GP commissioning ‘incentives’ should be based on outcomes, not activity, leading medics warn
Dr Stephen Shortt, chairman of the Principia GP consortium in Nottinghamshire, said there needed to be a much stricter rule on cash incentives to avoid the failures seen previously with practice-based commissioning (PBC), and to allay fears about possible conflicts of interest.
We need a system of incentives for GP commissioners and it will need to be a meaningful amount of money, or we won't get the change we need to deliver
He told last week's NHS Confederation annual conference in Manchester: "PBC failed because of weak incentives. We need a system of incentives for GP commissioners and it will need to be a meaningful amount of money, or we won't get the change we need to deliver.
"If the reward is formed around improving value, and not on activity, we can mitigate the risk to professionalism or conflicts of interest that might come about."
His views were supported by Dr Steve Kell, executive chairman of the neighbouring Bassetlaw Commissioning Organisation, one of the first GP pathfinders in the country. He said any financial reward would have to be based on overall service improvement, not just the amount of work commissioned.
He added: "If we are going to shift work from hospitals to community settings in a quality way, and if we are going to get people to look at activity, then there will be a cost at practice level. As a result there needs to be incentives, but that has got to be linked to delivery, not just proof of a plan for change."
The issue of the 'quality premiums' for GP commissioners has already come under fire from members of the British Medical Association (BMA), who last month raised concern that any reward based on financial performance could threaten a GP's role as the 'advocate for the individual patient'.
We continue to believe there should be no possibility that any patient should be able to believe that their access to an element of healthcare has been diminished in some way and that the GP has received a financial reward for so doing
In a statement, the BMA's General Practitioners' Committee (GPC) spoke of fears that patients could be denied treatment so as to qualify for payments based on lower overall spending. It added: "We continue to believe there should be no possibility that any patient should be able to believe that their access to an element of healthcare has been diminished in some way and that the GP has received a financial reward for so doing.
"Incentive schemes, if they are introduced against our advice, should only generate awards for consortia to spend on patient care via consortium activity, not become funds for individual GPs or practices.
"We do not believe it is ethical for practices to receive payments that arise from diminishing services."
Commenting at last weeks conference, GPC negotiator and north London GP, Dr Chaand Nagpaul, said: "Opinion polls show that 88% of patients trust their doctor. We do not want these changes to undermine that trust. We do not want to work in a system where any decision results in GPs gaining financially or in conflicts of interest. We want to work in a system that does not have the wrong incentives."
Consortia should receive financial benefits based not just on their performance in controlling the overall costs to the NHS of care for their population of patients, but also for the quality of care and for the patient experience
Linking pay to performance is an approach also supported by the Nuffield Trust health think tank. It has published a report entitled "Commissioning in the NHS in England: Ten suggestions from the United States", written by Lawrence P Casalino, a professor of public health from New York, which states: &ldquo The NHS should provide consortia with balanced incentives. That is, the consortia should receive financial benefits (or penalties, if performance is poor) based not just on their performance in controlling the overall costs to the NHS of care for their population of patients, but also for the quality of care and for the patient experience."
Commenting on whether the incentives should be paid to the consortia or the individual GP practices, the report adds: "Each GP consortium must be 'at risk' in some meaningful way for the cost of care provided to the consortium's patients; and the individual GPs within the consortium must have something 'at risk' as well. However, the risk should be for costs that the consortium can reasonably be expected to control, and should not be so large that it is likely to lead to under-treatment or avoiding the sickest patients.
"To succeed, GP consortia must be able to distribute savings and quality bonuses received by the consortium differentially to members based on their performance."