How do you see clinically-led commissioning reshaping secondary care working practices and patterns in the coming years?
TH: “I would not choose to use commissioning to reshape services but would like to see clinicians and patients work on this in partnership with managers and politicians who are ultimately accountable.
“There is little evidence that the fragmentation of the health service, the purchaser provider split, has of itself delivered significant efficiencies or greater patient focus over the last 20 years.
“To improve working practices and patterns I would favour focusing directly on patients’ needs and organise services around them rather than a multitude of competing purchasers and providers, each with their own need to survive. That would remove the distinction between primary and secondary care which continues to act as an artificial barrier to change.
“Some patients will want more ‘online’ healthcare with little face-to-face interaction; others integrated community care with seamless transition to and from their homes to community outpatient services and community beds. Some will need ambulatory care and a few, acute, high-tech medicine.
“Each group’s needs may demand differing working practices and patterns of care delivery if costs are to be minimized yet service standards maintained. Clinically-led commissioning is unlikely of itself to reshape services in this way.“
How would you characterise the overall level of trust between primary and secondary care clinicians?
TH: “As long as the decisions made by GP commissioners are open to public scrutiny and the commissioners remain directly accountability, the usually warm relationships between GPs and their hospital colleagues are likely to endure as they have through other managerial challenges, for instance that of pooled waiting lists that have discouraged named consultant referrals.”
Do you think GPs are ready to be explicit rationers of care?
TH: “Rationing of care is key to GPs’ gatekeeper function. Hospital doctors provide the next ‘line of defence’. In recent years, NICE guidance and PCTs have acted as the trump cards in denying patients more expensive, less effective treatments.
“GPs as commissioners will still maintain their gatekeeping role and clinical skills. Hospital doctors will continue to exercise their role judiciously taking into account their professional obligation to have regard to the affordability of treatments. NICE and its guidance will remain too.
“So to ask GPs to become commissioners of itself will have little direct effect on the rationing of scarce NHS resources.”
Do primary and secondary care clinicians trust one another's data?
TH: “Clinicians trust clinical data for which they have been responsible and over which they have some control. As more clinical data is entered by clinicians ‘at the bedside’, as it has been by GPs in their surgeries for many years, clinicians’ confidence in the data generated by each other is likely to rise.”
What data or information technology needs have to be met for commissioning to stand a chance of successfully driving healthcare reform and value for money?
TH: “Accurate data, entered and owned by clinicians is a key success factor. We need to have robust, transparent ways of adjusting for case mix and patient co morbidities.
“Clinicians and patients need to have confidence in the clinical quality outcome metrics on which any reforms are based, too.”
What lessons can be learned from the lack of impact of PCT commissioning?
TH: “In a public health system, funded by taxation and free and the point of use, there is an implicit compact between the Government and the population. It defines in broad terms the services that are to be provided and the minimum standards, whether of professional competence or delivery, that go with them.
“Decisions about which new drugs and technologies can be funded also need to be made centrally, ideally with the input of elected and accountable representatives to avoid a ‘postcode lottery’.
“Moreover, most hospitals that provide medical services have nurtured their relationships with the communities they serve. So the freedoms to commission locally and commission creatively, are in reality rather limited.
“To expect that GPs who have trained to deliver medical care rather than commission it will commission more efficiently or effectively than PCTs may well be unrealistic.”
Do secondary care clinicians broadly accept the need for reconfiguration of services, or will every local unit faced with closure be a special case?
TH: “Hospital doctors have long been enthusiastic about improving services for patients. For instance, as the evidence of benefit of primary angioplasty for myocardial infarct became clear, cardiologists in smaller units were willing to lose patients to larger centres that could provide a 24/7 service.
“Similar change are taking place in the management of acute stroke. Geriatricians are working together across sites to find innovative, safe ways to deliver thrombolysis within three hours.
“But to do so does not mean that smaller units have to close. Rather they need to refocused their efforts.
“Hospital doctors have a history of supporting change which benefits patients.”
Is the medical-political will there to close services and possibly even whole buildings?
TH: “Healthcare would be remarkable, dare I say unique, were the way it is delivered, and what is delivered, not to change over time as the population need changes, knowledge about how best to treat patients evolves and the society in which care is delivered develops too.”