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GP commissioning: insights from medical groups in the United StatesThe US groups had considerable scope to ‘make orbuy’ a range of services, for example urgent carecentres or skilled nursing facilities, that in turnensured lower rates of hospital admission and shorterlengths of stay. GP consortia will need similar freedomto invest in alternatives to hospitals, and these mightinclude such facilities. Consortia may, however, needcontractual flexibility to employ new kinds of staff, forexample versions of the ‘hospitalists’ used by theCalifornian groups as a way of carefully managing thecare of medical group patients when in hospital, orspecialist nursing case managers to coordinate the careof people with complex, long-term health and socialcare conditions.It will be important for GP consortia to be clear whichof their service investment decisions need to be subjectto procurement under full competition rules and the‘any willing provider’ policy, whereby any provider whois licensed by the economic regulator will be able tocompete for NHS patients (Department of Health,2010a). The Department of Health has publishedprocurement guidelines that set out the processes forcommissioners wishing to let or terminate contracts:under conditions of full and open competition these aredemanding of both time and resources (Department ofHealth, 2010d). Again, a balance will need to be struckbetween the need for transparency required by acompetitive market and the need to avoid overlybureaucratic processes that could hinder innovationamongst GP consortia.Integration of primary and secondary careTaking action to reduce inappropriate hospital admissionswill depend on close relationships between hospitalspecialists and primary care doctors, for it is arguablydue to the relative separation of these two medicalcommunities within the NHS that commissioners andproviders have struggled to make progress in this area. Oneof the biggest tasks for GP consortia will be to bridge thespecialist–primary care divide in the way American groupshave done.This represents a major challenge because of the structuraldifferences between the US and the NHS. The medicalgroups in our study were able to either employ specialistsdirectly, and therefore able to ensure collaborative workingwith primary care doctors, or contract with them, using theleverage of guaranteed patient referrals and flexibility inpayment mechanisms to incentivise collaboration. Theunity of specialists and hospital trusts in the case of theNHS makes it unlikely that there will be any immediatewidespread adoption of the US model of specialist ormulti-specialty groups of doctors that functionindependently of a hospital and contract with medicalgroups or insurers. It is possible that, over time, consortiawill seek to develop such provider networks that canintegrate, virtually or in reality, and take on a budget andresponsibility for the care of a whole patient populationwith a specific condition.In the meantime, GP consortia will need to workwith specialists, either in integrated networks oremploying them to deliver service, while negotiatingcontracts with hospitals for direct GP access to theadvice and expertise of other specialists. For this tohappen, the potentially adversarial relationshipbetween primary and secondary care fostered by thenational payment system and the mission offoundation trusts (in particular) to generate surpluseswill need to be overcome. Collaboration betweenprimary and secondary is possible but financialincentives need substantial redesign to support it(Ham and Smith, 2010).Performance management of doctorsin the groupAll of the US groups in this study aimed to performancemanage their doctors, both specialists and primary care.For primary care physicians especially, where qualityindicators were more prevalent, peer review of performancedata on productivity and quality was relied upon as avaluable route to improved performance. This reliance onthe natural competitiveness of doctors was sharpenedby the link with income. A consistently strong themefrom the US medical groups was the use of bonusesto motivate and reward doctors for deliveringgood-quality care. In the context of GP commissioning,the question of how incentives should be used has notyet been resolved. The possibility of redirecting savingsfrom efficient care to GP private incomes is controversialand could be unpalatable to the public. It is howeverlikely that there will need to be some sort of incentive forGPs to perform well as commissioners. At a minimum,savings will need to be retained by consortia to ploughback into improving local services.There may also be a lesson from the US medical groupleaders’ extreme caution about incentivising lowerutilisation of specialist care. If GP consortia attempt to linkfinancial incentives directly to rates of referrals intosecondary care or specialist advice at an individual GP16www.nuffieldtrust.org.uk/publications
January 2011level, this could backfire, with patients, GPs and the mediamaking common cause against GP leaders.It is notable that the US medical group leaders were clearthat the financial interests should never interfere withdecisions about what was best for individual patients. Incontaining utilisation, they attempted to appeal primarilyto doctors’ clinical professionalism, emphasising theoverlap between high-quality service provision andthe efficiency of avoiding unnecessary admissions,readmissions or excessive diagnostic tests. GP consortialeaders will also have to make a convincing clinical case totheir rank-and-file GPs for efficiency, based on evidenceabout service quality. Without this, GPs are unlikely tocooperate with a consortium’s wider goal of achievingcost-effective care.Performance-managing the quality of secondary care raisessome further challenges. In contracting with specialists, theUS groups needed good data on quality, price and volumeof cases. The US groups felt they did not always haveadequate data about the clinical quality of specialist care.The NHS may be in a stronger position with respect to itsnational datasets, for example with the gradual expansionof Patient Reported Outcome Measures (PROMs). It will beessential for GP consortia to become adept at analysingdata on outcomes. They will also need to take into accountthe verdict of national quality regulators and be vigilantabout the anecdotal evidence from patients and localcommunities, which often act as sentinel warnings ofserious quality failings.The US groups use what data they have on quality tonegotiate on price. What underpins these negotiationsis the guarantee of a certain volume of patients, whichcould be withdrawn if necessary. In the case of theNHS, it is not clear that GP consortia will be able toexercise any leverage about volume. ‘Preferred’ hospitalproviders would be in direct conflict with the policy ofpatient choice, that theoretically offers patients a moreor less free choice of hospital anywhere in England.There is no apparent appetite at a national policy levelto row back from the current broad offer of patientchoice of any hospital at the point of referral, but it doesappear to constrain the ability of a GP consortium inrespect of contracting for quality services on behalf ofits local patients.Management and ITThe experience of the US groups underlines theimportance of investment in high-calibre managers,analysts and IT systems. GP consortia will need to bewilling to follow the same path, although it is not clearwhether the ‘management allowance’ currently beingcalculated for GP consortia will be adequate to supportthe full management functions of consortia. In relation toIT and data, the NHS is potentially in a stronger positionthan the US, which has been traditionally weak on theuse of electronic medical records, particularly in primarycare. The introduction of a national system of prices(Payment by Results) and a strong focus on solid financialmanagement, following the deficits of the mid-2000s, hasmeant that many PCTs have more timely informationabout the cost and volume of many services being usedlocally. Some PCTs are now able to link datasets acrossprimary, secondary and social care. These datasets andthe skills to use them need to be transferred to GPconsortia. It will also be important to fill gaps about costand quality of many services not covered by nationalprices, such as chemotherapy and radiotherapy services(National Audit Office, 2010).ConclusionThe experience of these medical groups demonstratesthe challenges and the opportunities associated withimplementing GP commissioning in the English NHS.These successful physician-led medical groups in the UShave shown that holding risk-bearing budgets canmotivate doctors to deliver care that reduces avoidableand repeat admissions to hospital. For equivalentgroups to be established in the NHS, there needs to besubstantial investment in infrastructure, including IT andmanagement support, and sustained attention to thedevelopment of clinical leadership, both of current andfuture generations.When developing GP commissioning in a highlyconstrained financial environment, such investmentwill be hard to make and justify, and the temptationwill be to focus any investment on clinical activityrather than activities or roles that are not obviouslyconnected to ‘front-line’ services. The message fromthe US medical groups is however unequivocal:without a relentless focus on securing and sustaininghigh quality leadership and management of localservices and clinicians, many of these GP consortiacould struggle. This would not only be a failure for theclinicians committing time and energy to GPcommissioning but, more importantly, a lost opportunityfor both clinically-led service improvement and areduction in avoidable hospital admissions.www.nuffieldtrust.org.uk/publications 17
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