Should private companies advise the NHS on commissioning?
In our first ‘e-debate’, GPC negotiator Dr Chaand Nagpaul and BUPA’s Dr Natalie-Jane Macdonald exchange emails on the role of FESC
In our first ‘e-debate', GPC negotiator Dr Chaand Nagpaul and BUPA's Dr Natalie-Jane Macdonald exchange emails on the role of FESC
BUPA was successful in being one of the 14 companies chosen by the Department of Health under the FESC [Framework for procuring External Support for Commissioners] programme. What do you feel that your organisation and other commercial companies have to offer PCTs in their commissioning role, over and above what would normally be possible within current NHS arrangements?
Best wishes, Chaand
There are massive challenges facing PCTs, and with them, their practice-based commissioners, down to individual practices. Progress is being made in some locations, but is not consistent and largely too slow, reflecting an immaturity in complex programme management, and good practice is poorly shared across the country.
BUPA and other companies have no panacea to offer, but we do bring experience of funding, organising and delivering healthcare services in a variety of countries and healthcare systems around the world. We know how the different dynamics of payments systems, professional relationships and governmental involvement affect the implementation of change.
Two of our other significant capabilities may well have positive spin-offs for the NHS. We are accustomed to using data and information and facts to inform our decisions – it's the way we do things. We are also used to competitive environments – if we don't do well, and provide excellent customer or patient-focused services, we will lose our customers.
The relationships between PCTs, PBC, individual GPs and others are complex and often not aligned. We can help break this complexity by working with the different parties in an objective, fact-based way.
I note the expertise BUPA and other companies bring, however much of it relates to your experience as a provider, not as a commissioner. Further, the patient base you are used to is selective – mainly from those who can afford private insurance or have cover under employment.
Part of a provider ethos is based on maximising profit from invoicing systems and increasing clinical activity – not managing demand – as is our priority as commissioners. PCT commissioning has a different responsibility and remit: to address the health needs of a whole local population covering the breadth of social classes and deprivation, tackle inequalities, promote health, cut demand on secondary care and move care closer to home.
This context covers an interface with social care that affects health – such as education, employment, housing and deprivation – hence the aim for PCTs to work closer with local authorities. I don't see how BUPA or other commercial organisations can support PCTs in this wider function.
PCTs themselves do not ‘compete' but commission within a choice agenda of providers. I wonder whether your natural territory better relates to hospitals as providers rather than PCTs as commissioners?
You correctly say the relationship between PBC and PCTs is suboptimal in many areas; however, I don't see how FESC will enhance this. GPs have previously demonstrated through fundholding and commissioning groups their abilities to develop real service redesign based upon their close contact with patients. Many PCTs have failed to devolve necessary resources, trust and support to GPs to exploit the true potential of commissioning under PBC.
I'm unclear how a commercial third party can facilitate working between practice-based commissioners and PCTs. It should be for practice-based commissioners to determine whether there are any unmet commissioning needs and support, and a requirement for PCTs to meet these. Unfortunately, the FESC procurement exercise has bypassed GPs and essentially been centrally driven.
BUPA's understanding of how citizens, healthcare consumers and patients behave is built upon our knowledge and experience gained from providing commissioning-related services to nearly 30 million members around the world.
The socioeconomic spectrum of these individuals varies across the globe.
The key factor in serving people and populations is understanding how we can best support them to live healthy lives, and ensure that when they become unwell, we match healthcare resources in the most appropriate way to meet their needs.
For example, the focus on long-term condition management recognises we need not only put such patients in more control of managing their illnesses and lives, but also break the traditional link between acuity and treatment setting.
Reliance on hospital services is disproportionate. Often what is lacking in primary care is a sufficiently detailed view of population needs that looks end-to-end, rather than in a compartmentalised and episodic way. Private sector organisations have significant experience to bring to this territory. We also have more practical experience of managing healthcare demand than many in the NHS.
With regard to the optimal structures, you are right that this is unclear in terms of who is most appropriate and who is accountable. The prime minister's recent speech about seamlessness between primary and secondary care adds ambiguity to the purchaser-provider split. You rightly point out there is as much legitimacy in foundation trusts extending their services outside their four walls as the other way round.
Progress should be slowed while arguments about who is in charge and the relative role of PBC and PCTs take place. There are good examples of where those involved work well together – just not enough of them.
Surely the most important thing is to tackle the growing mismatch between supply and demand for healthcare funds and the continuing embarrassment of health inequalities writ large across our landscape.
This requires accessing the best brains, tools and skills and making good economic, patient-focused changes, designed so that they can be systematically evaluated for impact and to ensure value for money. The mechanisms to do this may be suboptimal – such as complex frameworks and procurements – but that does not behove us the obligation to try.
I wouldn't wish to diminish your company's global experience in any way. But the NHS is unique and different international models cannot necessarily be transferable here.
The NHS is state funded – not insurance based – and covers the entire UK population. It is free at the point of delivery, and crucially in general practice, has a list-based system for a defined local population, unlike the norm in other countries. Ideally, commissioning support should be from organisations rooted within this ethos.
Commercial organisations like yourself will legitimately wish to avail of business opportunities such as the FESC. But my bigger concern is with the Government's direction of travel, particularly the seeming ideological objective to involve the private sector as an end in itself.
We have witnessed the costly, centrally driven introduction of ISTCs, often superfluous to need; the huge expense of some PFI schemes; and the introduction of commercial providers within general practice via APMS. FESC is again government-led procurement that must have already incurred significant resource. There is likely to be an expectation for PCTs to use the chosen FESC companies.
Given that FESC is permissive, in exceptional circumstances, for end-to-end services in which a PCT's entire commissioning function could be run by a private company, there is concern this could signal the privatisation of commissioning.
The emphasis should instead be on developing PCT capability and capacity as commissioners in their own right, accountable to their local populations, rather than outsourcing this to third party commercial organisations. A preferable approach is to allow PCTs and acute trusts to continue to use their existing right to source external management support, according to local need.
It should be GPs in their commissioning role who should determine their commissioning needs – not have it decided on their behalf via a top-down approach.
Another concern about FESC is the potential conflict of interest between some companies' role as commissioners, while potentially benefiting in their simultaneous involvement as providers.
The debate about commissioning, how we achieve improved overall standards of health and wellbeing for populations, and ensuring money is well spent, is too often founded on misunderstandings.
Whether it is concern for how third parties will access data about ‘my patients' from GPs, or the eternal battle for ascendance between managers and doctors, the unfortunate consequence is that too little time is spent grappling with the big challenges our healthcare system faces.
We should be looking for input and expertise wherever it exists, and where that is from the commercial sector, ensure contracts are structured well and results can be measured.
I don't think that we are far apart at all in our thinking – we just need to spend more time working together to overcome high levels of suspicion over motive and capability.
I agree with you that some private companies may well have management skills that can benefit the NHS. But I am unconvinced they necessarily bring the ‘commissioning' skills that pertain to PCTs' wider remit and responsibility.
Thank you for an interesting debate.
Dr Chaand Nagpaul
GPC negotiator Dr Chaand Nagpaul