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Commissioners failing to make 'difficult' disinvestment decisions

PCT commissioners are failing to make ‘difficult decisions' to cut hospital services and transfer care to community settings, a new study warns.

A Nuffield Trust survey of 80 PCTs found NHS managers have ‘more weaknesses than strengths' when it comes to rationing 'core' spending, and warned PCT priority setting groups fail to involve patients and the public in key decisions.

The study also warned that PCTs are failing to make the necessary ‘disinvestment' in hospital services that the NHS needs if it is to meet the £20bn efficiency savings target demanded by the ‘Nicholson Challenge'.

The report urges GP commissioners to learn from the experiences and pitfalls of PCT priority-setting, and says GPs have the opportunity to redraft PCT tactics ‘that have been perceived locally as failing'.

It calls on clinical commissioing groups (CCGs) to confront tough decisions on curbing hospital care, rather than limiting rationing to the ‘comfort zone' of cuttiing spending on new services and exceptional treatments.

Yet, the report also warns that GP commissioners will be ‘vulnerable' to challenges over priority setting decisions from patient groups and local authorities.

It says a ‘critical question' remains on how the NHS Commissioning Board and NICE provide support for CCGs and how governance will be put in place to ensure that CCG decisions on care stand up to ‘legal and public scrutiny'. 

The report states: ‘Clinical commissioners will be particularly vulnerable in this area; having to make critical decisions about how local NHS resource is used at a time of flat (and in effect reducing) funding with fragile levels of management support.'

‘Governance of clinical commissioning will need to be robust enough to withstand challenges…and also potential judicial review of its decisions, assuming that CCGs as statutory organisations are regarded by the courts as public authorities. For GPs to be board members of public authorities and subject to this range of public and potentially legal scrutiny will be a new and challenging experience.'

Dr Suzanne Robinson, lecturer in health economics and health care policy at the health services management centre at the University of Birmingham and lead author of the report, said: 'Priority setting is moving centre-stage. The issue here is to make sure that the learning is transferred to the new world of clinical commissioning.'

'While politicians may want to move away from past government policy, the expertise and learning from the evolution of commissioning over the last ten to fifteen years is crucial to meeting the efficiency challenge.'

Dr Mike Dixon, chair of the NHS Alliance and a GP in Cullompton, Devon, said: ‘It was very difficult for PCTs to be good at priority setting because priorities were set so centrally. They didn't have the time to sit back and think about local needs. I think GPs will get priorities more finely tuned. We are used to making fairly tight decisions and we should have more head room to move.'

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