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Commissioning (with focus on GP’s) and HTA in the English/British NHS Professor David Colin-Thomé Independent Health Care Consultant Visiting Professor School of Health, University of Durham and Health Policy and Management Manchester Business School Former National Clinical Director for Primary Care, English Department of Health david@dctconsultingltd.co.uk www.dctconsultingltd.co.uk

Health technology assessment (HTA)•  Any intervention that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long-term care. This includes the pharmaceuticals, devices, procedures and organizational systems used in health care.[4]•  In the UK, HTA broadly focuses on two questions:•  – Clinical effectiveness – how do the health outcomes of the technology compare with available treatment alternatives?•  – Cost-effectiveness – are these improvements in health outcomes commensurate with the additional costs of the technology?

Key elements of Liberating the NHS•  Create a patient-centred NHS•  Focus on improving their experience and their health outcomes•  Empower professionals – end top-down control•  Or put another way•  No decisions about me without me - an information revolution arming patients and clinicians with more transparent data, helping patients to make more informed choices and hold the NHS to account.•  Outcomes that are amongst the best in the world – a shift to a future focussed on better outcomes and away from structures and process.•  Empowering clinicians to deliver results – setting them free to make decisions for their patients, for example GPs commissioning services for their local communities.

NHS Reform Shapiro, Colin-Thomé, Mulla. BMJ May 2011•  Although the current English NHS reforms have been developing over two decades1, their direction has been remarkably consistent.•  Three basic elements have emerged: the separation of provision from procurement (to try to reduce the acute sector’s supply side pressures on demand); the introduction of some contestability to further reduce complacency among providers; and the devolution of decision making more closely to the patient interface to increase clinicians’ personal involvement in these decisions.•  Naturally, the mechanisms have changed and evolved but the underlying principles have weathered changes in government, health secretaries, and financial circumstances. Indeed similar principles have underpinned health service reform internationally.

What is commissioning?•  Determining the health needs of a population•  Deciding how to align resources to meet those needs in a cost-effective way and within a budget•  Challenging providers in order to lever change•  Monitoring the quality of services to ensure that contract standards are fulfilled•  It has a proactive and strategic intent•  It takes place at different levels and scales depending on the service, availability of skills, etc.

Commissioning in the international context•  Arguably, what the English call ‘commissioning’, is strategic purchasing within other health systems (e.g. Netherlands, Germany, USA)•  Or ‘planning and funding’ in those systems that have abandoned an internal market and seek a more integrated approach (e.g. New Zealand, Scotland)•  What is common is the desire to lever change in the provision of services, in order to align funding and needs•  What is distinctive is the attempt to separate commissioning from provision•  And what to devolve from the centre (Italy 1992) and yet common package of benefits 1994 National Health Plan

Continuum of commissioning

Problems of Commissioners in England•  Knowledge, expertise and power tend to lie with providers who have few incentives to reduce use of their services•  Tends to be weak, especially in stemming avoidable demand and costs ‘Purchasing health services is inherently difficult in publicly financed health systems.’ (Mays and Hand, 2000)•  There are usually political constraints on service changes ‘The incentives were too weak and the constraints were too strong.’ (Le Grand et al 1998)•  Commissioning has low profile and legitimacy in the eyes of the public (compared with hospitals)

Core features of UK primary medical care•  - have been constant since the National Health Service (NHS) was created in 1948. There is universal registration with a single practice of the patient’s choice, and all primary medical care is provided by General Practitioners Primary and specialist care is almost entirely free at the point of delivery, funded nationally from general taxation•  . There is a strict divide between primary and specialist care, with specialists working largely in hospitals where they provide inpatient care for all and see new and follow up patients in clinics. GPs act as gatekeepers to specialists with some small exceptions including emergency room and sexual health service attendance. GPs work in practices which they usually own, in partnerships of four to six physicians on average. These practices derive the great majority of their income from contracts to provide NHS patient care. Under these contracts, approximately 75% of practice income comes from capitation, 20% from pay-for-performance under the Quality and Outcomes Framework (QOF) and 5% from Enhanced Services’ contracts for more specialist care (for example, services for substance misusers). From the income they receive, they employ staff in any configuration they wish, with GPs’ take-home pay being the practice profit. Currently, the average net pay of a GP is slightly more than the average NHS income of a specialist.• •  There are outpatient prescription charges of £7.20 per item in England, £3.00 in Scotland ($11.60, $4.80), no prescription charges in Wales. Around 90% of items are dispensed to people who are exempt from prescription charges. There are additional charges for dental care and care from opticians.

It is the unique attributes of the GP system that has lent itself well to being the central plank of post 1990 English NHS reform.•  GP Fundholding where budgets could be allocated to a GP practice population and not tied to a specific disease or care group. This allowed an opportunity for a more imaginative use of the monies to provide better care for their patients.( Julian Le Grand, Nicholas Mays, and Jo Mulligan (1998) (eds) Learning from the Internal Market: a Review of the Evidence. London, Kings Fund).•  The Quality and Outcomes Framework (QOF) which is the largest pay for performance system for clinicians world-wide and can only be successfully delivered to a defined population.•  And in 2013 the Clinical Commissioning Groups that will replace the current Primary Care Trust managerially led commissioners. The consortia will receive their monies based on aggregated practice list based allocations.• 

1990-1997 – NHS purchasers under the•  Conservative Government•  When the NHS market was established by the Conservative Government’s ‘Working for Patients’ reforms in 1990, the main purchasers were (a) health authorities whose role was to focus mainly on this planning and purchasing role (i.e. they did not also manage the provision of services such as hospitals, as they had done until 1990) and (b) GP fundholders. GP fundholders were family doctors who elected to take on a budget for buying a limited range of health services (e.g. outpatient visits and some common operations) on behalf of the patients registered with their general practice.• •  About 50% of GPs became GP fundholders, over the seven years of operation of the scheme. In parallel, many GPs formed different organisations from which they sought to influence the way in which NHS services were planned and purchased. Such arrangements included: locality or GP commissioning groups (typically constituted as sub- committees of health authorities); GP multifunds (organisations formed from collectives of GP fundholders); and total purchasing projects (a national set of pilot schemes where groups of GP practices were allocated a total health purchasing budget for their local population. Total purchasing projects were subject to a national evaluation study which reported in 1999.

The potential of GP commissioning•  GP fundholding in the 1990s enabled GPs to hold a real budget to purchase community, outpatient and elective care for their patients.•  Total purchasing pilots (TPP) went further and allowed GPs to hold a budget for a wider range of elective and emergency services. Other approaches such as GP and locality commissioning drew doctors together into consortia to plan and commission new forms of health care.•  Evaluation of these schemes showed that participating GPs were able to improve primary care services, make savings through more efficient prescribing (although such savings turned out to be short- lived), and develop community-based alternatives to hospital care, although they were rarely able to shift resources from hospital budgets to fund these.•  There was also some evidence that some 15 to 20 per cent of those groups holding real budgets were able to secure shorter waiting times, achieve lower referral rates and, in the case of TPP, reduce emergency bed-days.•  Primary care commissioners were not however able to reshape the volume and location of hospital services in a significant manner (Smith and others, 2004).

The potential of GP commissioning•  Since 2005, commissioning has been in the hands of both primary care trusts (PCTs) and GPs in the form of practice-based commissioning (PBC), the latter entailing practices holding an indicative budget for some services, delegated from the PCT. NHS commissioning has been unable to check the expansion of the acute hospital sector (and in particular foundation trusts), while evidence of cooperation between specialist and primary care to provide new models of care outside hospitals remains limited (House of Commons, 2010; Smith and others, 2010).•  Explanations for this lack of progress with respect to PBC include: an absence of clear financial incentives due to the indicative nature of the PBC budget; a lack of other incentives for clinicians to get involved in PBC; perceptions of poor support from PCTs and excessive bureaucracy associated with PBC business cases; small size of PBC groups resulting in weak purchasing clout with hospitals and lack of critical skills needed for successful commissioning; and poor data to inform referral and commissioning decisions (The King’s Fund and NHS Alliance 2009; Curry and others, 2008; Smith and others, 2010).

Quality improvement initiatives (including pay- for-performance – P4P)•  In 1990, the UK introduced modest P4P in primary care, in the form of payments for reaching target levels of childhood immunisation and cervical cytology. This led to increased performance followed by a slower reduction in socioeconomic inequalities .•  In 1998, the NHS embarked on a widespread programme of quality improvement under the general heading of ‘clinical governance’ . This included the development of national clinical guidelines and National Service Frameworks to guide implementation of improvement activity, a body to make recommendations on cost effective treatments in England (NICE, www.nice.nhs.uk), the introduction of annual appraisal for all NHS doctors, district wide audits of clinical care with identifiable data being shared with practices and sometimes with patients, and a range of local financial incentives schemes for quality improvement. These were associated with significant improvements in quality of care.• 

Quality and Outcomes Framework (QOF)•  In 2004, a new and much more ambitious P4P scheme was introduced in general practice, with 20-25% of GPs’ income dependent on a complex set of ~75 indicators relating to clinical care, and 75 relating to practice organisation and patient experience (the Quality and Outcomes Framework, QOF) .•  Since 2004, new clinical topics have been introduced and payment thresholds gradually raised. An important feature of QOF is that GPs can exclude patients if they judge incentivised care would be inappropriate for particular individuals. A scheme to tie GP payments directly to patient experience survey scores was introduced in 2008 but proved problematical and is being withdrawn from 2011.•  In general, QOF financial incentives have produced some increase in the rate of quality improvement for major chronic diseases, but against a background of quality that was already improving quite rapidly. Public reporting of QOF results is also likely to have contributed to quality improvements alongside financial incentives, which could probably have been smaller to produce the same effect. P4P has changed both the organisation of practices and relationships within them, ,,, in ways which are sometimes unfamiliar and unwelcome to physicians.•  Potential negative impacts on non-incentivised conditions appear to have been small and QOF may in some cases have helped reduce emergency hospital admissions and the introduction of QOF has also been associated with reduced socioeconomic inequalities in care for some conditions.• 

Proposals for NHS commissioning in England from 2013 Clinical commissioning groups•  The NHS White Paper Equity and Excellence: Liberating the NHS published by the Coalition Government in July 2010 had the reform of NHS commissioning as a core element. It proposed that all 150 primary care trusts in England (the current statutory local funders and commissioners of health care) be abolished in April 2012 and that new clinical commissioning consortia – later changed to clinical commissioning groups (CCGs) comprising of GPs and other health professionals - put in their place.• •  These new groups are to take full responsibility for both the clinical and financial outcomes of their referral and commissioning decisions, and become the local statutory commissioners of NHS care, being responsible for over 60% of NHS resource and the outcomes associated with its expenditure. The intention is that these CCGs will bring about stronger clinical engagement in NHS commissioning, being predicated on the idea that family doctors are well placed to act as agent of the patient and make sound decisions about the services that are funded and provided for a local population. It is also hoped that there will be improved alignment of financial risks and incentives, and reduced levels of bureaucracy, addressing two of the core criticisms often levelled at PCTs.• •  The proposals for CCGs have subsequently been modified during the parliamentary process (it should be noted that the Health and Social Care Bill is still making its way through parliament and as such the proposals are as yet to be enacted in legislation) and the plan is now for CCGs to assume commissioning rights from April 2013. There is to be a process of authorising CCGs as fit and ready for commissioning, led by a new NHS Commissioning Board.

Clinical Commissioning Groups•  every GP practice will have to be a member of a Clinical Commissioning Group However, our proposed model will mean that not all GPs have to be actively involved in every aspect of commissioning.•  - will receive a maximum management allowance•  - will need to include an Accountable Officer.•  - will need sufficient geographic focus•  - have a members of the public, nurse and hospital on their board•  - be managing the combined commissioning budgets of their member GP practices, and using these resources to improve healthcare and health outcomes•  - have a duty to promote equalities•  - have a duty of public and patient involvement,•  - envisage that other primary care contractors will be involved in commissioning services to which they refer patients

Clinical Commissioning GroupsClinical Commissioning Groupswill not be responsible for:•  Commissioning primary medical care•  Commissioning other family health services, such as primary dental services, community pharmacy and primary ophthalmic services•  National and regional specialised commissioning•  Health services for those in prison or custody•  Other exclusions from the budget include public health funds, which will be ring fenced and transferred to Local Authorities.

Draft of CCG Authorisation from DH The document outlines six key attributes that the commissioning board willrequire CCGs to achieve:• • A strong clinical and professional focus which brings real added value.• • Meaningful engagement with patients, carers and their communities.• • Clear and credible plans which continue to meet the QIPP (Quality,innovation, productivity and prevention) challenge within financial resources.• • Proper constitutional and governance arrangements, with the capacity andcapability to deliver all their duties and responsibilities, including financialcontrol as well as effectively commission all the services for which they areresponsible.• • Collaborative arrangements for commissioning with other CCGs, localauthorities and the NHS commissioning board as well as the appropriateexternal commissioning support.• • Great leaders who individually and collectively can make a real difference. CCGs will be required to undertake a risk assessment of their configurationfrom October to December 2011. Successful groups will take on a full range offunctions from April 2013

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