by Philip Boxer
Practice-based commissioning is intended to overcome the difficulty of driving a health care reform agenda centrally through locating management of the health care ecosystem not at its center, but at its edges where the primary care system meets the individual demands of patients’ conditions. There are a number of difficulties in making this work in practice (see what makes practice-based commissioning difficult in practice?), at the heart of which is the need for a different approach to managing primary risk.
The secondary care system supplies treatments provided by medical specialists to the primary care system. It includes the services of hospitals, but also of allied health professionals such as physiotherapists and orthotists. The primary care system is the customer of the secondary care system, supplying care provided by general practitioners (GPs) directly to patients within local communities, making the patient the customer of the primary care system.
The medical specialists in the secondary care system act as consultants to the primary care physician, and may themselves draw on the services of specialist consultants in the tertiary care system for such things as neurosurgery and cancer care. Taken all together, these different orders of care system form a health care system through which care pathways are formed for the patient, defined by the sequence of interactions the patient has with the health care system in the treatment of their condition. Can this pathway ultimately be the responsibility of the patient’s GP alone, as the gatekeeper to the health care system?
Change in the governance of the health care ecosystem
The health care system is itself a business ecosystem, being made up of large numbers of operationally and managerially independent organizations that have to be able to collaborate with each other in varying ways depending on the nature of the pathway the patient needs to take through this health care ecosystem. This need for horizontal forms of collaboration across the ecosystem is true even where its funding is provided centrally by the government: the ecosystem cannot be managed top-down as a planned economy. Nevertheless, health care reform by the UK Government has aimed to achieve some combination of reducing the costs of health care, increasing the quality of patient care, increasing the accessibility of possible treatments within the ecosystem, and broadening the availability of health care itself to a population.
But as discussed in the difficulties in implementing practice-based commissioning, innovation within the health care ecosystem has continued to increase the variety of possible treatments available, increasing the variety of patients’ conditions demanding treatment, and therefore the variety of (horizontal) pathways needed. If the agility of the health care ecosystem is defined by the variety of patient pathways that it can support (i.e. type III agility in organizations), then as the demand for agility within the health care ecosystem increases, so top-down approaches become ever less effective as they are overwhelmed by the variety of patients’ demands on them. This is the driver for moving from N-S dominant to E-W dominant forms of organization, with the history of reforms to the NHS reflecting this in the way changes to the governance of the ecosystem have made the Easterly role of the primary care physician ever more important to the way the ecosystem is aligned to the needs of the patient (the stages in this evolution can be described using patterns of evolving enterprise architecture). So given the difficulties in implementing practice-based commissioning, what more does the GP need to become effective in his or her East-West role?
The need for a different approach to leadership
The faustian pact made with clinicians by the top-down driven PCTs left the clinicians free enough to do what they could for their patients as long as they generated the aggregate results wanted by the PCTs. The problem with this faustian pact, however, was that it prevented the health care system from learning about how clinicians were to manage the care pathways that went beyond the scope of individual clinicians or practices. Thus abolishing the PCTs may have been necessary, but it will not be sufficient for practices to go wholly East-West dominant, since the clinicians will need new forms of support if they are to be effective in how they manage these more complex pathways in the through-life interests of their patients’ conditions. At the same time, the Government (or in the US the insurance companies) will not allow money to be used in this way unless they can hold clinicians accountable for the way they use their know-how to manage these pathways in the through-life interests of their patients. It has the danger of becoming a stand-off, with the clinicians simultaneously agreeing with the changes while needing to buy themselves time while they work out how to manage in this new environment!
Which brings us back to the ways in which clinicians are enabled to manage primary risk. In order to be effective, their leadership has to become systemic, able to bring together the different roles needing to work collaboratively in the interests of the through life management of the patient’s condition. Such an approach depends on the availability of systems of engagement that can support collaborative working around the patient’s condition. But more than that, it needs a collaborative approach to leadership that does not seek to place the burden of responsibility on the GP’s shoulders alone: it needs an asymmetric approach to leadership.