Wednesday, 21 July 2010

Commissioning, an opportunity?

While reading about commissioning recently my eye was caught by one particular phrase. “Commissioners will be free to buy services from any willing provider” Bearing in mind that secondary care providers will have to be specialists with the relevant qualifications it is initially difficult to see how, in practice, this could mean anything other than the local hospital already providing these services. But think for a moment. “any willing provider”. In theory this could include individual specialists or small consortia of individuals, independent from the local hospital trust. This would not be feasible I admit for many specialities, especially the surgical ones. However there are some specialities where much of the work currently done in the hospital could easily be done, by the specialist, in a primary care setting.

This could have certain advantages. First of all there would be the guarantee of a consultant delivered service. Patients would not be seen by trainees, or nurse specialists but by the consultant, every time. Secondly many of the frustrations afflicting GPs trying to book appointments at the hospital would disappear. No more referral management, or choose & book. You simply book your patient into the next session when the specialist visits. Also there is the convenience to the patients of being seen in their own local surgery, rather than trekking all the way to the hospital, and getting ripped off in parking charges.

There are also other aspects. I have commented before that there is a wedge driven between primary and secondary practitioners. We are isolated from one another, professionally, socially and philosophically. In my area I personally know only two GPs. There is a consequent failure of understanding between us, an “us & them” attitude which can only disadvantage our patients.

If GPs had their own specialists working in the practice they could gain much more than simply specialist care on tap. They would have access to advice for patients who might not justify a formal referral, and more rapid and personal communication. The specialist too would gain valuable information from the GP. Inevitably visiting specialists would share coffee and breaks and a better relationship would develop. The wedge and the isolation would disappear.

I am aware that doctors are by nature a conservative bunch and this idea may seem a bit radical for some. I expect that the idea would be shot down in flames by colleagues in both primary and secondary care.

But I think for some specialities this could work.


  1. "there would be the guarantee of a consultant delivered service. Patients would not be seen by trainees, or nurse specialists but by the consultant, every time."

    Actually, by a nurse, if even that, let alone a specialist one, if money is tight! - and money IS tight, and you're supposed to make 20 billion in 'effeciency' saving too, remember?!

    Bearing this in mind, the only chance of you and that GP having coffee together is when he is bankrupt and you've been made redundant!

  2. I have little doubt that a GP practice could get a service direct from the specialist far cheaper than using the same specialist in the conventional way through the hospital. That would represent an efficiency saving.

  3. I think it is exactly what some are considering right now. For some specialty like mine (Child Psychiatry ) there is phenomenal difference between inner city and middle class suburbia in terms of disturbance rate by as much as three times. Instead of evening out, the present reorganization could create even more inequality in society. Arguable you could pay some specialist 3X more to work in a deprive area, but I know what I would choose.

    Then there is a minority of patients that require inpatient treatment in Child Psychiatry and more often than not, many units are closed down and the private sector is used.

    When patients become a commodity, what would a private organization do? Especially when the money is from the State?

    It was a very socialist thing when consultants were roughly paid the same across the country (if we do not factor in awards) when in the US there is much difference in the different specialties. When the new reorganization gets going, there will be a new kind of Health Care. I am sure most doctors want to do the best and give patients what they want, but soon they will find the same problem: the money ran out.

    Before my retirement, we had two Fund Holding GP groups and three non-FH ones. We were discretely directed to give priority to the FH groups. This caused much upset and then at the end of the year, one of the FH group ran out of money and became non-FH again. Our hospital trust was never compensated for the 2 million we were owed.

    Money distorts.

    We need more hospital doctors to be writing blogs.

    The Cockroach Catcher

  4. As a patient I would find this a brilliant idea. I would tell my friends and my neighbours and the people in the queue in Sainsbury's. My worry is that if I didn't get my appointment with you sometime in May or June there would be no money left and by October either you would need to cut your prices or send in your specialist nurse.....

  5. This already does happen a bit with physios, I think. There is no reason why it couldn't work in theory with other specialisms.

    But the location angle is interesting. Maybe one unintended consequence of the WP will be that many specialists leave the hospital setting where they are currently obliged to work and set up business in a more profitable location (or even in some kind of mobile van) leaving some services unavailable in some areas.