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The Maynard Doctrine: How to reinvigorate practice-based commissioning? A tall order. |
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Professor of Health Economics at the University of York |
Alan Maynard |
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Plans are apparently afoot to “reinvigorate practice-based commissioning” (PBC). Such plans raise the question of whether any developments will resolve the ambiguity between PBC and PCT roles in ‘world-class commissioning’. Process drivers of change One key change affecting commissioning is the attempt in restructuring payment by results to develop best practice tariffs – in other words, enabling commissioners to tell providers, ‘we will pay you if you do what we demand as best practice, and those prices may be higher or lower than the national tariff accordingly’. So if a provider’s length of stay is higher than a best-practice average, their commissioner would pay them less. Equally, if their length of stay is better than average, the commissioner could pay them more. But will such incentive structures become national, or will they just be up to the local discretion of PCTs? This is being debated. This idea should not be confused with Lord Darzi’s proposed quality bonus scheme, as it is effectively paying for compliance with known best practice – such as operating for fractured neck of femur within 24 hours and having satisfactory rehabilitation and appropriately short length of stay in hospital. These are process measures – important, but incomplete without knowing about healthcare outcomes. Commissioners and providers should be using patient-reported outcome measures (PROMs) as well. Rewarding quality on measures that focus only on processes is eerily similar to the revised 2004 GP contract. Can we peer through the policy mist and see the DH putting PROMs on the end of the process measures? There is little health gain if the treatment of a patient with fractured neck of femur ticks every process box, but leaves them hobbling around in pain and with restricted mobility after three months. Putting PROMs into PBC? Should the decisions of practice-based commissioners be the real focus of PROMs? If we are serious about clinical engagement in commissioning, and given that GPs are the major resource committers, surely the way to achieve real change with PBC would be to put PROMs into the quality and outcomes framework (QOF) of the GP contract. If the PBC consortia and clusters put PROMs at the centre of their commissioning strategy, then commissioning could acquire some real traction. So far, the focus has been on tariff incentives to shift care out of hospitals. This has had limited success. Without care pathways that link up primary and secondary care in all the obvious major disease groups - COPD, stroke, hypertension, heart failure, cancer, and diabetes – commissioning will not make progress. We want pathways that identify and manage these conditions in primary care, and with quick, evidence-based and straightforward routes into secondary care if necessary. The integrated care organisation pilots promised in Darzi should be a means of offering this kind of integrated care pathways. Legislation prevents hospitals from integrating vertically into primary care (though FTs’ planned polyclinics seem to flirt with ignoring this …). Will ICOs make a difference? Only time and evaluation can answer this important question. |
