Interview: Andrew Donald – a PCT perspective on the coming of clinical commissioning

In the second of Health Policy Insight’s series of interviews in the run-up to the revised Operating Framework publication and the NHS Confederation annual conference, editor Andy Cowper interviews Andrew Donald, the chief operating officer of NHS Birmingham East and North PCT.

HPI: How will an independent commissioning board and GP-driven commissioning consortia change the meaning and practice of NHS commissioning?

AD: “Two things inform this. The first is good news - that commissioning is a central plank of the new policy, so it’s seen as important in the new system for organisations to be planning and contracting for services to drive up quality.

“The specific question about GP-driven commissioning reminds me of when I was a multi-fund chief executive in the 1990s era of GP fundholding. That system (and this new one) asked a philosophical question: who are the individuals who create cost in the NHS? It’s GPs, they write referrals and prescriptions, and it’s their patients using services in planned or unplanned ways.

“So if we can get GPs into commissioning to really manage demand, that can add huge value to the system of demand management. I can commission all the services in world, but I can’t control the decisions of GPs to refer to hospital.

“Our analysis of data on emergency admissions discovered one individual going to hospital 41 times in a year: only a GP can actually intervene with this individual patient to find out what is going wrong with that patients care and make a change to that pattern of care which would then avoid this level of hospital use in the future.”

HPI: Is the data and IT infrastructure available to make this work in the timeframe of one Parliament?

AD: “Yes. I always ask people in my organisation to give me the claims data of Mrs Smith – if I were an insurer, I would know how much an individual is costing the company on an annual basis.

“If we understood the cost of the 20% of people who consume 80% of NHS resource, we could target provision in a much more appropriate way.

“So the question for GPs is, once you’ve got a risk-stratified population, what will you as a GP do differently and commission differently to change the pattern of care for your patients?

“All the data for GPs to commission is available, but we have the classic challenge of getting it into a format that’s easy to understand, and avoiding the ‘paralysis by analysis’ syndrome.

“Another question for the new GP commissioning consortia is about the IT systems they will need to support them commissioning.”

HPI: GPs’ IT is traditionally the bit of NHS IT that’s been quite good …

AD: “Yes, they have the primary care data, and if we can align that with secondary care data, we’ll have enough to change patterns of care.”

HPI: Is the management capacity and capability available to make this work in the timeframe of one Parliament?

AD: “I think we’re into Donald Rumsfeld territory here: ‘known knows and unknown unknowns’ and all that!

“Perhaps the interesting question is not about timescale, but instead ‘what management capacity and capability is required to make this successful?’ And the answer absolutely depends on the size, scope and range of GP commissioning consortia that result.”

HPI: The general view has been that the population will be about 100,000, for ‘expensive patient affordability’ purposes.

AD: “Again, maybe that harks back to total purchasing, which said you needed 50,000-100,000 populations. The important bit is about risk stratifying a population: if this turns into a numbers game, then it misses the point, which is about deciding the best configuration to improve services to a population and drive up quality while reducing cost.

“The danger is that we default to talking about numbers, of population, or commissioning groups. Numbers are easy, once the overall shape is determined (how many regional offices of the independent commissioning board etc …), but it’s also easy to miss the point. We should focus on roles and functions, and then what is the appropriate size of population at which to carry out clinical commissioning. The question is does size matter? the answer it depends on what you are being asked to do.

“There are problems : could you carry out the totality of roles and functions of a commissioner for a population of 10,000 ? Probably not – you could do contacting at that scale, but not the totality of commissioning. The other side of the coin is that If you think about marginal analysis, it suggests that beyond a certain size, the gains of scale become less and less”.

HPI: How will the new system cope with the steady 28% of GPs who consistently tell the DH PBC survey they disagree with the policy?

AD: “Very easily. In the multifund, I had 28 practices: some  wanted to engage with everything; there was another group in the middle, who were interested in some things but not others; and the third group were mainly concerned not to miss out on opportunities. Roughly speaking, it followed the ‘rule of thirds’, as the number you’re stating implies.

“There will be some people and practices in the new commissioning consortia who want to be a part of the consortia I guess but will not, for genuine reason want to really engage in commissioning; there will be others who want to engage in elements where they can make a difference; and there will be the  clinical leaders who absolutely understand about commissioning and what to do from their perspective to make it successful.

“You have to work with that varying desire for involvement in any system.”

HPI: What else is needed to make this work?

AD: “It’s difficult to know without knowing a bit more detail about the what. The revised Operating Framework and coming White Paper should give a bit more clarity, then we can start to fill in the gaps.

“One thing needs to be made clear: we have got much better at using data and benchmarking, which helps drive up performance. We still need to drive out variation in the system, and we need data to help GPs do that.

“Once you see benchmarked data and variations, you start asking different questions, not ‘how many widgets do we get from each hospital’ – but more sophisticated questions, for example  – ‘what services do we need to provide differently to change patterns of care’.”

HPI: Does commissioning need regulation? If so, what kind and by whom?

AD: “There’s got to be some regulation - in any system, you need a set of rules and the ability to authorise and scrutinise the organisations. How you do this in practice needs to be worked through, but you do need a governance framework.”

HPI: Are GPs sufficiently corporate beasts to drive effective commissioning, out variations in clinical practice and close services or even whole hospitals?

AD: “They can be, in the medium to long term, but we’ve got to work at it.

“In the 1990s, at the start, the mulitfund was an amalgamation of practices, many of who didn’t know why they were doing what they were doing in terms of referrals and patterns of care. At the end of the multifund’s five-year life, those practices did not want to be taken apart. The GPs did a lot about to try and drive out variation: contrary to some perceptions, they were actually quite corporate.”

“Whether GPs will be up for reconfiguring services and in particular hospitals is another question.

“There is also the challenge: how to make sure of the service changes needed to drive out variation and save £15-20 billion over the next few years – GP commissioners have to buy into reducing the costs of acute services and delivering efficiency and productivity.

HPI: Is the residual legacy (or specialist) commissioning left to PCTs going to be a sufficiently interesting and worthwhile job to keep good staff in PCTs?

AD: “The simple answer is at this stage, we don’t know. But I would say that commissioning is important in the new system of healthcare.

“Therefore although the NHS will face challenge about cutting 1/3 of management costs, people with good skills and expertise will always be needed, wherever healthcare is commissioned.”