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GP commissioning: insights from medical groups in the United Statesmedical group. Medical groups also aim to cultivate adistinctive ‘mission’ which is also used to attractlike-minded doctors to the group. This diversity allowsdoctors to choose the group that suits them best, andmany doctors move from one to another over time aspriorities change. For example, the organised processesand predictable hours of the larger groups were consideredto be attractive to the growing number of younger doctors(men as well as women) looking to balance family andwork commitments.In the NHS, when GP consortia have matured, they maywell be able to provide a similar variety of culture andwork environments to draw in a committed workforcewell matched to each consortium. In the short run,however, the mandatory nature of GP consortia is likelyto bring together disparate groups of GPs in someareas, which will create a particular challenge for theirleaders, who will need sophisticated managementskills to build a robust and healthy corporate culturefor the consortium.Strength and longevity of leadershipA striking message from the Californian medicalgroups is that their leadership has often been in placefor many years and, as such, has extensiveorganisational memory, and significant support andrespect among group members and the wider healthcare community.The need to grow a cadre of medical leaders to makeGP commissioning a success has been recognisedby the Coalition Government and resources will haveto be committed to this in the short and long term.The experience of the leaders in our Californian casestudies suggests that the skills needed to make thissort of organisation a success extend considerablybeyond the usual range of clinical skills. Theseinclude: negotiation; communication and publicrelations; finance and accounting; risk management;clinical performance assessment and development;and organisational development. Above all thereis a requirement to understand when to hireprofessional help in specialised areas, as opposedto developing expertise within the group membersand support team.Building longevity of leadership for GP consortia impliestolerance of variable performance in the short run asindividual clinicians grow into their new roles. Whilstmany consortium leaders will come from the body of GPswho already have experience of practice-basedcommissioning and other managerial roles, some willbe new to GP commissioning, and will find those rolesto be more extensive and challenging that anythingthat has gone before. Tolerance of emerging GP leaderswill, however, need to be balanced with the need foraccountability for significant levels of public funds and thecommissioning of high-quality services that can secureimproved health outcomes. This may in turn lead to arequirement for the NHS Commissioning Board to allocatecommissioning risk to consortia on a gradual basis,increasing the responsibility of a consortium as itsleadership proves its competence to handle such risk anddeliver the desired results.Furthermore, the imperative to develop the firstgeneration of GP commissioning consortium leadersshould not obscure the need to develop the next. Allthe organisations in our study felt they could investmore energy in growing the next generation of leaders,so that the potential downsides of long-lived leadership,such as complacency, lack of new ideas, and a closedculture, are avoided.Engagement of doctorsThe Californian groups recognise that seniorleadership needs to be supported by active involvementof other doctors, across the ranks of the group.Attendance and participation in committees and otherleadership roles is encouraged as a core part of adoctor’s role. It is seen as a way of ensuring clinicalengagement with peer review and service development,and at the same time as a means of communicating withfront-line clinicians and building future leaders. Thesecommittee roles are nearly always compensated, ratherthan being at the expense of clinical work. Consortiawill therefore need to engage GPs (and other clinicalstaff) with a range of managerial, analytical and servicedevelopment tasks, and be prepared to reimburseclinicians for time spent away from clinics. It is vital toGPs’ engagement in consortium work that there doesnot appear to be an unreasonable trade-off betweenmanagement and clinical work. Such reimbursementneeds to be seen as integral to the consortium and notas a diversion of funds away from patient care.Management of riskLearning how to manage the financial risk of capitatedbudgets represents one of the biggest challenges forGP commissioners. It is difficult to understand fully the14www.nuffieldtrust.org.uk/publications
January 2011scale of this while the detail of what will be in thecommissioning budget is still to be worked out. Themost recent plans suggest that some low-volume,specialist services, for example high-security psychiatriccare, will be centrally commissioned but that thereshould be some flexibility over time as GP consortiadevelop commissioning expertise (Department ofHealth, 2010e).The experience of our American case study sites suggeststhat the ability to handle risk is not only dependent onsize, but also on the landscape of other providers inthe area relative to the negotiating power of anindividual medical group. For example, it will dependon whether the group has meaningful leverage over theprice of inpatient care at local hospitals. In the case ofthe NHS, it may be important to build in some localflexibility about which commissioning responsibilitiesare undertaken by a consortium, and at what point intime. In the US, groups took several years to learn whichrisks they could handle successfully, and were able tohand back some risks when faced with the impossiblechallenges of matching financial and service pressures.The current proposals for reform in the NHS makeimplementing such a flexible approach to risk appearproblematic. In the US, physician groups could hand backthe responsibility for purchasing a service to the insurers.With the abolition of PCTs, it is not clear what body willexist above the level of GP consortia to handle any residuallocal commissioning, apart from the NHS CommissioningBoard, whose scope will inevitably be large and perhapsinsensitive to local needs.There is an obvious logic to growing the scope ofservice responsibility within commissioning based oncapitated budgets. Covering more patients brings greaternegotiating leverage with hospitals and specialists.Larger numbers also reduce the insurance risk ofunforeseen expensive medical events – the larger thesize of the risk pool, the more easily a budget-holdingmedical group can absorb financial shocks. Experiencefrom the US medical groups suggests that there are,however, unwanted side effects of larger size. Inparticular, there is a risk of remoteness from front-linedoctors which can make leadership of the group moredifficult, particularly if challenging decisions need to betaken. The larger groups in California had attempted toresolve this by creating regional structures within theirgroup, with autonomy delegated to these regions orlocalities, for example for contracting with specialists.This did, however, reinforce the need for very clear,standardised clinical and business processes and systemsacross the group as a whole.Strategies to improve quality and efficiencyThe groups in this study employed numerous strategiesto deliver their business aims, and they were clear thatthe main objective was to achieve high-quality care thatwas lower or equal in cost to the capitated budget.A large part of their early profitability had come frombeing able to reduce unnecessary admissions to hospital,bringing their admission rates for people over 65down to levels considerably below the average for thestate or nation.Although the NHS is unlikely to experience the levelsof over-utilisation of the US, there are obviousopportunities to deliver more efficient care. On theprovider side, the productivity opportunities frommore efficient use of acute hospital beds are substantial.If all acute trusts could improve their performance (ona range of measures including length of stay andpre-operative bed days) to the standard of the top25 per cent, the productive opportunity is equivalentto £4.5 billion (Appleby and others, 2010). However,it is not clear under the current payment mechanismsfor hospital care, whether these opportunities can or willbe translated into savings for GP consortia rather thenacute trusts.More promising for GP consortia are the potential savingsfrom reducing emergency admissions, which have beenrising across the NHS and are not fully explained bydemographic or morbidity trends (Blunt and others, 2010).There are gains to be made from reducing variations inadmissions for chronic conditions, for example largevariations in emergency admissions for chronicobstructive pulmonary disease (COPD) and asthmain both the old and young (Department of Health,2010c). There are also unexplained variations in therates of elective procedures such as cataract surgery orknee replacements, which suggest there is over-utilisationin some areas that could be reduced by adhering toreferral guidelines. Conversely, in other areas,particularly deprived areas, referral rates for electivesurgery might have to increase to meet need(Department of Health, 2010c). Whether these savingscan be realised by the new GP commissioners dependson whether GP consortia can invest in the sort of servicesneeded to avoid or reduce admissions; something thatappears to have largely eluded their predecessor, PCTs(Blunt and others, 2010; Smith and others, 2010).www.nuffieldtrust.org.uk/publications 15
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GP commissioning: insights from medical groups in the United Statesmedical group. Medical groups also aim to cultivate adistinctive ‘mission’ which is also used to attractlike-minded doctors to the group. This diversity allowsdoctors to choose the group that suits them best, andmany doctors move from one to another over time aspriorities change. For example, the organised processesand predictable hours of the larger groups were consideredto be attractive to the growing number of younger doctors(men as well as women) looking to balance family andwork commitments.In the NHS, when GP consortia have matured, they maywell be able to provide a similar variety of culture andwork environments to draw in a committed workforcewell matched to each consortium. In the short run,however, the mandatory nature of GP consortia is likelyto bring together disparate groups of GPs in someareas, which will create a particular challenge for theirleaders, who will need sophisticated managementskills to build a robust and healthy corporate culturefor the consortium.Strength and longevity of leadershipA striking message from the Californian medicalgroups is that their leadership has often been in placefor many years and, as such, has extensiveorganisational memory, and significant support andrespect among group members and the wider healthcare community.<strong>The</strong> need to grow a cadre of medical leaders to makeGP commissioning a success has been recognisedby the Coalition Government and resources will haveto be committed to this in the short and long term.<strong>The</strong> experience of the leaders in our Californian casestudies suggests that the skills needed to make thissort of organisation a success extend considerablybeyond the usual range of clinical skills. <strong>The</strong>seinclude: negotiation; communication and publicrelations; finance and accounting; risk management;clinical performance assessment and development;and organisational development. Above all thereis a requirement to understand when to hireprofessional help in specialised areas, as opposedto developing expertise within the group membersand support team.Building longevity of leadership for GP consortia impliestolerance of variable performance in the short run asindividual clinicians grow into their new roles. Whilstmany consortium leaders will come from the body of GPswho already have experience of practice-basedcommissioning and other managerial roles, some willbe new to GP commissioning, and will find those rolesto be more extensive and challenging that anythingthat has gone before. Tolerance of emerging GP leaderswill, however, need to be balanced with the need foraccountability for significant levels of public funds and thecommissioning of high-quality services that can secureimproved health outcomes. This may in turn lead to arequirement for the NHS Commissioning Board to allocatecommissioning risk to consortia on a gradual basis,increasing the responsibility of a consortium as itsleadership proves its competence to handle such risk anddeliver the desired results.Furthermore, the imperative to develop the firstgeneration of GP commissioning consortium leadersshould not obscure the need to develop the next. Allthe organisations in our study felt they could investmore energy in growing the next generation of leaders,so that the potential downsides of long-lived leadership,such as complacency, lack of new ideas, and a closedculture, are avoided.Engagement of doctors<strong>The</strong> Californian groups recognise that seniorleadership needs to be supported by active involvementof other doctors, across the ranks of the group.Attendance and participation in committees and otherleadership roles is encouraged as a core part of adoctor’s role. It is seen as a way of ensuring clinicalengagement with peer review and service development,and at the same time as a means of communicating withfront-line clinicians and building future leaders. <strong>The</strong>secommittee roles are nearly always compensated, ratherthan being at the expense of clinical work. Consortiawill therefore need to engage GPs (and other clinicalstaff) with a range of managerial, analytical and servicedevelopment tasks, and be prepared to reimburseclinicians for time spent away from clinics. It is vital toGPs’ engagement in consortium work that there doesnot appear to be an unreasonable trade-off betweenmanagement and clinical work. Such reimbursementneeds to be seen as integral to the consortium and notas a diversion of funds away from patient care.Management of riskLearning how to manage the financial risk of capitatedbudgets represents one of the biggest challenges forGP commissioners. It is difficult to understand fully the14www.nuffieldtrust.org.uk/publications
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