The “Liberative” Government’s health reforms started life with a light and permissive vision of GP commissioning. But now they are mired in confusion. What happened? In short, the new vision collided with the old. Last week the Health Select Committee sided firmly with the old vision, calling for Consortia to be renamed as Commissioning Authorities with formal governance structures and stakeholder representation.

New vision or old, everybody wants commissioning to be done well. But what does commissioning mean, and how should it change?

In the conventional vision, commissioning starts with the carefully-assessed healthcare needs of your local population. Then you compare this against the services actually provided. Inevitably, you find plenty of areas where needs are not being met at all, or where provision could be improved, or where there is over-provision and ineffectiveness. Starting with the biggest mismatches, you work with other stakeholders to design new and better pathways, and then you seek providers to deliver them (or work with existing providers to improve things).

Conventionally, you manage “your” providers through the annual contracting process. You estimate the amount of activity to be done, and then apply the tariff price (if there is one) or negotiate a price (if there isn’t). You manage quality using Key Performance Indicators (KPIs). If quality falls short or activity is at variance with the contract volumes, then you apply the remedies specified in the contract.

So far, so familiar. But this is all office-based activity. What are the chances of it making a real difference to patients?

You hope to reach a position where need and provision roughly match. But your experience shows that anything you measure in healthcare displays huge and unexplained variations; if you do find a match between need and provision, it is only by chance. And if you achieve a match today, then it probably won’t match tomorrow. So trying to match need with provision is going to be highly inexact at best.

0.5% of the population consumed over 20% of acute spend

Patients also show great variety even within a single pathway, and the sickest patients usually have multiple conditions. The harder you try to tailor a pathway to a particular condition, the more you find there are exceptions to the rule. Do these exceptions matter? Yes, because they are your most expensive patients. Data from one PCT shows that a mere 0.5 per cent of the catchment population (about 1,000 people) accounted for over 20 per cent of acute expenditure. So good judgement by GPs trumps good pathway specification when it comes to handling the sheer variety of patients presenting.

What about quality? You hope that quality and performance can be managed with KPIs and contractual sanctions. But “quality” is too rich a concept to be described in even the most comprehensive list of KPIs. The harder you try to specify everything, the more you lock yourself into the status quo. Moreover, anything that isn’t in the KPIs is simply driven out: the effort of monitoring everything else in the contract takes over. So quality needs to managed through dialogue, not specification, and the organised concerns of GPs are a better guide to quality than words in a contract.

Even activity – the crunchiest of numbers – is hard to control in the standard contract. You can try to limit elective activity if the waiting list isn’t rising. You can try to throttle cost by using activity caps and restrictions on “procedures of limited clinical effectiveness”. However, most contractual changes need to be implemented with the agreement of the provider (which may not be forthcoming), and in any case tactics such as banning procedures tend to be blunt and limited instruments that displace or defer the problem rather than solving it.

Finally, awarding contracts only to selected providers (especially if the contracts specify guaranteed volumes) involves saying “no” to other potential providers. The argument is that this helps to control expenditure, but again there is a lot of hoping going on: you hope that, by restricting the availability of providers, you will reduce demand. As Don Giovanni said in a different context:

Wer nur einer getreu ist,
Begeht ein Unrecht an den andern;

If I am faithful to one,
I am unfaithful to all the others;

Mozart

So the old vision of commissioning falls short on a number of counts. How could a new vision improve on it?

In commissioning, as with everything else in healthcare, real life happens in the consulting room not in the office. So better commissioning needs to happen in the consulting room too: if individual GPs manage their referrals and patient pathways well, then quality and budgets will follow. So the Consortium should focus its attention “downwards” to practices, rather than “upwards” to the Commissioning Board or “across” to providers.

That way, the life of a commissioner no longer revolves around the annual contracting round or the enforcement of KPIs. Instead, it revolves around helping GPs manage value, by:

• monitoring and escalating quality concerns raised by GPs;
• providing a “bank manager” function to GPs;
• peer-reviewing GP referral patterns and pooling risk;
• providing back-office, scheduling, and financial services to GPs;
• calling for new and better services, and helping prospective providers with their market research;
• ensuring that GPs are aware of the services and drugs available to them.

This moves decisively away from the adversarial contract-driven approach of the past. But one major step needs to be taken to make it work, a step that is not taken in the Health and Social Care Bill. Consortia need to be able to enforce budgetary limits at practice level, which is something that politicians (understandably) have tended to shy away from.

However, there is nothing to prevent GPs from opting to accept practice-level budgetary limits within their Consortium, or even formalising this rule in their Consortium’s constitution. After all, many GPs are pretty fed up with having their referrals interfered with, and their choice of providers restricted from on high, whenever PCTs are struggling to achieve their statutory duties because they cannot control demand.

So GPs and their Consortia are faced with a choice: genuine freedom to refer within a limited budget that they control; or a continuation of the imposed and inconsistent restrictions that face them now. What will they do? Perhaps the best outcome would be for different Consortia to make different choices. That would truly test the two visions of commissioning.