Clinical Commissioning Groups and the NHS

As we race forwards into clinical commissioning, it is worth looking at other people’s experience.

The book The Innovator's Prescription: A Disruptive Solution for Health Care (Clayton M Christensen, Jerome H Grossman, Jason Hwang) dissects health systems in USA, using examples to show what has gone wrong, and what could be put right.  A lot of what they describe is highly relevant to NHS in this new era.

The big idea is that in order to contain the costs of healthcare, we need to diagnose proactively and keep people well; so they can continue to contribute to society and the wealth of the nation, and also so they don’t start running up big bills for expensive healthcare.

In USA, this is left to the vagarities of the system.  Large employers recognise the value of getting employees back to health and production, but until President Barak Obama came along with his reforms to healthcare, the general model was payment for activity (ie Payment by Results - PbR): 66% of personal bankruptcies were for paying health care bills; over 75% of people didn’t take prescription medicine because they couldn’t afford it; over $1 in every $6 of GDP was being paid to healthcare insurance companies, and only 60% of the money paid to the insurers was finding its way to the healthcare provider.  Compare that to our NHS, where only around 8% of NHS budget goes on all of Department of Health, the tiers of SHA and ALB management, and the commissioning arm of the PCT, where health spend is about £1 in £12 of GDP, and most people benefit from healthcare.

In UK we have a whole institution of people “paid to keep people well”:  General Practitioners, GPs.  It is so successful that the  2006 book Redefining Health Care: Creating Value-based Competition on Results (Tiesberg & Porter) pleaded with US policy makers to adopt the UK model – unfortunately at the time, UK NHS was trying to copy anything American.

A GP practice (typically owned in partnership by GPs) receive a fixed payment per registered patient.  There are some variations depending on the level of sickness and some demographic factors, but that’s fundamentally it.  Under the new Clinical Commissioning Group scheme, GPs will also have some responsibility for the rest of the costs of healthcare for their registered patients, the money that is spent on planned hospital care, maternity, mental health, emergency and unscheduled care and so on.  So the GP practice gets the money whether the person is well and never darkens their door, or the person is ill and spends half their time at the GP practice and the other half in hospital.  And the hospital in effect bills the GP for everything the hospital does to get the patient better, to relieve pain, or just to do stuff.

The GP looks after patients from cradle to grave – actually longer than this, from pre-natal and family planning, right through to post-bereavement counselling.  Some GPs (I can think of one I work with regularly) have practiced as GPs for longer than some of their patients lived, and care for 5 generations of the same family.  They have a big incentive to keep patients well – not just because their professional pride and human compassion says they should, but because it is cheaper and leaves them with more money left over after all the bills.

But GPs took up GP-ing to look after patients.  They don’t like turning patients into numbers in a spreadsheet, whether by pigeonholing them as “this group are the people with diabetes” or by putting a price tag on people’s care. 

So that’s where we need to make an effort to engage GPs and primary and community care clinicians in the commissioning process – to engage them with the CCG.