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GP commissioning

by Rob Findlay

Whether they want to be or not, GPs are commissioners. Every time they refer a patient, they are committing resources to them.

But not all GPs see themselves as commissioners. After all, isn’t commissioning a complex process of planning, analysing, monitoring, and contract management? PCTs employ whole departments to do that, so why would a GP want to take it on? And if they did, how could they do it well?

There are plenty of compelling reasons why things would be better if GPs (and other practice clinicians) did take a more active role in commissioning. After all, who else could do the job better? On the commissioning side, only they know the patient well enough and have the skill and knowledge to make the right clinical judgement.

When looking for ways to improve GP commissioning, the debate has tended to focus on incentives or, more narrowly, how money can be used to reward GPs for referring within a budget. But there is more to effective commissioning than just meeting a budget (clinical quality immediately springs to mind). And there is more to raising performance than financial reward; the three main factors being ability, motivation, and opportunity (the “AMO model“). So how can we use this broader approach to develop better GP commissioning?

Let’s start with ability, which is built of things like skill, reasoning and perception. We can’t easily improve all of these (improving skill and reasoning is a challenge), but we can improve perception because it depends on the information available to a GP.

A commissioning GP needs easily-accessible information that is up-to-date, accurate, and specific to their own referrals, so that they can monitor their referral spend and keep on top of it. In the past an information analyst would have been needed to crunch the numbers, but new web-based systems (like Mede) can now deliver digestible information and alerts from the SUS datasets directly to GPs.

GP commissioners also benefit from support from a real human, and this is where PCTs can provide a bank manager service: challenging overspends, spotting unusual activity on the account, and advising alternative courses of action.

Next: opportunity. To what extent do GPs have the clinical discretion to change referral patterns and adapt to budgetary constraints? The answer has got to be “some discretion”, at least, simply because clinical need is a grey area in which human judgements must be made. Beyond that, we are into the practicalities: are alternative pathways available?

Obviously an available pathway must physically exist as a service. Not only that, but GPs need to be able to refer to it, so there must be a contract in place with the PCT. Also, it is only worth using an alternative pathway if it provides suitable clinical quality (so GPs need the assurance of good clinical governance processes) at a lower cost (so the price needs to be directly comparable with the on-tariff alternative). PCTs can help here by providing pathway management support to make GPs aware of the alternative pathways available and help them weigh their merits.

Finally let’s look at motivation. Certainly money into the GP’s or practice’s bank account is going to motivate, and this can be formulated in more ways than the Fundholding approach of simply allowing practices to “keep the change” if they come in under budget. For instance, one or more budgetary ceilings can be set, and practices awarded a modest percentage of the underspend against each ceiling. Non-financial forms of encouragement include status (a consortium leadership, a new pathway directorship, a thought leader), and simple recognition and praise.

As well as encouraging GP commissioners, the PCT needs to be careful not to discourage them with upsets like frequent rule changes, unfair rewards, or failing to support GPs in disputes with providers.

So we have lots of possibilities for improving GP commissioning: information systems and bank-manager support to improve ability; financial and non-financial rewards to improve motivation; and alternative pathways with attractive contracts and assured quality to improve opportunity.

Would I prescribe any particular combination of all these things? No, because every situation is different, and nobody knows exactly what will work best in each case. It would be much better for PCTs and GPs to invent their own approaches together, trying things out, making mistakes, and constantly improving. Partly because that is a good way to solve a complex problem. But also because the satisfaction of problem solved and a job well done is itself a powerful motivator.

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