UK primary care physicians to gain greater control under NHS reforms

The United Kingdom plans to give more control over its national health care system to groups of primary care doctors in an attempt to reduce administrative spending and improve patient outcomes dramatically. But many U.K. physicians might not relish the new role, experts suggested.

New arrangements of primary care doctors -- called primary care consortia -- would have additional power to plan health care services and spending for their patients. Consortia also would be held accountable for overspending and for their patients' outcomes. That's according to the "Liberating the NHS" white paper proposal unveiled in July by U.K. Secretary of State for Health Andrew Lansley.

"This isn't top-down -- it is going to be bottom-up," Lansley wrote during a July 22 online discussion of the white paper. "It is going to be led locally by those who are most directly responsible for the care of patients." Lansley also intends to allow citizens a wider choice of primary care doctors, referred to as general practitioners or GPs.

"We welcome the focus on quality," said Dr. Richard Vautrey, deputy chair of the British Medical Assn.'s General Practitioners Committee. But one concern is that the NHS will be micromanaged, he said. The BMA is both a professional association and trade union for doctors.

The U.K. government probably will carry out the reforms as already outlined, Dr. Vautrey and other experts said, although the U.K. Dept. of Health is soliciting comments on the plan until October. Also, many details need to be ironed out, such as how primary care consortia will be held accountable for spending and quality.

The white paper sets a goal of having the consortia control 80% of the national health budget by 2013. The government also plans to reduce administrative spending by 45% by the end of 2014.

"This is a major seismic shock to the system," said Alan B. Cohen, ScD, an expert on international health systems and a professor of health policy and management at the Boston University School of Management.

Roots in Thatcher's reforms

Until 1991, the NHS operated much like the Veterans Health Administration in the U.S. Health care was provided by a tax-funded group of district health networks with perhaps a half-million patients each. Most care was -- and is -- free at the point of service for patients, said Donald W. Light, PhD, a professor of comparative health systems at the University of Medicine & Dentistry of New Jersey.

By the late 1980s, the Conservative government led by then-Prime Minister Margaret Thatcher developed a plan to increase efficiency and accountability at the NHS. The government encouraged hospitals to become independent entities.

Groups of GPs were paid capitated rates and encouraged to take charge of their budgets by contracting with hospitals and specialists for services in a form of managed competition, said Jonathan Weiner, PhD, professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore.

Such managed competition proved difficult, however, because the system already was lean on facilities, technology and staff after years of careful planning, Light said. Many towns had only one hospital and relatively few specialists, which posed a disadvantage for doctors and others contracting with the hospital for services.

"That has been a problem ever since," Light said.

Many expected Prime Minister Tony Blair to reverse the market-based reforms when he took control in 1997. Although the Labour government stopped additional small GP groups from taking on their own budgets, it did not end the contracting system. Instead, it attempted to counterbalance hospitals' negotiating power by requiring all GPs in a region to join a local primary care trust, each of which care for about 300,000 patients. Approximately 150 primary care trusts exist today.

More market-based approaches

The current Conservative government, led by Prime Minister David Cameron, is proposing more market-based reforms. The plan would replace primary care trusts with about 500 primary care consortia, each caring for about 100,000 patients.

Lansley said primary care trusts generally have failed to achieve many quality improvements. "Too often, the primary care trust did not understand the service they were commissioning, did not monitor the quality of the service being provided and did not challenge the out-of-hours service provider when things weren't right," he said.

Primary care consortia would be responsible for determining the services patients needed. They also would be accountable for overspending, with certain GPs taking new administrative roles in the consortia.

The white paper also proposes refocusing the NHS on patient outcomes instead of on patient waiting times, continuing work begun by the Labour government.

People would be allowed to register with GPs near where they work or live, instead of only the latter. And hospitals would be given more independence to provide private care, Dr. Vautrey said.

But will reforms work?

The white paper proposal has received mixed reviews from health experts on both sides of the Atlantic.

"In theory it's a medical home on steroids," Weiner said.

But splitting the purchase of primary and specialist services won't help integrate care, noted Dr. Martin Roland, a general practitioner and professor of health services research at the University of Cambridge Institute of Public Health in Cambridge, England.

"Handing GPs real budgets for commissioning care on behalf of their local communities has real potential to help shift care out of hospitals and reverse the upward trend in avoidable hospital admissions," said Dr. Jennifer Dixon, MPH, PhD, a pediatrician and director of the Nuffield Trust, a health policy research organization in London.

The challenge is huge, however, Dr. Dixon said. Previous similar reforms have not motivated enough GPs to manage budgets. Many have been far more interested in providing primary care than buying hospital care, she said.

Light said GPs "are being saddled with a job they were never trained to do." Perhaps 15% of them would be eager to take on the additional responsibilities, he said.

Lansley said most GPs would continue to do their regular jobs. "A smaller number of clinicians will be the leaders in this, and they will need support."

But Weiner said U.K. physicians already have a great deal of responsibility in the health system.

"A lot of this I think is more the appearance of major change than actual change," he said.