Philip Hewiston explains how an evaluation of an early Commissioning pilot in Bradford offers GPs lessons for today.
The NHS is about to undergo one of the most profound reorganisations in its history, a significant element of which will be the devolution of power and responsibility for commissioning services to GPs.
During the mid 1990s, the then Bradford Health Authority established a commissioning consortium of GPs – at their request - to purchase the totality of health care for part of its resident population. The Worth Valley Health Consortium (WVHC) was designed to purchase health care through devolved budgets for the authority's half a million population. The establishment of WVHC and its first three years of operation were independently evaluated by the Nuffield Institute for Health at Leeds University[ ] and the evaluation report provides some interesting insights into the themes and issues that are relevant to the forthcoming commissioning arrangements.
The Worth Valley Health Consortium
The Worth Valley Health Consortium went live on 1st April 1994 after 18 months preparatory work and consisted of eight practices with a registered population of approximately 66,000 people resident in Keighley, Oakworth and Haworth (only 2% of the residents of these adjacent towns were not registered with one of these practices). At its inception, there were 36 GPs in post, the majority of whom were strongly opposed to GP fundholding and saw the WVHC as an alternative model.
In the design, various options were considered and the final governance model set up the WVHC Board as a sub-committee of Bradford Health Authority (HA) and Bradford Family Health Services Authority (FHSA), comprising a ‘lead' GP from each of the eight practices, with a Chair and a Vice Chair elected from amongst them. Thus each practice had equal voting tights irrespective of size.
Initial funding to WVHC in 1994/95 was £29 million and further project funding of £265,000 was provided to meet additional management costs and the cost of the evaluation. Although the HA was below its capitation target, the nature of the Worth Valley population was such that within this, the WVHC funding was above its formula target by £314,000 and the strategic framework outlined progress that needed to be made towards this target. Purchasing of secondary and tertiary care was undertaken by the Board with a few areas (totalling approximately £2 million) blocked back to the HA. Hospital service funds were managed at Consortium level, while prescribing budgets were managed at practice level.
Seven formal objectives were agreed for the WVHC from the outset...
Objective 1- Provision of high quality health care as locally as possible:
• The evaluation report noted extensive research into the ‘contracting' process in the NHS which indicated that it was much more important to observe the relationship between contracting parties as evidence of change than to rely on the form and wording of contracts between purchasers and providers;
• Moving services closer to patients was the measure of the Consortiums success most often cited by GPs;
• There were numerous examples of services moved from Airedale General Hospital (AGH) to primary care settings as a result of WVHC efforts. These included outpatients in Paediatrics and Gynaecology, various specialist clinics, radiography, some ophthalmology, phlebotomy, some family planning and community paediatric nurses;
• Some services were introduced at AGH rather than remaining located further afield at other hospitals (e.g. Neurology and partial rheumatology service);
• There was an example where cost considerations were subordinate to access when a conscious decision was made not to move the ENT contract from AGH to Burnley;
• There were also failures and reversals. For example, the radiological services that were moved to the local health centre tended to be poorly utilised.
Objective 2 - Locality based health care contracts which represented local priorities:
• Localisation of services was a crucial priority for WVHC;
• WVHC was able to redirect some of its resources to secure a number of expansions of service ( e.g. more physiotherapy was purchased at the expense of orthopaedic services; resources were taken out of hospital services for the elderly)
• The aspirations WVHC had for releasing money from hospital services in order to develop community services were almost entirely frustrated by hospital acute and waiting list pressures;
• WVHC commission did not find explicit rationing of services particularly achievable and in this regard was unsuccessful;
• Purchasing discussions were characterised by a level of detail and understanding of both primary clinical matters and the logistics of care, which were felt to be significant in ensuring that integration between the various elements of care was properly addressed.
Objective 3 - Practice-based influence on locality purchasing decisions:
• Reporting arrangements were determined by the Board on the basis of views expressed by the wider body of GPs in the Consortium. In spite of this some GPs who were not Board members complained that they did not know what was going on in relation to purchasing, while others simply had no interest. However, overall member GPs expressed their satisfaction with the Board's efforts;
• Non-Board members did not always support WVHC by their actual referral behaviour, ignoring for example new services that were made available at Keighley Health Centre;
• There were a number of topics upon which the Board failed to make decisions because there was no consensus between member practices (e.g. fluoridation of the water supply, drug company discounts on vaccines, introduction of practice formularies). This was significant in the context of models of NHS organisations which are based upon federations of partnerships and which therefore rely on formal consensus in order to reach agreement.
Objective 4 - Local control of devolved resources leading to the provision of more care:
• WVHC employed various efforts and policies in order to obtain greater efficiency in its use of resources, but it was unable to avoid overspends in each of the years covered by the evaluation study;
• WVHC made a number of successful attempts to reduce the cost of certain services. Reductions in volume of services offered the greater potential for financial control than using alternative providers;
• WVHC successfully reduced elective extra-contractual referrals and was reasonably successful in controlling hospital spending through pre-referral examination by a WVHC GP, contracting for length of stay (rather than finished consultant episodes), ongoing review of patients by a liaison nurse and direct access to certain surgical waiting lists;
• WVHC gave consideration to refusing or limiting the purchase of expensive secondary care procedures, including dorsal implants, gender reassignment and cochlear implants, but in the event, particularly given the personal knowledge of the patient concerned, refusals proved difficult;
• Analysis of referral patterns by member GPs revealed wide variations, but action was stalled because of uncertainty about interpretation and a lack of confidence in the figures;
• WVHC moved its contracts for Orthopaedic and Trauma to a cost per case basis on the assumption that it could reduce expenditure by controlling caseload. In the event it was not possible to control caseload and the new contract arrangement led to greater expenditure;
• The devolution of resources allowed certain services to continue which would otherwise have ceased as providers withdrew them. Pain management and audiology services were replaced very quickly by arrangements with other providers after they had been withdrawn by the local provider.
Objective 5 – Improvement of the primary/secondary care interface:
• There was a large ongoing programme of appearances at WVHC Board meetings of representatives of various providers. Crucially such appearances were typically made by relevant consultants and specialty/professional managers and services were discussed in great detail with the GPs;
• ‘Quality forms' were introduced that could be completed by anyone working within the consortium, stating an area of dissatisfaction and how it might be tackled. These were dealt with by the Chair and Chief Executive of WVHC, taking the issue up with the relevant provider and many of the issues raised were dealt with constructively by the provider, usually at directorate or equivalent level;
• WVHC was the single largest purchaser of services (30%) from AGH and this meant that there was the possibility of a high level of interaction between the boards of the two organisations. By the third year of the Consortium, the Trust was sharing its plans as they developed.
Objective 6 – Targeted purchasing for the communities of the Worth Valley:
• WVHC had a Health Needs Assessment (HNA) sub group (three GPs, an HA consultant in public health and a Community Health Council representative) with a wide and varied agenda developed via extensive consultation. Much of the work consisted of service reviews and a number of service and commissioning changes occurred as a result, including health visiting, interpreting services, dental funding and the provision of counselling sessions in general practices;
• There was a potentially important project to investigate the incidence and distribution of asthma. This revealed a ten-fold variation in diagnosis between practices, but it proved difficult to establish a constructive (and self critical) dialogue about this amongst principals.
Objective 7 - Involvement in locality purchasing for small general practices:
• GPs in all three small practices felt that the consortium's activities had produced benefits for them through concessions negotiated with providers.
Summary of the Evaluation Report
1. The status of the WVHC as a property of general practice meant that ‘primary care' would continue to be defined as ‘primary medical care' and the management and operation were dominated by doctors, although this did not give rise to any particular criticism from other professions within primary care;
2. The ownership/partnership arrangements of general practice meant that key decisions could only be made by consensus and there were instances where member practices were treated as having a veto, even though WVHC's constitution allowed for majority decision making;
3. An important element of the successes achieved by the WVHC and the successful management of some of the instabilities and tensions could be attributed to the management style of the Chair and Chief Executive, who encouraged sufficient Board level discussion to work through the issues;
4. There were differences in terms and conditions of employment between those employed by GPs and those seconded to the WVHC, which suggested that in the longer term the rather unsystematic labour relations in general practice would be unsustainable;
5. There were differing levels of involvement from the Consortium GPs ranging from highly involved Board members, through occasional participation on working parties to GPs who were unfamiliar with, and disengaged from, the workings of the Consortium. This latter group complained that they did not know what was going on, although they also acknowledged that the situation arose from their own personal choices and priorities;
6. Members found it difficult to address critically such matters as their own diagnostic, referral and prescribing practice;
7. Explicit rationing of health care was difficult for the WVHC because the GPs were conscious that they were supposed to be the patient's advocate;
8. WVHC had difficulty in engaging with the public at large, in spite of genuine attempts to deal with collective issues through public engagement and consultation. When public meetings were held, these were poorly attended, often by people with a very specific interest;
9. WVHC employed various efforts and policies in order to obtain greater efficiency in its use of resources, but it had difficulty in managing demand for acute hospital services and was unable to avoid overspends in each of the years covered by the evaluation study;
10. There were however notable achievements of change management including the establishment of an on-call co-operative and rapid re-provision of services abandoned by providers.
Philip Hewitson is chief executive of Parabola Ltd management consultants, and former chief executive of Bradford Health and Bradford Family Health Services Authorities.
1.Harrison S. 1997. The Worth Valley Health Consortium: Evaluation Report Nuffield Institute for Health, Leeds University