To what extent could local general practitioners commissioning help increase the effectiveness of NHS at primary care? A meta-ethnographic study in the UK.
Abstract: There have been clear policy themes in the development of primary care in the last two decades. Devolving decision-making power using localised purchasing has developed into commissioning, making health service providers part of a competitive market-based service with a user-driven approach, whilst protecting service standards through bottom-up planning and a vigorous quality system: these are the main tried and tested strategies in health systems reform across the world. More recently the UK coalition government announced in its White Paper (Department of Health (DH), 2010a, 2010b) that local general practitioners (GPs) will be given responsibility for taking these policies on to the next stage with devolved National Health Service (NHS) budgets (80bn [pound sterling]) given to GP consortia whereby GPs would be at the centre of commissioning nearly all healthcare services, with the important aim of producing a major impact on public health and health inequalities. This paper examines the effectiveness of local GP commissioning in improving primary care services in the UK NHS using meta-ethnographic analysis, an interpretative qualitative research approach, and review of the relevant published evidences. The evidence on GP commissioning is positive but limited and its effectiveness cannot be predicted with great certainty largely due to insufficient data on services provision, lack of commissioning skills analysis and the continuous changes in government policies. This paper concludes that local commissioning of health services should best address people's health in the community.
Subject: Physicians (General practice) (Political aspects)
Health care reform (Political aspects)
Coalition governments (Political aspects)
Decision-making (Political aspects)
Public health (Political aspects)
Authors: Regmi, Krishna
Bone, Anthony
McGowan, Fiona
Pub Date: 06/22/2011
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2011 Source Volume: 26 Source Issue: 3
Topic: Event Code: 290 Public affairs
Product: Product Code: 8098000 Medical Management Services; 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 56111 Office Administrative Services; 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Accession Number: 308741519
Full Text: INTRODUCTION

Reform of national health systems are often contentious in both developed and developing countries. To date, several studies (Regmi et al., 2009; Bossert, 1998; 2000; Bossert & Beauvais 2002) have documented different ways and means of delivering primary care at local level, for example, devolving central and regional authorities, developing public-private partnerships and decentralising decision making power and authority through community involvement/participation at local level. Cameroon (2011) strongly argues that:

The UK coalition government's recent White Paper 2010 places GPs at the centre of the commissioning process through the establishment of GP consortia by April 2010 (DH, 2010a, 2010b) where GP consortia will be responsible for commissioning primary care services. In the past, the commissioning authorities and responsibilities were given to the PCTs (DH, 2010c). It has been noted that under these reforms public health responsibilities will be divided between local authorities and the new national public health service (DH, 2010a,b,c). It is claimed that local GP commissioning will bring high-quality and cost-effective care to local communities by 'patient empowerment, local professional judgement and greater provider dynamisms' (Steven, 2010, p.231). Making "... services more directly accountable to patients and communities" is the key aim of the NHS reform (Great Britain. Parliament. House of Common, 2011, p.x). But is that often the case? This paper will attempt to further discuss this question.

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To date, limited evidence exists in and around commissioning and its effects in improving health services and few papers would even attempt to challenge this assertion (Macq et al., 2008). Yet there is no clear-cut policy over the structure and functions, as well as the constitutional arrangement of GP consortia plus the ill-defined role of community and/or service users' involvement in the process of commissioning (Great Britain. Parliament. House of Common, 2011). Therefore the aim of this paper was to describe the extent to which GP commissioning --if any--and in what context, would help increase the effectiveness of the NHS in the delivery of primary care.

COMMISSIONING

In the past six decades, several organisational reforms have been made within the NHS, notably in the area of technological developments and as a result 'people will live longer and can be treated faster' (Rowe, 2009, p.51). The Department of Health (DH, 2008a) committed to world class commissioning where resources will be rationalised to improve quality health standards. UK Government (Great Britain. Parliament, House of Common, 2010a) de fines commissioning as a "... crucial process in the NHS. It ensures that the health and care services provided effectively meet the needs of the population. It is a complex process with responsibilities ranging from assessing population needs, prioritising health outcomes, procuring products and services to managing service providers" (p.3). The commissioning cycle comprised of four key stages-situational analysis, strategy formulation, purchasing and assess/ evaluate of services (See Fig. 1).

The notion of GP commissioning is that "GPs should be involved in all these aspects, not just in the purchasing of care" (Singer, 1997, p.7). DH (2010c) argues that the key purpose of GP commissioning is to offer primary care services:

The coalition government (UK) has proposed radical reforms for a reorganisation of the NHS by GP commissioning and recently published the White Paper (DH, 2010) which sets out the closure of both Primary Care Trusts/Care Trusts (PCTs) (151) and Strategic Health Authorities (SHAs) (10) in England by 2013, after which groups of GP (GP consortiums) will be responsible for commissioning health services in terms of planning care and managing budgets specifically tailored to meeting people's healthcare needs. Maynard (2010) notes that "PCTs will be replaced by GP consortia, membership of which is to be compulsory and each consortium will have budgets to buy healthcare for their patients" (p.304). DH (2010c) states that the role of GP consortia is not to engage in commissioning process but it would rather to play an important role in making quality GP services. In addition, GP consortia will play a role to promote equalities working with patients, practitioners, local communities and local authorities.

The DoH (2006) argues that effective commissioning considers a series of activities and processes to meet the health needs of the people and represent value for money. The notion of a world class commissioning process emerged in 2008 with the aim of improving the quality of people's health by "adding years to life and life to years" (DH, 2008a, p.x). The current White Paper also advocates that "empowerment of doctors and patients to influence the design of clinical services, the commitment to reduce tiers of management with their associated costs, and the greater emphasis on public health" to make the commissioning process more effective and efficient (Lechler, 2010, p.230). A recent report published by six NHS organisations noted that the commissioning process would give GPs more power and greater autonomy. Smith and Throlby (2010) have, however, argued that there are "significant challenges in trying to engage more than an enthusiastic minority of GPs in holding real budgets for commissioning" (p.2). From an international perspective, Ham (2008) advocates that effective commissioning means better healthcare systems which help to identify, assess and analyse public needs to bring change. Others, however, did not agree to such assertion, as in fact they claim that this would cause impact the other way around, i.e. the path is a ploy to "destroy the NHS" (Steven, 2010, p.23; see also Klingenberg et al., 2010). Lechler (2010) further argues that "the most important shift of emphasis is from target inputs to outcomes outputs" [italics added] (p.230). Some public health staff will be relocated within the GP consortia whilst others will suffer redundancies. For the first time in the history of England, GPs will be handling large budgets of 89bn[pound sterling] (80% of the budget) for frontline services, and will also be responsible for providing services such as hospitals, dentists and opticians. During the 1990s fund-holding GP's were primarily concerned about elective treatment over which a decision could be made, and whether to proceed or to wait for treatment (Hunter, 2008). These policy changes were implemented amid a sense of concerned ambition of improved costumer-led health services. Milestones in terms of the reorganised NHS in the light of commissioning has been summarised in Table 1.

It has been argued that "The DoH is relying on GP commissioning to provide the bulk of the 20bn[pound sterling] designated as effective saving" (Lobley, 2010, p.36). Lobley further argues that "only a couple of month ago the coalition [Conservative and Liberal-Democrat] promised to 'stop the top-down reorganisations of the NHS that have got in the way of patients care' by giving local communities greater control over health budgets as well as giving GPs greater incentives to tackle public health problems" (p.36).

Appleby (2010, p.228), however, argued that "although choice, competition, plurality of supply, and devolved decision making were the health policies" of the former Labour regime, it had never been implemented in a systematic manner. Curry et al. (2008) found that access to health services and the performance of GPs has been impacted negatively due to conflicts and 'power play' between PCTs and GPs. The recent report of the Health Committee of the Parliament (House of Commons, Health Committee, 2010b, p.3; DH, 2010a, 2010b; Hunter, 2008; Curry et al., 2008) also highlights some important reasons behind commissioning in the NHS:

1. "Weakness remain 20 years after the introduction of the purchase/provider split;

2. Commissioners continue to be passive, when to do their work efficiently they must insist on quality and challenge the inefficiencies of providers; and

3. Weaknesses are due in the large part to PCTs' lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management. The situation has been made worse by the constant re-organisation and high turnover of staff."

The coalition government advocates that more empowered and more effective commissioning should be the key strategy to minimise these challenges (DH, 2010a). Appleby (2010) argues that "choice was never a reality for most patients and as for PCTs as commissioners--total [and expensive] failures at their jobs" (p.228). As part of the policy implementation, several GPs have been brought together to work under the umbrella of 'GP Consortia' to develop and deliver primary care services tailored to meet the local population health needs. It has been globally documented that involvement of clinicians in the process of commissioning brings better public health outcomes (Hynes, 2010). However Appleby (2010) raises a critical question which still remains unanswered; "whether these reforms are a cost effective way to achieve better health outcomes and more productive use of every NHS pound" (p.228).

Additionally concerns about the management of GPs over a clash of cultures, relations between and within GPs and GP consortia, and particularly foundation hospitals--a lack of cooperation, an unmanageable agenda and political isolation--have been raised (Curry et al., 2008). To document the effect on service effectiveness, this paper aims to examine to what extent could GP commissioning help increase the effectiveness of the NHS at primary care, drawing on experiences from the UK and other similar geo-political countries, by utilising qualitative meta-analysis.

METHODS

Meta-ethnography has been adopted in this study as it has been argued that a meta-ethnographic approach has been considered as one of the most well developed methods of qualitative study (Taylor et al., 2008). In a wider context, all data are qualitative in nature as they often refer to essences of people, objects and situations based on "watching, asking, or examining" (Berg, 1989; Wolcott, 1992, see also Miles and Huberman, 1994). Meta-ethnography, according to Paterson et al. (2001) is an interpretative qualitative approach "involving analysis of theory, methods and findings of qualitative research and the synthesis of these insights into new ways of thinking about the phenomenon" (p.1). It is about the "interpretative explanation, comparative textual analysis and practising the synthesising of multiple [qualitative] field studies" (Noblit & Hare, 1988, p.9; see also Dixon-Woods et al., 2004). Glass et al. (1981), Evans (2002) and Hunter et al. (1982) take the view that this approach is itself considered as qualitative meta-analysis, that is analysis of multiple relevant qualitative studies to improve the robustness and transferability of the studies. Atkins et al. (2008, see also Vermeire et al., 2007; Jensen and Allen 1996) contend that such an approach helps to "provide an account of a particular community or phenomena through thick description of behaviours and practices, and to contribute to theoretical understanding of these social phenomenon" (p.9).

Several authors (Denzin, 1989; Guba & Lincoln; 1994; Weinstein & Weinstein, 1992; Silverman, 2010; Atkins et al., 2008) argue that the philosophical discourses of meta-ethnography is rooted in the social constructivist model with the aim of understanding people's views and constructing particular knowledge about a phenomenon. Both Zhao (1991; 1996) and Noblit and Hare (1988) argue that meta-ethnography is an appropriate method when research attempts to analyse the current understanding of emerging themes within an evolved context for consideration in future research from different distinct perspectives. According to Stern and Harris's (1985), this approach is called qualitative meta-analysis to synthesise qualitative studies (reductionist) into explanatory theories, models, or descriptions (see Paterson et al., 2001, p.2). Noblit and Hare (1988) argue that the notion of meta-ethnography is "interpretation rather than aggregative" (p.11; see also Harden, 2010, p.4) as this process would allow emergence of new knowledge from existing information. For example, maximising the value of contributions made by respondents about the implementation of an intervention looking from the diverse perspectives, such as barriers and facilitators to accessing the intervention, intervention experienced by the involved stakeholders, examining the impact of/on other policy initiatives, and exploring how a particular intervention needs to be adapted for large-scale roll-out if needed. As Campbell et al. (2003) proclaim qualitative synthesis aims to "achieve greater understanding and attain a level of conceptual and theoretical development beyond that achieved in any individual empirical study" (p.672). It has also been argued that "This synthesis method has the potential to provide a higher level of analysis, generate new research question and reduce duplication of research" (Atkins et al., 2008, p 4). Similarly, Britten et al. (2002) argue that "full contribution of qualitative research will not be realised if individual studies merely accumulate and some kind of synthesis is not carried out. There are generalisations to be made across qualitative research studies that do not supplant the detailed findings of individual studies, but add to them" (p. 214). In Thorne et al.'s (2004) view "Meta-syntheses are integrations that are more than the sum of parts, in that they offer novel interpretations of findings. These interpretations will not be found in any one research report but, rather, are inferences derived from taking all of the reports in a sample as a whole" (p.1358).

It has been argued that most methods of qualitative data analysis or synthesis at some (critical-analytical) stage, results will be compared or some not but meta-ethnography differs from other qualitative analysis in that "it describes the act of 'translation' where terms and concepts which have resonance with one another are subsumed into 'higher order constructs'" ie developing a new model or theory about the phenomenon (Barnett-Page and Thomas, 2009, p.15). Therefore one can argue that the notion of meta-ethnography is more on constructing interpretations-categories or descriptors, rather than analysing the data (Campbell et al., 2003; Noblit & Hare, 1988).

In a similar vein, as Harden (2010) notes, in this study we draw firm conclusions after "pooling findings from studies, key concepts are translated within and across studies, and the synthesis product is a new interpretation" (p.4) using the following common phases (Noblit & Hare, 1988; see also Taylor et al. 2008; Atkins et al., 2008): (i) identify the area 'getting started'; (ii) decide what is relevant; (iii) repeat reading and noting of interpretative metaphors (concepts); (iv) create a list of related studies, concepts or themes and their relations used in each account and to juxtapose them; (v) develop central concepts of each account; (vi) compare different translations; and (vi) draw final synthesis/conclusion--either agreement or disagreement.

In addition to this, evidences were searched for GP commissioning and its effect to make primary care service effective at the local level using the following criteria:

* Databases searched include PubMed, Medline, Kings Library, EMBASE, DoH and Cochrane library

* The period range covered is 1997/1999-2010, using a mixture of free text terms and MeSH headings.

* Internet searches (for example Google scholar) were also carried out on various websites including UK, US, Australia

* Articles published in English language only were included in the paper.

Some information available from literature other than the above electronic databases for example, internal publications, unpublished reports, snowballing from the reference lists and personal contacts, including contacting relevant papers' authors and subject experts within and outside the UK were also included in the search so as not to leave out any important aspects of health service commissioning.

FINDINGS

A summary of the results of the meta-synthesis is given below. The analysis emerged five broad primary themes from the review:

* Service quality

* Service access

* Autonomy

* Challenges

* Opportunities

These themes were not mutually exclusive, but overlapped and contained contradictions.

SERVICE QUALITY

The narrative analysed revealed a number of over-arching issues related to the quality of healthcare services. Some respondents were spontaneously in favour of GP commissioning and argue that good commissioning would lead to management and delivery of better service quality and re-organising of service configuration. A recurring question was whether this would lead to better management of GP services.

Goodwin (2010) argues that commissioning means:

This point resonates with Cameron's suggestion that the key element of GP commissioning is shifting the power and authority from the centre to local, therefore this process would be likely to break the 'existing bureaucratic mechanism' in shaping policy and practice. His concept of quality services means ending the

Era of old fashioned, top-down, take-what-you're-given public services will be ending. (Cameron, 2011, p.1)

However, Thomson (2010) argues that much has been written about the GP commissioning process in the light of 'what' and 'where', but this policy seems inadequate at the operational level--mostly in the 'process element'--for example 'how and in what context' GP commissioning would be appropriate. He further states that even within the existing NHS services at the local levels, services are offered at three levels--primary, secondary and tertiary levels. The recent policy has not yet spelled this out in any detail. Therefore he states:

... more is not said in the white paper about integrating primary and secondary care. Effective management of the growing chronic disease burden will require GPs and their specialist colleagues to collaborate more closely if their shared patients are to see their right person, in the light of place, and at the right time. (Thomson, 2010, p.231)

Interestingly, there has been huge doubt about the effectiveness of GP commissioning in terms of delivering service quality. Some argue that there is no strong evidence to support whether devolving power to local level would work adequately, given the fact that authority, accountability and resources including coordination and participation, have not been clearly discussed in the current policy. Some relevant quotes echo this notion:

There is no evidence that a reckless shift of power and resources on this scale will be a success. The evidence from the past 14 NHS "redisorganisations" suggest otherwise. (Hunter, 2010, p.229)

I believe reorganisation is irrelevant to the needs of the health service. Its (GP commissioning) introduction will cause temporary harm in the short term as managers and clinicians try to find out what they should be doing, and in the long terms it will make little difference. (Davis, 2010, p.228)

I believe we have lost the plot when it comes to NHS organisation. Once it was designed as a top down almost paternalistic system with the district health authority as the basic building block. Money came from central government and was distributed to hospitals and practices by the district health authority according to the need on the basis of population and pathology. It worked, but it was grossly under-funded. (Davis, 2010, p.228)

Davis (2010) further argues that to some extent there have been attempts to "trial" this practice but is reluctant to credit success:

In 1990, district health authority was abolished. In its place GPs become purchasers and hospitals become providers. The internal market arrived and was supposed to improve services as competition improved grocery provision. We had a fund holding practice for a while, but they were inefficient and wasteful. (Davis, 2010, p.228)

SERVICE ACCESS

This was viewed in many cases as a positive aspect of commissioning GPs at local level. It has been highlighted that GP practices might be the best place to seek essential health services at local level--therefore in light of recent policy and from the patient's perspective, shifting a substantial amount of budgets to local services, through the GP, seems more appropriate, since it has been suggested that

... what patients always want is more access to their GP. (Rabindra, 2010, p.231)

While noting the achievement of service access, one argues that there should be

Fair funding, ensuring fair competition, and ensuring that everyone--regardless of wealth--gets fair access. (Cameron, 2011, p.2)

Two important points here are of particular relevance to make the service at the local level. Firstly, several authors (Higton, n.d; McPherson, 2010; Hunter, 2010) argue that the commissioning process will put people at the centre of health service delivery including the planning process and will help them develop some degree of accountability and ownership for services and this will impact access to services and continuity in getting care. Secondly, the performance of better GP consortia would deliver improved outcomes with greater efficiency and increased equity.

.... Concrete change only happens with GP involvement and where there is real collaboration in a local area between GPs and their clinician colleagues in, for instance, hospitals and community nursing teams. (Higton, n.d.)

GP commissioning gives high value to patients' views of the services, it [White Paper] says that it upholds the values and principles of the NHS, it continues to support quality standards developed by NICE to inform commissioning, and it has the ambition to provide a world class service. It also highlights the need to increasingly take account of patient experiences. (McPherson, 2010, p.230)

Putting patients at the heart of everything may improve care for some, but probably not for all with the "inverse case law" becoming more entrenched. (Hunter, 2010, p.229)

Success will be judged not only by the performance of the best consortiums, but whether reforms as a whole deliver improved outcomes with greater efficiency and increased equity. (Haines, 2010, p.229)

The hallmark of our health service is public funding raised through general taxation; public ownership, and public accountability for services; and area based planning and allocation of resources for services delivered on the basis of need and not ability to pay. (Pollack, 2010, p.230)

AUTONOMOUS SERVICE

Arguments highlighted by some papers were that the commissioning process --if implemented correctly--will have the effect of making GP services more autonomous at the local level:

End the "state's monopoly" over public sector work. (Cameron, 2011, p.1)

Bring about a complete 'transformation' that will release public services from the grip of state control. (Cameron, 2011, p.1)

The government has been astute. It knows that doctors are tired of bureaucracy so the phasing out of PCTs and SHAs is attractive, as is the prospect of GPs having charge of the commissioning budget. Knowing this, they have set up a bear trap baited with GP commissioning. (Davis, 2010, p.229)

Consortiums will look inside and outside the NHS for help in their new roles. (Johnson, 2010, p.230)

There will be more freedom, more choice and more local control ... (Cameron, 2011, p.2)

CHALLENGES

At the same time, there were some concerns or fears expressed by a number of articles that given the nature of fast track commissioning without proper consultations with service providers and managers, the results would impact negatively and the process would lead to reductions in training and inadequate preparation of staff for new roles (Nolan, 2005).

There is a risk that the good ship NHS Titanic will be in serious difficulties if its navigation is not improved. (Maynard, 2010, p.304)

In theory, we [GPs] do know more than the managers about what our patients want and need. We are not trained as experts in commissioning and planning services, however, so is it right to give such a big responsibility to us? (Rabindra, 2010, p.231)

I am sceptical that 500 or so GP consortiums commissioning services will save money or result in better patient care, let alone provide more efficient planning of appropriate services. They will probably open the door to private enterprises, which will initially offer services cheaply as loss leaders, along with inducements to GPs to commission their services, and then tighten the financial screws to ensure they make greater profits. (Pollack, 2010, p.231)

Commissioning will end up in the hands of private companies who will buy care from other private companies under the "any willing provider" agenda. (Davis, 2010, p.229)

The principal beneficiaries of the changes, apart from some enthusiastic GPs, will be private healthcare companies already circling and ready to swoop to make a killing from the NHS's ring fenced budget and, in the process, fragmented services, "gaming" the system to cherry pick patients, and driving up transaction costs. (Hunter, 2010, p.229)

GP consortiums will be vulnerable to being bought up by the health corporations, as they have been in the United States. Hospitals will have to become social enterprise bodies outside the NHS, with loss of national terms and conditions and pensions and pensions for their staff in a short term. (Davis, 2010, p.229)

GPs do not have professional training or experience in health service planning let alone commissioning; meanwhile private for profit sector and multinational healthcare companies are lining up to take control of the 80bn[pound sterling] of NHS resources. (Pollack, 2010, p.230)

The White Paper is guaranteed to do at least three things: it will accelerate the commissioning and delivery of NHS care by the private sector; it will direct blame for the inevitable cuts and closures away from politicians; and it will divide the profession. (Davis, 2010, p.229)

Reflecting on the challenges, the following points were highlighted in several articles:

Planning and management

NHS staff on national terms and conditions will rapidly become an endangered species. (Davis, 2010, p.229)

Budgeting

... it is budget crunches, not system reforms. (Stevens, 2010, p.231)

PCTs control 80% of the NHS budget and are responsible for providing services such as hospitals, dentists and opticians. (BBC, 2010)

Private companies will be queuing up to provide solutions with huge pound--and dollar--sings in their hungry eyes. (Abbasi, 2010, p.303)

Given the likely increased transaction costs from engagement of a large number of commissioning consortiums that is a challenging goal. (Haines, 2010, p.229)

In addition to these above points, O'Dowd (2010) raised the issue of the operational aspect of commissioning:

The policy of giving GPs real budgets to commission health services could improve the care of patients and save money but it will be difficult to implement. (O'Dowd, 2010, p.1377)

Bloomla (2010) further adds a degree of scepticism:

It is unlikely that GP consortiums will be so much more efficient than primary care trusts in commissioning. (Bloomla, 2010, p.228)

A failure regimen is being established that will allow chucks of the commissioning and provider side to be handed over to the private sector as the public sector fails. (Bloomla, 2010, p.228)

Public services should be ... fair, consistent and needs- rather than profit-based. (Needham, 2008, p.193)

Similarly Tritter (2011, cited in Great Britain. Parliament. House of Common, 2011) argues that GPs might not offer the best place for delivery of local service:

OPPORTUNITIES

Several authors found that although GP commissioning came to be operational without adequate groundwork, people still expressed the view that it would reform health services in novel ways, that appropriate decisions would be made at local level giving people both more of a voice and more choice over local provision of services:

Although much of the commentary has focused on commissioning, it is probable that most dramatic and permanent changes will be around provision. Existing and new providers will have opportunities to deliver services in novel ways, and it is fair to expect an increasingly competitive marketplace to emerge in which, among others, GP led provider organisations are ideally placed to progress. (Johnson, 2010, p.230)

Decision making power will be given back to professionals--who have in the past been hampered by red tape--while people will be able to have control over the budget for the service they receive. (Cameron, 2011, p.1)

Services should be delivered at the lowest possible level to give people more choice over how their public services [including healthcare] are being delivered. (Cameron, 2011, p.2)

Devolve power even further. (Cameron, 2011, p.2)

In addition to this, public services will be developed collaboratively with joint 'multipartite' efforts --public-private as well as professional group partnerships.

Move of public health to local government and an expanded role of NICE [National Institute for Health and Clinical Excellence] is a good prospect but at the same time 'handing responsibility for commissioning to 500 or so GP consortiums is high risk. (Hunter, 2010, p.229)

It [white paper] shows little understanding that health care is complex and does not just involve one group of doctors, but many professional groups working together. (Waxman, 2010, p.231)

Similarly, some service users/providers advocate GP services:

Patients not the needs of the systems should--must--be at the centre of all what we do. (Haslam, 2010, p.229)

Commissioning is something that clinicians do on an individual scale on a daily basis. If you ever question why there are constraints on what you want for your patient, if you ever question why a particular pathway must be followed, if you have ever thought that there is an easier way for things to happen, then you are on the first steps to seeing commissioning as a natural progression of your doctor role. It is not only the right thing to do, it is enormously satisfying too. (Hynes, 2010. p.37)

DISCUSSION

Practice-based commissioning (PBC) is considered as one of the key policies of NHS reform, whereby GPs become commissioners under the PBC on the basis of knowing the patients' needs and designing the appropriate care to meet these needs (Marks & Hunter, 2005; DH, 2007; Health Committee, 2011; Curry et al., 2008; Luft, 2009). Hunter (2008) states the key purpose of PBC is to "encourage GPs to have a direct stake" in commissioning health services (p.75). The DoH (2008b) highlights that by providing support and resources at GPs, PBC 'will lead to high quality services for patients in local and convenient settings [as] GPs, nurses and other primary care professionals are in the prima position to translate patient needs into redesigned services that best deliver what local people want" (p.x). Curry et al. (2008; see also DH, 2008a, 2008b) pointed out that the key strands of PBC are to achieve--"better clinical engagement, better services for patients and better use of resources" (p.2) Hunter (2008), however, argues that PBC seems rather "optimistic as there has been little marked enthusiasm on the part of GPs to become commissioners, especially as they were to be given only indicative, in place of hard, budgets while PCT continued to hold the purse strings over PBC" (p.76). Therefore it has been well debated that "GPs could foresee a lot of additional bureaucracy for little apparent gain" which was in fact a clear sign of policy incoherence and confusion (Hunter, 2008, p.76; see also Audit Commission, 2006; 2007). There could be possible conflicts between patient choice and the priorities of the PBC, and patients obviously communicate on the basis of their own needs, but each practice will need to take a more overall view of service provision. With the emergence of GP consortia covering a population much larger than traditional practice numbers it is expected that the scale of change in service delivery will be substantial. It is here that the emergence of "Alternative providers of medical services will be expected to emerge to offer the flexibility and savings envisaged with PBC. Our aim is to free up provision of healthcare, so that in most sectors of care, any willing provider can provide services, giving patients greater choice and ensuring effective competition stimulates innovation and improvements, and increases productivity within a social market" (DH, 2010a, p 4.26).

Evidence from established PBC groups, like the Nene Commissioning practices in Northamptonshire (UK), show that involvement in patient care happens earlier; "Shifting the emphasis of care from reactive treatment to proactive prevention" (Nene Practice, Annual Report 2009-10, p.12). Such practices are also better placed to control demand for elective services, to redesign services to better meet patient needs and also to be more effective in discussions with providers (also see Zoorob and Morelli, 2008). "... in shaping the design and delivery of the commissioning agenda ... The Nene 'Pro Active Care' for example has reduced the need for emergency admission by increasing support by the health and social care services for vulnerable patients" (Nene Practice, Annual Report 2009-10, p.6).

The intention of Clinical Commissioning: our vision for practice-based commission (DoH 2009) was to offer clinicians a central role in the commissioning of healthcare with the intention of improving services delivered to the patient. An important aspect of the commissioning process was setting clinical outcomes and being able to feed back to providers on the quality of their service delivery. However, the very skills needed to carry out PBC were often the ones lacking in the commissioning processes. Zollinger (2011) argues that "consortia will need to have the capacity and capability to tackle variations" (p.1). In examining the commissioning process commanded by the PCT, the Parliamentary Health Committee identified these deficiencies as insufficient data on services provision, lack of commissioning skills, not being in control over providers and government policies. If these are examined in a little more detail they may be ones that can be better solved by PBC. Direct and immediate contact with patients could produce the transparency needed in what care is being provided. What better way of judging the success of a provider-delivered service than asking the patient and monitoring the patient's recovery afterwards? The commissioning skills can be acquired--after all, clinicians really do know what they want for their patients. "While traditional expenditure patterns have favoured the acute sector the use of competition and APMS could provide the practices with stronger 'arms' on the levers of service provision" (House of Commons Health Committee, 2010, p 18). The final point refers to government policy--here favouring traditional acute sector with policy emphasis and revenue streams. On this last point the healthcare policy is now--if anything-shifting towards non-acute/institutional care. It is clear that hospital care remains overused; care that is expensive and not the first preference of the majority of patients, who very much value general practice and community-based care delivery. Such care can is more likely to be offered using PBC.

This paper has highlighted that the providers of services will have new freedoms, they will be more accountable encouraging greater competition in the NHS and between service providers. The government views greater cooperation between the various commissioners and service providers as ultimately providing more joined up services which will be coordinated within local authorities and which will forge links between health and social care providers/ services. Hunter (2008) also noted that key changes have been implemented in order to reduce top-down bureaucracy including "re-engagement of clinicians [professionals] as co-producers and responsible autonomy" (p.190) involved in health and social care services. Whilst on paper this appears to be a positive move towards eliminating bureaucracy and individualising services to local need, this reform has the potential to cause further inequity in delivery and provision, especially in areas where there are fewer GPs or fewer service providers. Therefore, Maynard (2010) strongly suggests that "investment in standard setting and enforcement with demonstrably efficient incentive systems, non-financial and financial, would be a better investment in securing NHS than yet another un-evidenced re-organisation of its structure " (p.305).

LIMITATIONS

Though Atkins et al. (2008, p.9) claim that the use of meta-ethnography would help (re)interpretations of meaning across many qualitative studies; there are some methodological limitations in this paper. Peterson et al. (2001) notes two important limitations regarding using a meta-ethnography approach: firstly, this approach often 'decontextualises data, removing from emotional and physical context'; and secondly, the quality depends on the "primary researcher's ability to articulate the research design and research findings" (p.15). Though this paper was based on the review of the relevant qualitative papers, it was not possible to analyse the operational context, challenges and opportunities at the implementation level. Caution, therefore, must be applied while interpreting the findings of the paper, as assessing the internal validity for many of the published studies is problematic, particularly those in which relatively "little information is provided on the research and sampling design" (Liu et al., 2008, p.12). As Munro et al. (2007) highlight the level and the extent of interpretation in the included studies was fairly basic as "most were descriptive studies that used thematic analysis to identify key themes and did not draw extensively on theory or on a particular theoretical tradition" (p.1241). Similarly, there might be a risk of publication bias as positive results are more likely to be published in peer-reviewed journals (Regmi et al., 2009). In addition, time and resources were severely constrained for this study, as this study was not externally funded.

CONCLUSION

GP commissioning is an ambitious programme of the present coalition government of the UK to redress health reform in the local NHS. This paper has highlighted some progress but also noted limited outcomes, for example, the quality, access and autonomy in improving primary care services in the NHS in the UK. This paper therefore suggests that it is difficult to conclude that GP commissioning would have a positive impact in the history of reform of GP services at a local level. This is largely due to insufficient data on services provision, lack of commissioning skills analysis, limited evidence-based approach to healthcare commissioning, and the continuous changes in government policies (DH, 2010a, 2010b). Wider consultations with different but appropriate professional groups/stakeholders would be warranted. This study strongly suggests that sometimes it might be dangerous to embark on further radical reform in health services (NHS) before assessing the impact of those changes (Hunter, 2008; see also Wanless et al., 2007). As Close (2011) notes "any changes to the reforms will have considerable implications for public health" (p.6) therefore the role of public health and healthcare professionals should be made explicit in the light of the GP service reform. This paper concludes that commissioning of health services should be based on evidence and sound principles to address people's health by making health service access, utilisation and performance available at the local level.

ACKNOWLEDGMENTS

We are grateful to Dr Philip Kemp, University of East London, Stratford (UK), for his helpful comments on an earlier draft of this paper.

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Krishna Regmi, PhD, Lecturer, University of East London, London, UK and Faculty of Health & Social Care, Open University, UK, Anthony Bone, MPhil, Principal Lecturer/Director for External Affairs, University of East London, London, UK, Fiona McGowan, PhD, Lecturer, University of East London, London, UK and Faculty of Health & Social Care, Open University, UK, Corresponding Author: Dr Krishna Regmi, School of Health & Bioscience, University of East London, London W15 4LZ, UK. E-mail: Krishna@uel.ac.uk. Telephone +44(0) 2082234578
In this new world of decentralised,
   open public services (healthcare) it will be
   up to government to show why a public
   service cannot be delivered at a lower level
   than it is currently; to show why things
   should be centralised, not the other way
   around. (p.2)


Free from top-down managerial control ...
   This will push decision-making
   much closer to patients and local communities
   and ensure that commissioners
   are accountable to them. It will ensure that
   commissioning decisions are underpinned
   by clinical insight and knowledge of local
   healthcare needs. (p.4)


Better quality and cost-effective care,
   as well as enabling a shift of care from hospital
   to community settings. (p.x)


I don't think GPs are much closer to
   their patients. They have a patient list, but
   if you ask them what proportion of that
   patient list they see on an annual basis, it
   is about a third. Secondly, that patient list
   does not represent all those who need or
   utilise health services within that locality.
   Thirdly, the patient list is not representative
   of the community in any real way.


Table 1: Milestones--reorganised NHS, UK

* 1948--noted unequal distribution of resources in the NHS;

* 1970s-1980s re-organisation of clinical services and establishment
of a system of general management in the NHS (DHSS, 1983);

* 1990-6 Split between purchaser and provider of healthcare
(DH, 1989). Money given to some GPs and
health authorities to purchase care for the local people (GP fund
holding practice; GP-led commissioning with health authority
purchasing);

* 1990s--The New NHS: Modern, Dependable (DH, 1997) advocate
targets-performance driven systems established through 10 health
authorities and 200 Primary Care Trusts (PCTs);

* 1996/97--Local commissioning pilots;

* 1998--Primary care groups;

* 2000--Primary care trusts;

* 2000--Highlights four principles for the NHS:

-- Patient-focused service;

-- Competitive providers;

-- Active buyers, giving PCTs authority to plan and buy care for
the population; and

-- Affordability and cost-effectiveness of care.

* 2004--First practice-based commissioning issued;

* 2006--Restructuring of NHS through strengthening of PCTs and
Strategic Health Authorities (SHAs).

Source: Rowe, 2009, pp.51-52; Audit, 2007; also see Hunter, 2008
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