Wednesday, 12 December 2012

The engine behind GP-led commissioning? The private sector | Colin Leys

The engine behind GP-led commissioning? The private sector | Colin Leys: GPs taking on the commissioning role of primary care trusts will be more accountable to private shareholders than the public
The authorisation of the "first wave" of 34 GP-led clinical commissioning groups to replace primary care trusts in April is a good moment to take stock. What kind of health service are CCGs – which are the centrepiece of the controversial Health and Social Care Act 2012 – going to give us?

There will eventually be 211 CCGs to commission healthcare in England instead of 152 primary care trusts (PCTs) that are being abolished. They will spend about £65bn of the NHS's £95bn annual budget. The 34 approved so far have a population of about 10 million people and cover areas including Portsmouth, Cumbria and Islington in north London.
One key difference between CCGs and PCTs is that CCGs are not democratically accountable to us, the voters. PCTs were the local arms of the Department of Health. CCGs are simply England's 40,000 GPs, divided into 211 local groups, who will be answerable only to the NHS commissioning board and the market regulator, Monitor. PCTs were – indirectly – accountable to us. CCGs are not accountable to us at all.
A second difference concerns who will actually do the work. The big advantage claimed for CCGs is that GPs know what patients need.
Announcing the first wave on Tuesday, Sir David Nicholson, chief executive of the commissioning board said: "In future, the vast majority of decisions about how we use the public's money will be made in the community by clinicians who are closest to the needs of the people they look after. They have the knowledge and expertise to lead the improvements in services that we all want to see."
Of course GPs should know what healthcare a patient needs, but what about "use of technology and informatics, including risk stratification and acute invoice validation; population-based health assessment; and analytics capabilities to predict health trends"? These are all set out in guidance from the commissioning board to develop service excellence.
Very few of even the most business-minded GPs can do this work. It will in fact be done for them by organisations collectively known as "commissioning support services", all of which will eventually (from 2016) be private companies, employing roughly two-thirds of the commissioning workforce. So in effect commissioning is being outsourced from PCTs to the private sector.
A revealing glimpse of the new reality is given by the row over gagging clauses. CCGs have been told to ensure that details of commercial contracts don't "leak out", and many draft CCG constitutions have clauses preventing any GP from speaking publicly about any CCG matter without prior approval from the CCG board. Many GPs are outraged. What is left of their independent status? What becomes of their role as patients' advocates? What the proposed gagging rules show is that GPs will be more accountable to the shareholders of the companies they are contracting with than to the public.
Tight funding means CCGs will have to try to get more for less, especially by diverting care from hospitals to cheaper non-hospital facilities that in practice will often be privately operated. Half of a group of CCG leaders polled last month thought they would be doing this. It means more NHS hospitals being forced to close services, or even close altogether. Yet 96% of the same CCG leaders also said they expected to "encourage increased integration of current providers".
This confusion of aims reflects a lack of basic strategic competence on the part of many CCGs that numerous observers have commented on. Even Nicholson has openly worried that the whole exercise could end "in misery and failure".
And the official "priorities" of the first 34 CCGs are far from reassuring. They are often so vague as to be meaningless , such as "supporting communities to help one another", "delivering sustainable services when people need them", and they also vary improbably from one area to another, from children's services prioritised in one area, to services for older people in another, and so on. The result will be 211 local health services of differing scope and quality.
Yet if CCGs are not left free to determine what care we get they could represent as much as £3bn of wasted public funds.
Dr Kailash Chand, the deputy chair of the BMA, fears CCGs will end up "relegated to the role of debt managers, with the dumbed-down function of following central imperatives" while the NHS is fragmented and privatised. The Guardian

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