I professionisti e l'HTA al 4° Congresso SIHTA, Udine 17-19 novembre 2011

1. Commissioning (with focus on GP’s)
and HTA in the English/British NHS
Professor David Colin-Thomé
Independent Health Care Consultant
Visiting Professor School of Health, University of Durham
and Health Policy and Management
Manchester Business School
Former National Clinical Director
for Primary Care, English Department of Health
david@dctconsultingltd.co.uk
www.dctconsultingltd.co.uk

2. Health technology assessment (HTA)
• Any intervention that may be used to promote health, to prevent,
diagnose or treat disease or for rehabilitation or long-term care. This
includes the pharmaceuticals, devices, procedures and
organizational systems used in health care.[4]
• In the UK, HTA broadly focuses on two questions:
• – Clinical effectiveness – how do the health outcomes of the
technology compare with available treatment alternatives?
• – Cost-effectiveness – are these improvements in health outcomes
commensurate with the additional costs of the technology?

3. Key elements of Liberating the
NHS
• Create a patient-centred NHS
• Focus on improving their experience and their health outcomes
• Empower professionals – end top-down control
• Or put another way
• No decisions about me without me - an information revolution
arming patients and clinicians with more transparent data, helping
patients to make more informed choices and hold the NHS to account.
• Outcomes that are amongst the best in the world – a shift to a
future focussed on better outcomes and away from structures and
process.
• Empowering clinicians to deliver results – setting them free to make
decisions for their patients, for example GPs commissioning
services for their local communities.

5. NHS Reform
Shapiro, Colin-Thomé, Mulla. BMJ May 2011
• Although the current English NHS reforms have been
developing over two decades1, their direction has been
remarkably consistent.
• Three basic elements have emerged: the separation of
provision from procurement (to try to reduce the acute sector’s
supply side pressures on demand); the introduction of some
contestability to further reduce complacency among providers;
and the devolution of decision making more closely to the
patient interface to increase clinicians’ personal involvement
in these decisions.
• Naturally, the mechanisms have changed and evolved but the
underlying principles have weathered changes in government,
health secretaries, and financial circumstances. Indeed similar
principles have underpinned health service reform
internationally.

6. What is commissioning?
• Determining the health needs of a population
• Deciding how to align resources to meet those
needs in a cost-effective way and within a
budget
• Challenging providers in order to lever change
• Monitoring the quality of services to ensure that
contract standards are fulfilled
• It has a proactive and strategic intent
• It takes place at different levels and scales
depending on the service, availability of skills,
etc.

7. Commissioning in the international
context
• Arguably, what the English call ‘commissioning’, is strategic
purchasing within other health systems (e.g. Netherlands,
Germany, USA)
• Or ‘planning and funding’ in those systems that have abandoned
an internal market and seek a more integrated approach (e.g.
New Zealand, Scotland)
• What is common is the desire to lever change in the provision of
services, in order to align funding and needs
• What is distinctive is the attempt to separate commissioning
from provision
• And what to devolve from the centre (Italy 1992) and yet
common package of benefits 1994 National Health Plan

8. Continuum of commissioning

9. Problems of Commissioners in England
• Knowledge, expertise and power tend to lie with
providers who have few incentives to reduce use of their
services
• Tends to be weak, especially in stemming avoidable
demand and costs
‘Purchasing health services is inherently difficult in publicly financed health
systems.’ (Mays and Hand, 2000)
• There are usually political constraints on service
changes
‘The incentives were too weak and the constraints were too strong.’ (Le
Grand et al 1998)
• Commissioning has low profile and legitimacy in the eyes
of the public (compared with hospitals)

10. Core features of UK primary medical care
• - have been constant since the National Health Service (NHS) was created
in 1948. There is universal registration with a single practice of the patient’s
choice, and all primary medical care is provided by General Practitioners
Primary and specialist care is almost entirely free at the point of delivery,
funded nationally from general taxation
•
. There is a strict divide between primary and specialist care, with specialists working largely in
hospitals where they provide inpatient care for all and see new and follow up patients in clinics.
GPs act as gatekeepers to specialists with some small exceptions including emergency room and
sexual health service attendance. GPs work in practices which they usually own, in partnerships
of four to six physicians on average. These practices derive the great majority of their income
from contracts to provide NHS patient care. Under these contracts, approximately 75% of practice
income comes from capitation, 20% from pay-for-performance under the Quality and Outcomes
Framework (QOF) and 5% from Enhanced Services’ contracts for more specialist care (for
example, services for substance misusers). From the income they receive, they employ staff in
any configuration they wish, with GPs’ take-home pay being the practice profit. Currently, the
average net pay of a GP is slightly more than the average NHS income of a specialist.
•
• There are outpatient prescription charges of £7.20 per item in England, £3.00 in Scotland ($11.60,
$4.80), no prescription charges in Wales. Around 90% of items are dispensed to people who are
exempt from prescription charges. There are additional charges for dental care and care from
opticians.

11. It is the unique attributes of the GP system that has
lent itself well to being the central plank of post 1990
English NHS reform.
• GP Fundholding where budgets could be allocated to a GP practice
population and not tied to a specific disease or care group. This
allowed an opportunity for a more imaginative use of the monies to
provide better care for their patients.( Julian Le Grand, Nicholas Mays, and
Jo Mulligan (1998) (eds) Learning from the Internal Market: a Review of the
Evidence. London, Kings Fund).
• The Quality and Outcomes Framework (QOF) which is the largest
pay for performance system for clinicians world-wide and can only
be successfully delivered to a defined population.
• And in 2013 the Clinical Commissioning Groups that will replace the
current Primary Care Trust managerially led commissioners. The
consortia will receive their monies based on aggregated practice list
based allocations.
•

12. 1990-1997 – NHS purchasers under the
•
Conservative Government
• When the NHS market was established by the Conservative Government’s
‘Working for Patients’ reforms in 1990, the main purchasers were (a) health
authorities whose role was to focus mainly on this planning and purchasing
role (i.e. they did not also manage the provision of services such as
hospitals, as they had done until 1990) and (b) GP fundholders. GP
fundholders were family doctors who elected to take on a budget for buying
a limited range of health services (e.g. outpatient visits and some common
operations) on behalf of the patients registered with their general practice.
•
• About 50% of GPs became GP fundholders, over the seven years of
operation of the scheme. In parallel, many GPs formed different
organisations from which they sought to influence the way in which NHS
services were planned and purchased. Such arrangements included:
locality or GP commissioning groups (typically constituted as sub-
committees of health authorities); GP multifunds (organisations formed from
collectives of GP fundholders); and total purchasing projects (a national set
of pilot schemes where groups of GP practices were allocated a total health
purchasing budget for their local population. Total purchasing projects were
subject to a national evaluation study which reported in 1999.

13. The potential of GP commissioning
• GP fundholding in the 1990s enabled GPs to hold a real budget to
purchase community, outpatient and elective care for their patients.
• Total purchasing pilots (TPP) went further and allowed GPs to hold
a budget for a wider range of elective and emergency services.
Other approaches such as GP and locality commissioning drew
doctors together into consortia to plan and commission new forms of
health care.
• Evaluation of these schemes showed that participating GPs were
able to improve primary care services, make savings through more
efficient prescribing (although such savings turned out to be short-
lived), and develop community-based alternatives to hospital care,
although they were rarely able to shift resources from hospital
budgets to fund these.
• There was also some evidence that some 15 to 20 per cent of those
groups holding real budgets were able to secure shorter waiting
times, achieve lower referral rates and, in the case of TPP, reduce
emergency bed-days.
• Primary care commissioners were not however able to reshape the
volume and location of hospital services in a significant manner
(Smith and others, 2004).

14. The potential of GP commissioning
• Since 2005, commissioning has been in the hands of both primary
care trusts (PCTs) and GPs in the form of practice-based
commissioning (PBC), the latter entailing practices holding an
indicative budget for some services, delegated from the PCT. NHS
commissioning has been unable to check the expansion of the acute
hospital sector (and in particular foundation trusts), while evidence
of cooperation between specialist and primary care to provide new
models of care outside hospitals remains limited (House of
Commons, 2010; Smith and others, 2010).
• Explanations for this lack of progress with respect to PBC include:
an absence of clear financial incentives due to the indicative nature
of the PBC budget; a lack of other incentives for clinicians to get
involved in PBC; perceptions of poor support from PCTs and
excessive bureaucracy associated with PBC business cases; small
size of PBC groups resulting in weak purchasing clout with hospitals
and lack of critical skills needed for successful commissioning; and
poor data to inform referral and commissioning decisions (The
King’s Fund and NHS Alliance 2009; Curry and others, 2008; Smith
and others, 2010).

15. Quality improvement initiatives (including pay-
for-performance – P4P)
• In 1990, the UK introduced modest P4P in primary care, in the form
of payments for reaching target levels of childhood immunisation
and cervical cytology. This led to increased performance followed by
a slower reduction in socioeconomic inequalities .
• In 1998, the NHS embarked on a widespread programme of quality
improvement under the general heading of ‘clinical governance’ .
This included the development of national clinical guidelines and
National Service Frameworks to guide implementation of
improvement activity, a body to make recommendations on cost
effective treatments in England (NICE, www.nice.nhs.uk), the
introduction of annual appraisal for all NHS doctors, district wide
audits of clinical care with identifiable data being shared with
practices and sometimes with patients, and a range of local financial
incentives schemes for quality improvement. These were associated
with significant improvements in quality of care.
•

16. Quality and Outcomes Framework (QOF)
• In 2004, a new and much more ambitious P4P scheme was introduced in general
practice, with 20-25% of GPs’ income dependent on a complex set of ~75 indicators
relating to clinical care, and 75 relating to practice organisation and patient
experience (the Quality and Outcomes Framework, QOF) .
• Since 2004, new clinical topics have been introduced and payment thresholds
gradually raised. An important feature of QOF is that GPs can exclude patients if they
judge incentivised care would be inappropriate for particular individuals. A scheme to
tie GP payments directly to patient experience survey scores was introduced in 2008
but proved problematical and is being withdrawn from 2011.
• In general, QOF financial incentives have produced some increase in the rate
of quality improvement for major chronic diseases, but against a background
of quality that was already improving quite rapidly. Public reporting of QOF
results is also likely to have contributed to quality improvements alongside
financial incentives, which could probably have been smaller to produce the
same effect. P4P has changed both the organisation of practices and
relationships within them, ,,, in ways which are sometimes unfamiliar and
unwelcome to physicians.
• Potential negative impacts on non-incentivised conditions appear to have been
small and QOF may in some cases have helped reduce emergency hospital
admissions and the introduction of QOF has also been associated with reduced
socioeconomic inequalities in care for some conditions.
•

17. Proposals for NHS commissioning in England from 2013
Clinical commissioning groups
• The NHS White Paper Equity and Excellence: Liberating the NHS published by the Coalition
Government in July 2010 had the reform of NHS commissioning as a core element. It proposed
that all 150 primary care trusts in England (the current statutory local funders and commissioners
of health care) be abolished in April 2012 and that new clinical commissioning consortia
– later changed to clinical commissioning groups (CCGs) comprising of GPs
and other health professionals - put in their place.
•
• These new groups are to take full responsibility for both the clinical and
financial outcomes of their referral and commissioning decisions, and become
the local statutory commissioners of NHS care, being responsible for over 60%
of NHS resource and the outcomes associated with its expenditure. The
intention is that these CCGs will bring about stronger clinical engagement in
NHS commissioning, being predicated on the idea that family doctors are well
placed to act as agent of the patient and make sound decisions about the
services that are funded and provided for a local population. It is also hoped
that there will be improved alignment of financial risks and incentives, and
reduced levels of bureaucracy, addressing two of the core criticisms often
levelled at PCTs.
•
• The proposals for CCGs have subsequently been modified during the parliamentary process (it
should be noted that the Health and Social Care Bill is still making its way through parliament and
as such the proposals are as yet to be enacted in legislation) and the plan is now for CCGs to
assume commissioning rights from April 2013. There is to be a process of authorising CCGs as fit
and ready for commissioning, led by a new NHS Commissioning Board.

18. Clinical Commissioning Groups
• every GP practice will have to be a member of a Clinical
Commissioning Group However, our proposed model will mean that
not all GPs have to be actively involved in every aspect of
commissioning.
• - will receive a maximum management allowance
• - will need to include an Accountable Officer.
• - will need sufficient geographic focus
• - have a members of the public, nurse and hospital on their board
• - be managing the combined commissioning budgets of their
member GP practices, and using these resources to improve
healthcare and health outcomes
• - have a duty to promote equalities
• - have a duty of public and patient involvement,
• - envisage that other primary care contractors will be involved in
commissioning services to which they refer patients

19. Clinical Commissioning Groups
Clinical Commissioning Groupswill not be responsible for:
• Commissioning primary medical care
• Commissioning other family health services, such as
primary dental services, community pharmacy and
primary ophthalmic services
• National and regional specialised commissioning
• Health services for those in prison or custody
• Other exclusions from the budget include public health
funds, which will be ring fenced and transferred to Local
Authorities.

20. Draft of CCG Authorisation from DH
The document outlines six key attributes that the commissioning board will
require CCGs to achieve:
• • A strong clinical and professional focus which brings real added value.
• • Meaningful engagement with patients, carers and their communities.
• • Clear and credible plans which continue to meet the QIPP (Quality,
innovation, productivity and prevention) challenge within financial resources.
• • Proper constitutional and governance arrangements, with the capacity and
capability to deliver all their duties and responsibilities, including financial
control as well as effectively commission all the services for which they are
responsible.
• • Collaborative arrangements for commissioning with other CCGs, local
authorities and the NHS commissioning board as well as the appropriate
external commissioning support.
• • Great leaders who individually and collectively can make a real difference.
CCGs will be required to undertake a risk assessment of their configuration
from October to December 2011. Successful groups will take on a full range of
functions from April 2013