My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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Suggestions from the USA’s equivalent family doctor commissioners

Filed Under (GP Commissioning, Health and Social Care Bill, Reform of the NHS, US opinion) by Paul on 29-06-2011

There was a time during the last few months when those who were defending the NHS status quo turned the US into a pariah. I heard very sensible people say in public meetings “I won’t take any lessons from the USA about health care because their system is so bad’. This became a sort of “know nothing” rejection of an entire nation – and all of its knowledge. NOTHING from the USA was any good because their overall system was so bad.

Quite a few years ago I had similar feelings about the US because of the Vietnam War. I felt that the whole nation was irredeemably wrong and could find nothing of any use in the whole country. My Dad shared my politics but felt that the dismissal of an entire civilisation because of one, admittedly very large, experience was wrong. He used to have some very brief arguments with me.

His first line was always, “If nothing good had ever come out of the US we would have had a very tough time on the Normandy beaches in 1944”. Given how much more recent World War 2 was in the 1960s this was a pretty relevant argument.

But if I spluttered on in my condemnation of the entire nation he would point to his own, my brother’s and my own record collections and just say the word “jazz”. This always clinched the argument because a nation that had synthesised music into the creation of jazz simply could not be all bad. (Although it didn’t change my mind about the war in Vietnam).

Well for most people in the NHS the US health care system is pretty crazy as a non-system. How can you spend twice as much, as a proportion of GDP, than the NHS and get worse life expectancy outcomes? And yet… in a way similar to my father’s whispered words about jazz comes a phrase that confounds the view of US health provision as universally bad – integrated care.

It’s true that I can get as excited about integrated care as I can about jazz, but in the last few months the phrase has had the same impact upon the debate as jazz had on my rejection of the US. The government has been a late convert to integrated care as a rationale for improving NHS care. The reform of its reforms has liberally sprinkled the duty to create integrated care around the NHS.

I have posted a couple of times previously on both the importance and difficulty of creating integrated care within the NHS and in the last month another lesson has emerged from the US. In fact, since the Government launched its White Paper last July, the King’s Fund and the Nuffield Trust have invited a number of interesting US speakers over to talk about a wide range of experiences.

This month the Nuffield Trust consolidated some of these lessons by publishing a pamphlet by Lawrence P Casalino called “GP Commissioning in the NHS in England; 1- suggestions from the United States” (Nuffield Trust June 2011, Viewpoint Issue 1)

The rest of this post examines the 10 suggestions in the pamphlet and if you find this interesting it’s worth downloading the entire pamphlet.

Suggestion 1 is a reflection of my point above. It suggests that GP Commissioning Consortia should seek to learn from Independent Practice Associations in the US (IPAs) rather than just from integrated care organisations. This is a good point. IPAs are networks of independent physicians that come together and hold a budget for an insurance company. Nothing is exactly the same in health from one nation to another, but the fact that clinical commissioning groups of GPs are going to hold a budget for the state makes them much more like IPAs than say Kaiser Permanente.

Suggestion 2 underlines a lesson that many consortia are learning the hard way. To succeed they will have to invest heavily in leadership management and infrastructure. The great majority of IPAs in the USA have failed. Their failure has disrupted care and cost money. The lessons from those failures are that where IPAs were closely structured organisations that lacked strong physician leadership they had insufficient organisational resilience to survive. Many GPs might view investing in leadership as wasting money, but they would be wrong. (As of course will the Government be if they continue their fatwa on spending resources on managers).

The third suggestion is to provide resources for training GP leaders. Whilst in general the NHS has sort of ‘got this’ (My own Practice Makes Perfect published by Demos in September 2010 underlined my own appreciation of the necessity for development) but here we are given the outcome of experience which suggests that a consortium with 100,000 patients will need at least two physicians who spend ‘the great majority of their time’ leading the consortium. I think the phrase “the great majority” against two GPs puts this at the high end of the leadership resource that exist with current GP consortium. They make the point that you cannot outsource leadership in an organisation.

Fourthly they suggest that there must be a mix of incentives. If GP commissioning is focussed primarily on cost, it will likely generate a backlash from both physicians and patients. This needs to be balanced with quality outcomes and patient experience. Given the importance of productivity in the next few months and years it will be difficult to get this mix right.

Fifthly they argue that getting the financial incentives right to create good commissioning is going to be difficult. If this is going to be any different from PCTs (a big ‘if’ given the current debacle of Government policy) then there needs to be some financial incentive for getting commissioning right. But provide too much of an incentive and the public will feel that money is disappearing from their care to go into GP’s pockets. The government have not won the argument for financial incentives in the NHS. Their failure to do this will leave GPs exposed to local and national attack for ‘making money’ out of good commissioning. Because of this failure I would expect that there will not be strong financial incentives for GPs to make difficult commissioning decisions well.

Sixthly the consequences for poorly performing consortia should be made clear in advance and should be consistently enforced. This is a good idea but flies in the face of the NHS culture – present and the past. The NHS has failed to create and implement a failure regime in any of its organisational structures. Some people do very badly and nothing happens; others do a little badly and the roof falls in on them. At the moment the main system of consequences within the NHS has all the trappings of a feudal court. It is capricious and depends upon how you get on with the feudal baron or baroness for whom you work. The pamphlet is right. Part of the system that accredits GP commissioning organisations must be a clear set of outcomes for bad or not good enough behaviour. Commissioners need to know what both failure and success look like and what happens if you fail or succeed.

Seventhly given the US systems of private and employer insurance, they are alive to the problems of too much risk coming from dealing with too small a number of patients. I know that when I have been working with GPs in small towns or villages, their first question they ask is why they can’t just have the resource allocation for their village. They know everyone and can deal with their health needs more effectively. It only takes a couple of examples of high cost health care coming into their village for them to realise this will not work. The pamphlet suggests that you need 100,000 patients to cover all the possible risks. Since clinical commissioning groups are expected to cover the boundaries of local authorities, it is very unlikely that their numbers will be fewer than that.

Eighthly, whether real or virtual budgets are given it is important that there are clear consequences. GPs come to commissioning as successful business people. They really only want to make real contracts about real goods and services that are exchanged for real money. That means they want the contractual forms and the information that allows them to know what money is being paid out when, and for what services. If they don’t get that detailed information about these interactions then they don’t want to be a part of the process. So I think the pamphlet is right to say the importance of detail is a deal breaker.

Ninthly – and this has been one of the main confusions caused by the Government’s initial reforms – it is important to ensure that specialist physicians co-operate with GP Consortia. Last summer the Government’s emphasis on them alone left GPs under attack by all other doctors – who felt excluded. In the scramble to go backward with NHS reform the Government are now coming up with a daft structural solution to make up for what is a cultural problem. Of course there will be occasions when there are conflicts of interests between commissioners and hospital providers, but mainly there is day by day co-operation. One of the biggest failures of the government was to explain that much of the experience of the private sector combined co-operation with the important experience of competition. As I have said several times in this blog. Kaiser Permanente is an example that is held up as one of good co-operation between different aspects of care. But, as I have pointed out, the only way in which Kaiser gains any business at all is by winning competition against other potential providers. The Government have failed to explain this at all.

The tenth suggestion is about the most counter-intuitive for the NHS, especially given its own experience of ‘top down’ reform. They quite rightly suggest that if all of this works it will take many years for most consortia to become highly competent. Commissioning is not an easy task. After several years some PCTs were getting very good at it. It would be a pity if in several years’ time just as clinical commissioning groups were getting good at it they were to be abolished just as PCTs have been.

No two health care systems are exactly the same. There are no simple transfers of experience from one to the other that fit together like pieces in a jigsaw. But there are, as these have been, framed suggestions for learning.

And they are worth looking at.

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