GP fundholding

[StealthPolarBear]

GP practices are set to be handed responsibility for most health services under ministerial plans for a radical shake-up of the NHS in England.

Local trusts and strategic health authorities would be sharply scaled back to make way for their new role.

Health Secretary Andrew Lansley believes GPs are best placed to understand patients' needs and to decide where money should be spent.

from here

What do you think?

anyone have an opinion?
I really don't see how this will work, does anyone have any experience of how it worked in the 90s?

big fat headache is my succinct but not terribly chatty opinion.

I used to work with GP fundholders many years ago. I did start to write a long and boring response, but have wisely deleted it!

Basically, I've seen it worked really well - but there are some significant downsides to it too.

Can't see how it can save money though.

Labour (and the Tories too) already tried this. Most GPs do not want to run health services, nor are they in a good position to do so. Basically this just gives power back to the hospitals, and moves the staff from the PCTs out to GP practices (will probably require a lot more of them too, as there will be no economies of scale). Oh, and GPs will expect to be well paid to do it too, so where any savings will come from is beyond me.

It's just roundabouts again, will be very expensive and stop any useful reform/savings for another few years. More structural change is the last thing needed, but quelle surprise, politicians like to leave their mark. I once was reorganised three times in two years - my CV is full of no longer existent organisations.

Some GP fundholders were excellent, but it was optional, and really only worked for larger practices. It made accounting very complicated, and that was when the way that hospital costs were calculated was relatively simple.

ex
actly, no economies of scale, and how do they commission without knowing their population needs? Who does health needs assessments? Do they do it themselves? Does the HA do it on their behalf?

(Have to admit to an interest - I work for a PCT, but genuinely do not see how this leads to better patient care or saves any money)

yes, good point, how will they have any idea whether they're being charged the right amount? Are they going to wade through PbR guidance and apply it to their records? Or is that going too?

I also work for a PCT and seeing it a bit more close up, I think it's going to be a disaster. Ironic as Lansley said there would be no major reorganisation of the NHS. What's this then?

More worrying are the plans to move hospitals out of the NHS and into not-for-profit companies, which really is backdoor dismantlement (a real word?) of the NHS.

Also why do we think GPs want or know how to design, develop and then procure services? What about screening programmes or the rare but complicated operations, such as some of the specialist cardiac surgeries. It's crazy. Yes stealth, I really can't see GPs getting to grips with the vagaries of HRG4.

Also I read in the Guardian that GPs won't be able to provide any extra services as some do now, as they can't buy from themselves. So things will just shift back to hospitals again. Can't believe I voted Lib Dem and that they're letting this happen, they should be ashamed.

Can anyone on the inside explain this further as I find it very confusing?

What do PCTs and SHAs actually do? What would GPs need to do and would there be time for them to do it or would some have to turn to non clinical only?

PCTs commission care from hospitals and other healthcare providers for the population under their care (usually something in the region of 300,000 plus). They negotiate with the healthcare providers, argue about what has and hasn't been delivered, monitor standards of care (lots and lots of performance numbers). When I was working (a couple of years ago now) they also provided directly all the community health services, like district nursing, childrens therapies etc, but there has been a move to have those as stand alone services, and make PCTs just commission.

For the hospital services there's not much room to maneuver, because the hospitals hold the balance of power, and always have done (perhaps less with some smaller hospitals, but for my inner London PCT the power was very much in the favour of the very large teaching hospitals hands), but for smaller services, there is a lot of figuring out the needs of the population, consultation, finding the best service provider (which might be NHS, private or voluntary sector), negotiating contracts, and then contract monitoring. I seem to recall that we had something in the region of thirty or so contracts, and then some one off arrangements for patients who needed something different. PCTs are also where public health and health promotion sit. Our PCT also worked very closely with social care, so we had lots of joint schemes with the council, and the last reorganisation was to make sure that PCTs and councils shared boundaries to make that easier.

In answer to your second question, GPs already spend a fair bit of time on non clinical work, as the majority run their practices, and of course there is lots of paperwork associated with their work (referrals etc) too. Many will be on various committees and working on initiatives, also there are already GP consortia who are supposed to be involved in commissioning. In our area they were extremely reluctant to do this, as most had been opposed to fundholding, and a lot of resources had been dedicated to try and get them involved (as it was a performance criteria for PCTs to make progress). I'm not sure how you could require GPs to pick up commissioning, as they are independent contractors, so you can't make them do things very easily. Essentially you either have to pay them extra, or try and change the contract, difficult to do as the BMA are probably the most effective union in the UK.

Oh, and SHAs make sure that the PCTs do what they are supposed to do, and coordinate some of the negotiations and systems wide change (for example in London). I suspect that if they are abolished the DoH will simply grow, as historically there has always been flux at this level of the NHS. Health Authorities grow as the DoH shrinks and vice versa. It's all just a form of very stressful musical chairs, with the politicians living in a state of constant surprise that the reforms they thought would make great changes do very little, mainly because as soon as people recover from the last change and get to work again the next one is announced. Evidence from academic studies is that mergers, acquisitions etc generally divert progress for about 18mths (this was from the private sector, so was measured in profits).

Sadly although politicians like to spout off about evidence based practice, they don't like to apply it to their own decisions.

Thanks for posting that...although my head hurts from reading it!

Will be very interested to see the White Paper when it appears.

I read that Landsley's wife is a G.P., wonder if she's influenced this?

Tales of doom and disaster aren't realistic. We have had similar systems in the UK before and the world did not cave in.

Anyway, it seems that it's not going to be a "big bang" revolution - rather the PCTs and SHAs will be phased out.

I believe in pushing down accountability for decision-making to the lowest possible level. Most people don't even know that PCTs exist, let alone SHAs. Whereas everyone knows their GP.

There will be continue to be economies of scale because GPs will form consortia.

We sure have had similar systems before... I've seen 2 rounds of attempts to abolish health authorities and they keep reforming at that higher level. when PCTs first came in they were for about a population of 50,000 - they've already got to 6 times that. The complications of buying more specialist services (e.g. for serious mental health problems) within the internal market aren't fun if you have to do them for the very small numbers of patients that they apply to per practice.

But certainly fundholding worked very well (if expensively) for the patients who belonged to fundholding practices - patients of non-fundholding practices used to have to hope for the Patient's Charter waiting list level of 18 months for non-emergency surgery whereas fundholders would be something like 2 - 6 months.

Who's telling tales of doom and disaster? I'm just saying (and this is not just my opinion, it's well documented) that reorganisations (and it doesn't matter if they are big bang or not - generally that just means you get a deadline of say two years instead of a single fixed date) do not save money.

In fact this proposal isn't particularly radical, it's been the direction of travel for at least four or five years, just not a very successful one because many GPs are resistant. Many want to run their practices with the minimum amount of interference and have no interest in running the NHS. Plus the whole revolving chairs aspects of changes in the health service. It's rare to find a configuration that hasn't been tried at least once before.

The preferential treatment of fundholders patients is what led to the GPs in my area deciding en mass that it wasn't something they wanted to be involved in. Of course you can't have a two tier service if everyone is forced to join in, but then you lose the benefits too. Fundholding was expensive because you had both the management costs at GP level and at the HA (as they were then).

Of course reorganisations can save money. If they didn't then private companies wouldn't bother reorganising either.

Whether this particular change will save money or not is a legitimate question though. I doubt it will save much, but at the same time I don't think it will cost more than the current system. For me it is more about accountability than about cost.

I expect the way the transition will work is that PCTs will become "seed" consortia at the start - but then the GPs will have the freedom to move between consortia, or create new ones, if they feel it will get a better deal for their own patients.

The effect after a few years will probably be to break each PCT into about 4 or 5 consortia, abolish SHAs, and push all essential SHA functions into the central Department of Health.

Entrepreneurial GPs and health managers will take the lead in setting up and running the new consortia. Those GPs who just want a quiet life diagnosing patients will choose a consortium and delegate the decisions to them. The difference being that the GP is accountable to the patient directly for their commissioning decisions.

There is a brilliant blog post by a retired GP on his experience with fundholding

www.retired-doc.com/2009/01/fundholding.html

Actually reorganisations cost the private sector too, you often see the costs being written down in the financial statements. however my point was that in the NHS (which is after all what is relevant here) reorganisations have never been shown to save money. Given that they happen regularly, mostly after elections, but oftentimes in between - once the organisation I was in had finally moved to a new headquarters from the previous two buildings of the predecessor HAs, and on the day we moved in it was announced we were to be abolished. Less than three years later the body that that organisation made way for was replaced again. The result of this is instability, anxiety, recruitment costs, career counseling costs, loss of good staff who move to the private sector because they've had enough, time lost when staff can't focus on their job because they are too worried about their personal futures, time taken from management of the health service because the managers are figuring out how the new organisation will work, who will move where, writing new job descriptions etc etc

and then two or three years later it all goes around again.

As for your opinion, no I doubt it will happen like that. It's much more likely that the consortia will be PCG size or smaller (the organisations that were created before PCTs) and based on the existing GP consortia. PCTs are all much too large - they were amalgamated to save costs and increase purchasing power, which no doubt these consortia will be once they have been formed, don't do what the government would like and reorganisation comes around again. All the links with social care will presumably be lost too, which is a huge shame as there were some excellent pieces of work there around children and care for older people.

Well, I defer to your superior knowledge on the mechanism of change - but I really do urge you to read that GP's blog post. It is very illuminating to see how patient care can really improve under good GP-led fundholding.

It goes without saying that reorganisations cost money in the private sector too - but they generally save money long-term. I take your point that "long-term" doesn't exist in the NHS because of the constant political choices. That is entirely valid.

The best way of ensuring that the cost savings are given time to work is for the country to keep voting Tory

Well not really, because historically the Tories have been just as happy to reorganise as Labour. I think that politicians just get very frustrated when the change they want to bring about doesn't happen (the NHS being such a big beast change takes years not months) so they turn to the latest guru who tells them that if only the structure was different whatever they wanted to fix would get fixed.

My experiences of working in the NHS under the Tories was not very good though, as they pushed competition so hard that they forgot that co-operation was often more in the interests of patients. For all the crap that Labour threw at us, at least I could talk to my counterparts across the NHS, share experiences, borrow techniques etc. At the height of competition is king sharing learning was frowned upon in case there was some possibility that your thoughts were marketable.

I've no doubt that fundholding brought about some very real gains in some areas, I've certainly heard some very good stories. But they were very localised, and some of the gains for fundholder's patients came at significant loss to other patients. Good blog by the way, and he is totally right about the effect of block contracts, but they have gone now, replaced with Payment by Results (which has it's own issues). In fact probably that's been replaced by something else by now too.

"There will be continue to be economies of scale because GPs will form consortia"

yes, back to 'mini PCTs" then
Who will assess the population's health needs?

Who will commission public health and health promotion?

thanks everyone BTW, was thinking I had posted a thread that had bored everyone

I think looking to save money through reorganisation is a red herring. The long-term issue is quality of healthcare as evidence shows (mainly from the US) that the more you improve the quality, the more money you save. This is logical if you think that lowering someone's blood pressure means they are less likely to have a stroke and spend months in rehab.

longfingernails where I disagree with you is that by pushing commissioning to GPs (many, many of whom really don't want it), you are likely to get good care for the specialities they are interested in.

I work with a local GP who has a special interest in diabetes. Great for the diabetics on his list, but not so good if you have mental health problems or rheumatism. The quality of care you receive for your condition will vary massively.

The free market argument is that people will choose GPs who specialise in their health conditions. But this is impractical (could live on the other side of the city) and how would you know?

In answer to an earlier questions, Mrs Lansley is undoubtably influencing health policy. But she certainly does not represent GPs as a whole, nor the rest of the healthcare system.

has anyone read the white paper then?

Mystic Meg here.... I foresee swathes of redundancies at the PCTs and SHAs only for the managers to be re-hired by GP consortia as management consultants to run them, thereby handing over management of the NHS to the private sector by stealth. Discuss!!!