0(0) 1–8 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819615594825 jhsrp.rsmjournals.com
Rosalind Miller1, Stephen Peckham2, Anna Coleman3, Imelda McDermott4, Stephen Harrison5 and Kath Checkland6
Abstract Objective: To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. Methods: A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. Results: The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with ‘virtuous cycles’ (experience of being able to make changes feeding back to encourage greater engagement) and ‘vicious cycles’ (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. Conclusion: Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.
Keywords GP commissioning, primary care organizations, primary care purchasing
Introduction In 2010, the UK coalition government announced a reorganization of the English NHS that involved responsibility for commissioning (purchasing) of services being transferred from primary care trusts (PCTs) to newly established ‘Clinical Commissioning Groups’ (CCGs). The White Paper1 outlining the changes argued that general practitioner (GP) involvement would improve services for patients by bringing together ‘. . . responsibility for clinical decisions and for the financial consequences of these decisions . . .’ and ‘. . . increase efficiency, by enabling GPs to strip out activities that do not have appreciable benefits for patients’ health or healthcare’ (para. 4.4). Since the separation of the purchasing and provider functions within the NHS in 1991, a number of policy initiatives have sought to increase the influence of clinicians in health care
1
PhD Student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK 2 Professor of Health Policy, Centre for Health Services Studies, University of Kent, UK 3 Research Fellow, Centre for Primary Care, University of Manchester, UK 4 Research Associate, Centre for Primary Care, University of Manchester, UK 5 Professor of Social Policy, Centre for Primary Care, University of Manchester, UK 6 Reader in Health Policy and Primary Care, Centre for Primary Care, University of Manchester, UK Corresponding author: Rosalind Miller, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK. Email: [email protected]
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Table 1. History of GP commissioning in England. Date
Innovation
Scope of scheme
1991–1995
Introduction of purchaser–provider split
Provision of care split from purchasing, with Health Authorities established as purchasers of care for geographical populations Volunteer GP practices provided with budgets to purchase care for their registered populations. Budgets covered elective care and prescribing A variety of locally developed models of GP involvement, with varying degrees of power and responsibility An extension of GP fundholding. Volunteer groups held a budget covering a range of services that was agreed with local Health Authority PCGs officially subcommittees of Health Authorities. Responsible for commissioning full range of services. GP majority on Board
GP Fundholding (GPFH)
1995
1997
Locality commissioning and GP commissioning Total purchasing pilots
2000
New Labour government elected – GPFH abolished, Primary Care Groups (PCGs) established PCGs became primary care trusts (PCTs)
2005
Practice-based commissioning introduced
2010–2012
Coalition government elected, announce abolition of PCTs and establishment of Clinical Commissioning Groups
Health Authorities abolished, PCTs given responsibility for commissioning full range of services and providing community services. GPs no longer in a majority, few GPs involved Volunteer groups of GPs given indicative budgets covering variable range of services. Most covered elective services, prescribing and some also covered community and emergency services GP-led organizations with full statutory responsibility for commissioning all services other than primary care and highly specialized services. Fully established by 2012
Note: GP, general practitioner.
planning and resource allocation. The current reorganization represents the most far-reaching attempt. Table 1 shows a time line of these initiatives (see Refs.2,3 for details of the schemes mentioned). Whilst the UK has, perhaps, placed the greatest emphasis on this form of purchasing, it is not alone in this endeavour. Several other countries, both within Europe and outside, have introduced quasi or planned markets within their health care systems and many have experimented with using primary care providers to strengthen the commissioning function.4,5 The longest established primary care organizations outside the UK are independent practitioner associations and community health organizations in New Zealand.6 On a smaller scale, in Europe, Estonia, Catalonia and the former Soviet Union have introduced schemes allowing clinicians to hold budgets. For example, in Catalonia, doctors and nurses hold budgets, for defined populations of around 50–100,000, to cover primary care costs, diagnostic tests and specialist referrals.7 Approaches to primary care purchasing range from the exercise of professional influence – advising the main purchaser – to active purchasing where primary care clinicians have autonomy through budgetary control.5 The degree to which primary care organizations have autonomy depends specifically on the regulatory
framework within individual countries. The UK experience shows that this can vary over time. Drawing lessons from experience in other countries is not straightforward. As Marmor et al.8 cautioned, there is a ‘considerable gap between the promise and the actual performance of comparative policy studies’ (p. 331). One solution is to situate policy in different countries within an overarching comparative framework.4,9,10 However, such approaches may tend to play down contextual differences and are often limited by lack of suitable evidence.8 An alternative approach is to focus on the micro level, providing good evidence on specific aspects of practice and organization, which are relevant within a variety of settings, especially where regulatory and institutional frameworks are similar. For example, Robinson and Steiner11 provided detailed evidence about the operation of managed care systems in the US, and applied this to the UK, whilst McDonald et al.12 explored the micro-level operation of financial incentives in primary care. In this paper, we take this latter approach, providing a detailed synthesis of the evidence relating to clinical involvement in commissioning that is not only relevant in the UK, but which should also be of interest elsewhere to those interested in involving frontline clinicians in the purchasing of health care services.
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We ask: ‘what happens when GPs engage in commissioning? presenting findings from examination of the UK’s two decadelong history of engaging clinicians in commissioning, up to the most recent reforms.13 We specifically looked at: (a) the roles played by clinicians in commissioning; (b) the nature of clinical engagement in the commissioning process; (c) the extent to which clinicians can exercise control and influence over commissioning decisions; (d) the impact of clinical engagement on: . the ability to effect patterns of care; . changing primary care practice including prescribing and performance management; . quality and patient experience; . financial issues such as costs versus savings and the awareness of costs; . relationships within commissioning groups and with other agencies. Having reviewed this evidence, the paper discusses the implications of the findings for clinical commissioning in England and internationally.
Methods This review builds on a previous systematic review of evidence on commissioning or public service purchasing undertaken by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) between October 2009 and August 2010.14 Of the 600 studies identified, 339 were concerned with health. We conducted a search to update this work. In March 2011, an electronic literature search was conducted in ‘social policy and practice’, ‘econlit’, ‘Medline’, ‘PsychINFO’ and ‘CINAHL’ following the same search strategy used by the EPPI-Centre. Additionally, we handsearched three key journals and the bibliographies of key reviews on primary care commissioning, and the research reports of evaluations of previous primary care–led commissioning schemes.2,3,15–19 This search yielded an additional 175 references. Abstracts were obtained for the 514 references identified. Three reviewers independently reviewed each abstract. Full texts were obtained for the 288 that were empirical, which examined the relationship between purchasers and (potential) providers, made reference to clinician involvement and were UK based. A standard tool was used to extract data relating to the four review topics listed above. The quality of each study was assessed in five areas: . quality of the sampling process (including the sample size);
. appropriateness of the analysis; . comparability of the intervention (clinical engagement in commissioning) and comparison groups; . quality of the intervention delivery (including whether consistency of the intervention was measured or whether there was risk of contamination); . outcome assessment. Researchers were paired, with data extracted by one researcher and checked by a second. Papers were included in the review if they met the following criteria: . focused on secondary, tertiary and community care (including mental health and other specialized services), and primary care service developments (e.g. outreach clinics, general practice services, prescribing) but not other primary care (medical, dentistry, ophthalmology and pharmacy); . mentioned clinician involvement; . UK studies; . undertaken after 1991 (when the purchaser–provider split was first introduced in the UK); . an empirical study. We retained 218 papers with 70 papers either out of scope, purely descriptive or too poor methodologically.13 Using extraction forms, we constructed a number of evidence matrices and identified themes drawing on our key research questions and issues emerging from the data.
Results The nature of the evidence The evidence varied between different commissioning/ primary care purchasing schemes both in terms of quantity and focus. The majority of papers discussed GP fundholding (GPFH) and its derivatives, including the total purchasing pilots (TPPs). There was less relevant research on primary care groups (PCGs) and PCTs, and only limited evidence on practice-based commissioning (PbC). The pattern of evidence is likely to have been influenced partly by novelty. GPFH was a new type of health care purchasing and the first model of primary care–led purchasing to be introduced in the UK and although there was no centrally funded evaluation of GPFH, unlike the TPPs, GP commissioning and PbC, it was the subject of substantial interest. For many early schemes, the key research focus was on outcomes, with a tendency to examine those that were easy to measure – for example changes to GP prescribing. Few studies focused on how these were achieved and whether clinical engagement was an important factor or explored the relationship
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between clinical leaders and the wider body of GPs. Only a small number of studies shed light on the kind of leadership positions clinicians held and the degree of influence they exerted over commissioning decisions. Even fewer studies examined the influence of GP fundholders on other bodies with which they interacted, for example the Health Authority (HA) or provider organizations.
The nature of clinical involvement in the commissioning process Exploration of the nature of clinical involvement in the commissioning process included an examination of the type of roles assumed by clinicians; attitudes of clinicians towards the different schemes and their motivations for joining; the dynamic between clinical leaders and the wider clinical body; the level of clinical control over commissioning decisions and the perceived level of influence over external organizations. Evidence under this heading was fairly limited; few papers specifically addressed GPs’ role and involvement. Central to all models was the concept of clinical leadership. The hierarchical structure of general practice reportedly allowed the lead GP and business manager to take decisions on behalf of the fundholding practice. These actors assumed most of the responsibility for running the scheme.20 GPs also took leadership roles in nonfundholding commissioning models such as locality-based groups, transmitting their views to health authorities or as advisers within HAs. Impact in these models was more limited than in GPFH.21 The limited scope of some of the other clinical commissioning schemes (e.g. PbC, see Table 1) did not seem to prevent GP leaders from becoming actively engaged.3 In broader-based commissioning organizations, which had full responsibility for commissioning across a geographical area (such as PCTs and HAs), only a selected number of GPs were engaged (e.g. the Professional Executive Committee chair of the PCT) or they were not perceived as influential.22 In terms of motivations for joining clinically led commissioning schemes, most of the different models of primary care–led commissioning (excluding PCGs and PCTs) were introduced with calls for volunteers or ‘pilots’, and subsequently expanded. Practices choosing to join schemes did so at different stages. Each new scheme generated differing levels of engagement driven by differing motivations depending upon the focus of the scheme. For example, fundholding enabled ‘entrepreneurial’ GPs to generate investment in their practices (with this effect most marked in so-called early adopters), whilst engagement in alternative schemes tended to be driven by hostility to fundholding.17,23 However, a common theme for all schemes was the
view that GPs were better informed about patients’ needs than managers, as they had assess to practicelevel data and direct feedback from patients.3,17,24 For GP fundholders, motivations could be broadly categorized into two groups. ‘Positive’ motivations were seen more commonly in the first wave and were primarily concerned with improving the quality of service for patients25 and local, community-based services. Financial incentives were important in fundholding (and in PbC26) where savings could be reinvested in practice-based services and other service developments.26,27 Those with ‘negative’ motivations were concerned with preserving their perceived threatened autonomy, not missing out on any financial inducements and getting on the ‘bandwagon’ for fear of being left behind.20,25,27 By the time PCGs were announced in 1997, many GPs were tired of organizational change and there was limited enthusiasm to invest substantial time and effort for fear that PCGs would be short-lived.28 This phenomenon was again observed with the subsequent reorganizations, including the introduction of PbC in 2005.3 Overall, most schemes were led by a relatively small number of enthusiasts, with ‘rank and file’ GPs exhibiting varying degrees of engagement from acquiescence to outright hostility.24 In all clinical commissioning models, the ability to innovate, determined by the extent to which those involved enjoyed autonomy over such things as decisions about services and budget allocation, was cited as a key motivator.2,15,16 The TPP evaluation showed that groups given the most autonomy were most likely to be innovative in terms of changes made.26 Interestingly, commitment tended to grow.29 Under PbC, this process was also facilitated by supportive PCTs.3 However, where autonomy was restricted, this limited the degree of influence or the extent of influence and this was likely to create less engagement by the wider GP and clinician communities.29 The evidence clearly demonstrates that GPs who were engaged in commissioning enjoyed more autonomy and were generally more engaged in GPFH than in later schemes, even though their budgetary responsibility was limited in scope.27 Fundholding practices also tended to have the strongest links between their GP leaders and the wider group of GPs with lead GPs supported and provided with legitimacy by those not involved.20 This may have been a function of size as GPFH schemes were often single practices or small networks of practices. Securing this engagement, however, required substantial time, which could have otherwise been spent in patient consultations as well as access to management resources.30 In 1997, the Labour Government abolished GPFH and introduced mandatory membership of PCGs
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leading to some broader engagement in commissioning activities.31 With the subsequent shift to PCTs, clinical engagement in commissioning (prior to PbC) diminished, although both PCTs and PbC were marked by low levels of GP participation.19,22 GPs cited heavy workloads and time constraints as barriers to more involvement, and they reported being marginalized in key decision-making processes.19 With PbC, clinical engagement improved but devolved decision making was often nominal – especially regarding budgetary decisions.26 However, some PbC clinicians did scrutinize budgets in detail, itemizing expenditure across all elements of the budget by GP practice, including the presentation of ‘league tables’ and ‘naming and shaming’ of overspending practices.3 Similarly in TPPs, GPs were willing to participate in the management of a budget.30 Thus, real responsibility and control over the budget does appear to be possible and accepted by GPs, although generally the evidence suggests that in all manifestations of GP-led commissioning only a handful of GPs became actively involved.32
care indicating possible service duplication and doubts over cost-effectiveness. Again, these new services led to questions regarding equity.29 We found limited evidence of success in changing secondary care services, although this was the main focus of clinically led commissioning.42 In general, acute hospitals were reluctant to release the necessary resources to fund such initiatives.3,19,26,29 Few GPs were interested in wider, population-based commissioning.3,26,29 Whilst improving the quality of care for their patients was a prime motivator for many GPs to engage in commissioning,25 there is little convincing evidence to suggest that any of the primary care–led commissioning schemes improved patients’ overall quality of care.41,46,47 There was also no evidence to demonstrate that GP commissioners prioritized or addressed issues of care quality, although research into PbC suggests that the development of commissioning networks provided a mechanism for supporting quality development in general practice.47
Engagement and outcomes
We examined how GPs and, where possible, other primary care clinicians, were involved in commissioning and what impact this had. The evidence suggests that a key determinant of clinical engagement was the extent to which GPs felt that they had some autonomy and control to respond to what they perceived as the key issues that affected their patients’ experience of health care.22,33 The attitude of the ‘parent’ commissioning body to GP commissioners was a key factor. Those prepared to cede control and to support clinical commissioners to act were rewarded with increased GP commitment. For GPs who were engaged with, or participated in, commissioning, maintaining wider clinical engagement was felt to be a priority, but the extent to which this was achieved varied considerably.3,34 Engagement was easier in smaller schemes, but these tended to be limited in scope. We found no evidence to determine whether the inclusion of non-GP clinicians added value. Some schemes such as PCGs included nurses, but there is no research evidence reporting on any impact of this, although nurses involved did express the desire to become more involved in commissioning activities.48 The degree and impact of clinical engagement varied both between and within different commissioning models. In terms of the factors enabling success, more GP engagement in GPFH, TPPs and PbC seemed to lead to more success in achieving goals and stated objectives.3,20,26,29 Governance systems that engaged the wider GP community and other clinicians provided the commissioning organization, and those leading it, with greater legitimacy.3,20 However, in larger schemes
The evidence on the impact of clinically led primary care commissioning was variable in scope and quality. Most evidence related to easy to measure activity such as changes in prescribing,20,35,36 waiting times,37–39 referrals3,29,40 and specific service changes.3,41,42 Success in making changes was related to the ability to influence the behaviour of rank and file GPs and this was generally easier in smaller organizations.3,43 Lack of high-quality evidence makes it complicated to determine the extent to which change was successful. Although it is possible to compare groups engaged with the various schemes with those not engaged, and to track change over time, establishing causality is difficult. Key areas of success include reductions in prescribing costs and reduced waiting times.2,3,15 However, concerns about equity were raised.43 Others claimed positive outcomes relating to the development of services at the community level, both within practices (e.g. in-house physiotherapy clinics) and at the interface between primary and secondary care (e.g. creation of a discharge liaison officer).19,21,38,43,44 There is little critical appraisal of these services and the benefits they confer are unclear, although clinical commissioners tended to claim that their presence alone represented a ‘success’. Areas chosen for development were mostly chosen on the basis of GPs’ interest or perceived local need.45 In many cases, these developments were not accompanied by the necessary resource shifts out of secondary
Discussion
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such as TPPs, this engagement was expensive. Study of seven TPPs found that more than 50% of the incremental cost associated with TPPs (compared to purchasing as GP fundholders) was committed to managing internal relations – i.e. coordinating the views of independent GPs and involving them in the commissioning process.30 The benefits of increased engagement must therefore be weighed against these higher transaction costs. Across the schemes, there is also evidence that higher management costs were associated with greater success.3,29,46 These findings need to be set in a context where clinical engagement is generally driven by clinicians wanting to improve services for their patients. GPs felt that they were in a better position to know what their patients needed and that the information held in the practice was better than that held by HAs or PCTs. Whilst there was little evidence that clinical involvement had improved the delivery of health care services or outcomes, we identified four themes that are relevant to the development of clinically led commissioning in future: 1. There are ‘virtuous cycles’ (experience of ‘success’ is more likely to lead to greater engagement) and ‘vicious cycles’ (clinicians withdraw from engagement if they feel they have had no influence). Perceived success is linked to an increased willingness to accept financial responsibility for clinical decisions. 2. The environment within which primary care–led commissioners operate is very important in determining ‘success’. Primary care commissioners are more likely to achieve their stated objectives in a more permissive and supportive environment. 3. The internal relationship between the clinical leaders and the membership is key to successful initiatives. Continued support from the wider clinician community is important in sustaining the legitimacy of commissioning actions by the leading clinicians and in ensuring membership buy-in to any changes required. 4. GP-led commissioning tends to focus on activities that are seen as most relevant to primary care, including addressing prescribing, and developing primary and community care services. There is little evidence that GPs change secondary care services and there is very little evidence that clinical involvement in commissioning will lead to better outcomes. Tuohy has described how different phases of primary care–led purchasing in the UK have provided opportunities for institutional entrepreneurialism49 and that similar effects are found in other structural reforms,
breaking down existing institutional structures and providing opportunities for professional leadership.4,49 This review highlights the varying degrees of autonomy between the different models highlighted by McCallum et al.5 and suggests that whilst autonomy may be important, whether primary care clinicians feel that they have successfully changed or influenced services remains the most important aspect from their perspective.
Conclusion There remains a high degree of optimism in the English NHS amongst those involved as to the value of involving GPs in commissioning.50 How this plays out in the longer term remains to be seen, but the evidence on clinical engagement in primary care–led commissioning identifies a number of lessons of relevance to the CCGs established in 2013 as they continue to develop. Despite differing contexts,8 we believe that there are likely to be some similarities between GP behaviour and attitudes across countries. The findings of this review suggest that prescriptive guidance regarding membership of commissioning organizations may squeeze out GPs’ interest and influence. Further, grassroots engagement appears to be key to affecting the behaviour of individual GPs. Other findings relevant to CCGs in England should be interpreted with caution by other countries with an awareness of the similarities and differences between their health care systems and the English NHS. GPs need to be given sufficient space to innovate. Most of their early changes are likely to be small scale, with a focus on issues closely relevant to general practice. On the other hand, experience in the NHS shows that, over time, GPs do start to engage with wider strategic issues. However, their ability to make these more strategic service changes in England has been limited by the tendency to abolish each scheme after a relatively short time. Lastly, primary and community care are likely to be pinpointed for development, especially with the goal of reducing use of secondary care services. Attempts to change patterns of secondary care will need to be accompanied by resource shifts away from acute hospitals to avoid duplication and realize efficiency savings. Acknowledgements We would like to thank Dr Julia Segar for her comments on an earlier version of this work.
Authors’ note A full list of papers included in the review can be found in Miller R, Peckham S, Checkland K, Coleman A, McDermott
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I, Harrison S, et al. Clinical engagement in primary care–led commissioning: a review of the evidence. London: Prucomm; 2012. The views expressed here are those of the researchers and not the Department of Health.
Conflict of interest The authors declare that there is no conflict of interest.
Funding This research was funded by the Department of Health Policy Research Programme, as part of the work programme of the Policy Research Unit in Commissioning and the Health Care System (www.prucomm.ac.uk).
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Review Article
What happens when GPs engage in commissioning? Two decades of experience in the English NHS
Journal of Health Services Research & Policy 0(0) 1–8 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819615594825 jhsrp.rsmjournals.com
Rosalind Miller1, Stephen Peckham2, Anna Coleman3, Imelda McDermott4, Stephen Harrison5 and Kath Checkland6
Abstract Objective: To review the evidence on commissioning schemes involving clinicians in the United Kingdom National Health Service, between 1991 and 2010; report on the extent and impact of clinical engagement; and distil lessons for the development of such schemes both in the UK and elsewhere. Methods: A review of published evidence. Five hundred and fourteen abstracts were obtained from structured searches and screened. Full-text papers were retrieved for UK empirical studies exploring the relationship between commissioners and providers with clinician involvement. Two hundred and eighteen published materials were reviewed. Results: The extent of clinical engagement varied between the various schemes. Schemes allowing clinicians to act autonomously were more likely to generate significant engagement, with ‘virtuous cycles’ (experience of being able to make changes feeding back to encourage greater engagement) and ‘vicious cycles’ (failure to influence services generating disengagement) observed. Engagement of the wider general practitioner (GP) membership was an important determinant of success. Most impact was seen in GP prescribing and the establishment of services in general practices. There was little evidence of GPs engaging more widely with public health issues. Conclusion: Evidence for a significant impact of clinical engagement on commissioning outcomes is limited. Initial changes are likely to be small scale and to focus on services in primary care. Engagement of GP members of primary care commissioning organizations is an important determinant of progress, but generates significant transaction costs.
Keywords GP commissioning, primary care organizations, primary care purchasing
Introduction In 2010, the UK coalition government announced a reorganization of the English NHS that involved responsibility for commissioning (purchasing) of services being transferred from primary care trusts (PCTs) to newly established ‘Clinical Commissioning Groups’ (CCGs). The White Paper1 outlining the changes argued that general practitioner (GP) involvement would improve services for patients by bringing together ‘. . . responsibility for clinical decisions and for the financial consequences of these decisions . . .’ and ‘. . . increase efficiency, by enabling GPs to strip out activities that do not have appreciable benefits for patients’ health or healthcare’ (para. 4.4). Since the separation of the purchasing and provider functions within the NHS in 1991, a number of policy initiatives have sought to increase the influence of clinicians in health care
1
PhD Student, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK 2 Professor of Health Policy, Centre for Health Services Studies, University of Kent, UK 3 Research Fellow, Centre for Primary Care, University of Manchester, UK 4 Research Associate, Centre for Primary Care, University of Manchester, UK 5 Professor of Social Policy, Centre for Primary Care, University of Manchester, UK 6 Reader in Health Policy and Primary Care, Centre for Primary Care, University of Manchester, UK Corresponding author: Rosalind Miller, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK. Email: [email protected]
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Table 1. History of GP commissioning in England. Date
Innovation
Scope of scheme
1991–1995
Introduction of purchaser–provider split
Provision of care split from purchasing, with Health Authorities established as purchasers of care for geographical populations Volunteer GP practices provided with budgets to purchase care for their registered populations. Budgets covered elective care and prescribing A variety of locally developed models of GP involvement, with varying degrees of power and responsibility An extension of GP fundholding. Volunteer groups held a budget covering a range of services that was agreed with local Health Authority PCGs officially subcommittees of Health Authorities. Responsible for commissioning full range of services. GP majority on Board
GP Fundholding (GPFH)
1995
1997
Locality commissioning and GP commissioning Total purchasing pilots
2000
New Labour government elected – GPFH abolished, Primary Care Groups (PCGs) established PCGs became primary care trusts (PCTs)
2005
Practice-based commissioning introduced
2010–2012
Coalition government elected, announce abolition of PCTs and establishment of Clinical Commissioning Groups
Health Authorities abolished, PCTs given responsibility for commissioning full range of services and providing community services. GPs no longer in a majority, few GPs involved Volunteer groups of GPs given indicative budgets covering variable range of services. Most covered elective services, prescribing and some also covered community and emergency services GP-led organizations with full statutory responsibility for commissioning all services other than primary care and highly specialized services. Fully established by 2012
Note: GP, general practitioner.
planning and resource allocation. The current reorganization represents the most far-reaching attempt. Table 1 shows a time line of these initiatives (see Refs.2,3 for details of the schemes mentioned). Whilst the UK has, perhaps, placed the greatest emphasis on this form of purchasing, it is not alone in this endeavour. Several other countries, both within Europe and outside, have introduced quasi or planned markets within their health care systems and many have experimented with using primary care providers to strengthen the commissioning function.4,5 The longest established primary care organizations outside the UK are independent practitioner associations and community health organizations in New Zealand.6 On a smaller scale, in Europe, Estonia, Catalonia and the former Soviet Union have introduced schemes allowing clinicians to hold budgets. For example, in Catalonia, doctors and nurses hold budgets, for defined populations of around 50–100,000, to cover primary care costs, diagnostic tests and specialist referrals.7 Approaches to primary care purchasing range from the exercise of professional influence – advising the main purchaser – to active purchasing where primary care clinicians have autonomy through budgetary control.5 The degree to which primary care organizations have autonomy depends specifically on the regulatory
framework within individual countries. The UK experience shows that this can vary over time. Drawing lessons from experience in other countries is not straightforward. As Marmor et al.8 cautioned, there is a ‘considerable gap between the promise and the actual performance of comparative policy studies’ (p. 331). One solution is to situate policy in different countries within an overarching comparative framework.4,9,10 However, such approaches may tend to play down contextual differences and are often limited by lack of suitable evidence.8 An alternative approach is to focus on the micro level, providing good evidence on specific aspects of practice and organization, which are relevant within a variety of settings, especially where regulatory and institutional frameworks are similar. For example, Robinson and Steiner11 provided detailed evidence about the operation of managed care systems in the US, and applied this to the UK, whilst McDonald et al.12 explored the micro-level operation of financial incentives in primary care. In this paper, we take this latter approach, providing a detailed synthesis of the evidence relating to clinical involvement in commissioning that is not only relevant in the UK, but which should also be of interest elsewhere to those interested in involving frontline clinicians in the purchasing of health care services.
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We ask: ‘what happens when GPs engage in commissioning? presenting findings from examination of the UK’s two decadelong history of engaging clinicians in commissioning, up to the most recent reforms.13 We specifically looked at: (a) the roles played by clinicians in commissioning; (b) the nature of clinical engagement in the commissioning process; (c) the extent to which clinicians can exercise control and influence over commissioning decisions; (d) the impact of clinical engagement on: . the ability to effect patterns of care; . changing primary care practice including prescribing and performance management; . quality and patient experience; . financial issues such as costs versus savings and the awareness of costs; . relationships within commissioning groups and with other agencies. Having reviewed this evidence, the paper discusses the implications of the findings for clinical commissioning in England and internationally.
Methods This review builds on a previous systematic review of evidence on commissioning or public service purchasing undertaken by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) between October 2009 and August 2010.14 Of the 600 studies identified, 339 were concerned with health. We conducted a search to update this work. In March 2011, an electronic literature search was conducted in ‘social policy and practice’, ‘econlit’, ‘Medline’, ‘PsychINFO’ and ‘CINAHL’ following the same search strategy used by the EPPI-Centre. Additionally, we handsearched three key journals and the bibliographies of key reviews on primary care commissioning, and the research reports of evaluations of previous primary care–led commissioning schemes.2,3,15–19 This search yielded an additional 175 references. Abstracts were obtained for the 514 references identified. Three reviewers independently reviewed each abstract. Full texts were obtained for the 288 that were empirical, which examined the relationship between purchasers and (potential) providers, made reference to clinician involvement and were UK based. A standard tool was used to extract data relating to the four review topics listed above. The quality of each study was assessed in five areas: . quality of the sampling process (including the sample size);
. appropriateness of the analysis; . comparability of the intervention (clinical engagement in commissioning) and comparison groups; . quality of the intervention delivery (including whether consistency of the intervention was measured or whether there was risk of contamination); . outcome assessment. Researchers were paired, with data extracted by one researcher and checked by a second. Papers were included in the review if they met the following criteria: . focused on secondary, tertiary and community care (including mental health and other specialized services), and primary care service developments (e.g. outreach clinics, general practice services, prescribing) but not other primary care (medical, dentistry, ophthalmology and pharmacy); . mentioned clinician involvement; . UK studies; . undertaken after 1991 (when the purchaser–provider split was first introduced in the UK); . an empirical study. We retained 218 papers with 70 papers either out of scope, purely descriptive or too poor methodologically.13 Using extraction forms, we constructed a number of evidence matrices and identified themes drawing on our key research questions and issues emerging from the data.
Results The nature of the evidence The evidence varied between different commissioning/ primary care purchasing schemes both in terms of quantity and focus. The majority of papers discussed GP fundholding (GPFH) and its derivatives, including the total purchasing pilots (TPPs). There was less relevant research on primary care groups (PCGs) and PCTs, and only limited evidence on practice-based commissioning (PbC). The pattern of evidence is likely to have been influenced partly by novelty. GPFH was a new type of health care purchasing and the first model of primary care–led purchasing to be introduced in the UK and although there was no centrally funded evaluation of GPFH, unlike the TPPs, GP commissioning and PbC, it was the subject of substantial interest. For many early schemes, the key research focus was on outcomes, with a tendency to examine those that were easy to measure – for example changes to GP prescribing. Few studies focused on how these were achieved and whether clinical engagement was an important factor or explored the relationship
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between clinical leaders and the wider body of GPs. Only a small number of studies shed light on the kind of leadership positions clinicians held and the degree of influence they exerted over commissioning decisions. Even fewer studies examined the influence of GP fundholders on other bodies with which they interacted, for example the Health Authority (HA) or provider organizations.
The nature of clinical involvement in the commissioning process Exploration of the nature of clinical involvement in the commissioning process included an examination of the type of roles assumed by clinicians; attitudes of clinicians towards the different schemes and their motivations for joining; the dynamic between clinical leaders and the wider clinical body; the level of clinical control over commissioning decisions and the perceived level of influence over external organizations. Evidence under this heading was fairly limited; few papers specifically addressed GPs’ role and involvement. Central to all models was the concept of clinical leadership. The hierarchical structure of general practice reportedly allowed the lead GP and business manager to take decisions on behalf of the fundholding practice. These actors assumed most of the responsibility for running the scheme.20 GPs also took leadership roles in nonfundholding commissioning models such as locality-based groups, transmitting their views to health authorities or as advisers within HAs. Impact in these models was more limited than in GPFH.21 The limited scope of some of the other clinical commissioning schemes (e.g. PbC, see Table 1) did not seem to prevent GP leaders from becoming actively engaged.3 In broader-based commissioning organizations, which had full responsibility for commissioning across a geographical area (such as PCTs and HAs), only a selected number of GPs were engaged (e.g. the Professional Executive Committee chair of the PCT) or they were not perceived as influential.22 In terms of motivations for joining clinically led commissioning schemes, most of the different models of primary care–led commissioning (excluding PCGs and PCTs) were introduced with calls for volunteers or ‘pilots’, and subsequently expanded. Practices choosing to join schemes did so at different stages. Each new scheme generated differing levels of engagement driven by differing motivations depending upon the focus of the scheme. For example, fundholding enabled ‘entrepreneurial’ GPs to generate investment in their practices (with this effect most marked in so-called early adopters), whilst engagement in alternative schemes tended to be driven by hostility to fundholding.17,23 However, a common theme for all schemes was the
view that GPs were better informed about patients’ needs than managers, as they had assess to practicelevel data and direct feedback from patients.3,17,24 For GP fundholders, motivations could be broadly categorized into two groups. ‘Positive’ motivations were seen more commonly in the first wave and were primarily concerned with improving the quality of service for patients25 and local, community-based services. Financial incentives were important in fundholding (and in PbC26) where savings could be reinvested in practice-based services and other service developments.26,27 Those with ‘negative’ motivations were concerned with preserving their perceived threatened autonomy, not missing out on any financial inducements and getting on the ‘bandwagon’ for fear of being left behind.20,25,27 By the time PCGs were announced in 1997, many GPs were tired of organizational change and there was limited enthusiasm to invest substantial time and effort for fear that PCGs would be short-lived.28 This phenomenon was again observed with the subsequent reorganizations, including the introduction of PbC in 2005.3 Overall, most schemes were led by a relatively small number of enthusiasts, with ‘rank and file’ GPs exhibiting varying degrees of engagement from acquiescence to outright hostility.24 In all clinical commissioning models, the ability to innovate, determined by the extent to which those involved enjoyed autonomy over such things as decisions about services and budget allocation, was cited as a key motivator.2,15,16 The TPP evaluation showed that groups given the most autonomy were most likely to be innovative in terms of changes made.26 Interestingly, commitment tended to grow.29 Under PbC, this process was also facilitated by supportive PCTs.3 However, where autonomy was restricted, this limited the degree of influence or the extent of influence and this was likely to create less engagement by the wider GP and clinician communities.29 The evidence clearly demonstrates that GPs who were engaged in commissioning enjoyed more autonomy and were generally more engaged in GPFH than in later schemes, even though their budgetary responsibility was limited in scope.27 Fundholding practices also tended to have the strongest links between their GP leaders and the wider group of GPs with lead GPs supported and provided with legitimacy by those not involved.20 This may have been a function of size as GPFH schemes were often single practices or small networks of practices. Securing this engagement, however, required substantial time, which could have otherwise been spent in patient consultations as well as access to management resources.30 In 1997, the Labour Government abolished GPFH and introduced mandatory membership of PCGs
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leading to some broader engagement in commissioning activities.31 With the subsequent shift to PCTs, clinical engagement in commissioning (prior to PbC) diminished, although both PCTs and PbC were marked by low levels of GP participation.19,22 GPs cited heavy workloads and time constraints as barriers to more involvement, and they reported being marginalized in key decision-making processes.19 With PbC, clinical engagement improved but devolved decision making was often nominal – especially regarding budgetary decisions.26 However, some PbC clinicians did scrutinize budgets in detail, itemizing expenditure across all elements of the budget by GP practice, including the presentation of ‘league tables’ and ‘naming and shaming’ of overspending practices.3 Similarly in TPPs, GPs were willing to participate in the management of a budget.30 Thus, real responsibility and control over the budget does appear to be possible and accepted by GPs, although generally the evidence suggests that in all manifestations of GP-led commissioning only a handful of GPs became actively involved.32
care indicating possible service duplication and doubts over cost-effectiveness. Again, these new services led to questions regarding equity.29 We found limited evidence of success in changing secondary care services, although this was the main focus of clinically led commissioning.42 In general, acute hospitals were reluctant to release the necessary resources to fund such initiatives.3,19,26,29 Few GPs were interested in wider, population-based commissioning.3,26,29 Whilst improving the quality of care for their patients was a prime motivator for many GPs to engage in commissioning,25 there is little convincing evidence to suggest that any of the primary care–led commissioning schemes improved patients’ overall quality of care.41,46,47 There was also no evidence to demonstrate that GP commissioners prioritized or addressed issues of care quality, although research into PbC suggests that the development of commissioning networks provided a mechanism for supporting quality development in general practice.47
Engagement and outcomes
We examined how GPs and, where possible, other primary care clinicians, were involved in commissioning and what impact this had. The evidence suggests that a key determinant of clinical engagement was the extent to which GPs felt that they had some autonomy and control to respond to what they perceived as the key issues that affected their patients’ experience of health care.22,33 The attitude of the ‘parent’ commissioning body to GP commissioners was a key factor. Those prepared to cede control and to support clinical commissioners to act were rewarded with increased GP commitment. For GPs who were engaged with, or participated in, commissioning, maintaining wider clinical engagement was felt to be a priority, but the extent to which this was achieved varied considerably.3,34 Engagement was easier in smaller schemes, but these tended to be limited in scope. We found no evidence to determine whether the inclusion of non-GP clinicians added value. Some schemes such as PCGs included nurses, but there is no research evidence reporting on any impact of this, although nurses involved did express the desire to become more involved in commissioning activities.48 The degree and impact of clinical engagement varied both between and within different commissioning models. In terms of the factors enabling success, more GP engagement in GPFH, TPPs and PbC seemed to lead to more success in achieving goals and stated objectives.3,20,26,29 Governance systems that engaged the wider GP community and other clinicians provided the commissioning organization, and those leading it, with greater legitimacy.3,20 However, in larger schemes
The evidence on the impact of clinically led primary care commissioning was variable in scope and quality. Most evidence related to easy to measure activity such as changes in prescribing,20,35,36 waiting times,37–39 referrals3,29,40 and specific service changes.3,41,42 Success in making changes was related to the ability to influence the behaviour of rank and file GPs and this was generally easier in smaller organizations.3,43 Lack of high-quality evidence makes it complicated to determine the extent to which change was successful. Although it is possible to compare groups engaged with the various schemes with those not engaged, and to track change over time, establishing causality is difficult. Key areas of success include reductions in prescribing costs and reduced waiting times.2,3,15 However, concerns about equity were raised.43 Others claimed positive outcomes relating to the development of services at the community level, both within practices (e.g. in-house physiotherapy clinics) and at the interface between primary and secondary care (e.g. creation of a discharge liaison officer).19,21,38,43,44 There is little critical appraisal of these services and the benefits they confer are unclear, although clinical commissioners tended to claim that their presence alone represented a ‘success’. Areas chosen for development were mostly chosen on the basis of GPs’ interest or perceived local need.45 In many cases, these developments were not accompanied by the necessary resource shifts out of secondary
Discussion
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such as TPPs, this engagement was expensive. Study of seven TPPs found that more than 50% of the incremental cost associated with TPPs (compared to purchasing as GP fundholders) was committed to managing internal relations – i.e. coordinating the views of independent GPs and involving them in the commissioning process.30 The benefits of increased engagement must therefore be weighed against these higher transaction costs. Across the schemes, there is also evidence that higher management costs were associated with greater success.3,29,46 These findings need to be set in a context where clinical engagement is generally driven by clinicians wanting to improve services for their patients. GPs felt that they were in a better position to know what their patients needed and that the information held in the practice was better than that held by HAs or PCTs. Whilst there was little evidence that clinical involvement had improved the delivery of health care services or outcomes, we identified four themes that are relevant to the development of clinically led commissioning in future: 1. There are ‘virtuous cycles’ (experience of ‘success’ is more likely to lead to greater engagement) and ‘vicious cycles’ (clinicians withdraw from engagement if they feel they have had no influence). Perceived success is linked to an increased willingness to accept financial responsibility for clinical decisions. 2. The environment within which primary care–led commissioners operate is very important in determining ‘success’. Primary care commissioners are more likely to achieve their stated objectives in a more permissive and supportive environment. 3. The internal relationship between the clinical leaders and the membership is key to successful initiatives. Continued support from the wider clinician community is important in sustaining the legitimacy of commissioning actions by the leading clinicians and in ensuring membership buy-in to any changes required. 4. GP-led commissioning tends to focus on activities that are seen as most relevant to primary care, including addressing prescribing, and developing primary and community care services. There is little evidence that GPs change secondary care services and there is very little evidence that clinical involvement in commissioning will lead to better outcomes. Tuohy has described how different phases of primary care–led purchasing in the UK have provided opportunities for institutional entrepreneurialism49 and that similar effects are found in other structural reforms,
breaking down existing institutional structures and providing opportunities for professional leadership.4,49 This review highlights the varying degrees of autonomy between the different models highlighted by McCallum et al.5 and suggests that whilst autonomy may be important, whether primary care clinicians feel that they have successfully changed or influenced services remains the most important aspect from their perspective.
Conclusion There remains a high degree of optimism in the English NHS amongst those involved as to the value of involving GPs in commissioning.50 How this plays out in the longer term remains to be seen, but the evidence on clinical engagement in primary care–led commissioning identifies a number of lessons of relevance to the CCGs established in 2013 as they continue to develop. Despite differing contexts,8 we believe that there are likely to be some similarities between GP behaviour and attitudes across countries. The findings of this review suggest that prescriptive guidance regarding membership of commissioning organizations may squeeze out GPs’ interest and influence. Further, grassroots engagement appears to be key to affecting the behaviour of individual GPs. Other findings relevant to CCGs in England should be interpreted with caution by other countries with an awareness of the similarities and differences between their health care systems and the English NHS. GPs need to be given sufficient space to innovate. Most of their early changes are likely to be small scale, with a focus on issues closely relevant to general practice. On the other hand, experience in the NHS shows that, over time, GPs do start to engage with wider strategic issues. However, their ability to make these more strategic service changes in England has been limited by the tendency to abolish each scheme after a relatively short time. Lastly, primary and community care are likely to be pinpointed for development, especially with the goal of reducing use of secondary care services. Attempts to change patterns of secondary care will need to be accompanied by resource shifts away from acute hospitals to avoid duplication and realize efficiency savings. Acknowledgements We would like to thank Dr Julia Segar for her comments on an earlier version of this work.
Authors’ note A full list of papers included in the review can be found in Miller R, Peckham S, Checkland K, Coleman A, McDermott
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I, Harrison S, et al. Clinical engagement in primary care–led commissioning: a review of the evidence. London: Prucomm; 2012. The views expressed here are those of the researchers and not the Department of Health.
Conflict of interest The authors declare that there is no conflict of interest.
Funding This research was funded by the Department of Health Policy Research Programme, as part of the work programme of the Policy Research Unit in Commissioning and the Health Care System (www.prucomm.ac.uk).
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