The NHS has traditionally been organized, like most public services, on the basis of place.
This has been both a control and a planning mechanism. It is a planning mechanism because it uses available information about the demographic and health profile of an area and seeks to match provision to need. It is also a control mechanism, that ensures that spending doesn’t get out of control and that the distribution of resources is fair, in relation to need.
Commissioning of services has thus been mainly place-based. Whether it was Regional and District Health Authorities (RHAS and DHAs) 20 years ago, or Strategic Health Authorities and Primary Care Trusts (SHAs and PCTs) more recently, they were rooted in place-based control and planning.
What was new, in the original proposals for the English NHS, is that this place-based system would have disappeared. The intermediate layer (SHAs) that controls the distribution of DoH money would go. Money would flow directly from DoH to new commissioning bodies that would be based on GP practices, groups and consortia that are not place-based. They would have been a confusing mosaic of geographically overlapping units.
The key question would the be – on what basis will resources be allocated to these new units? At the moment this is done, however imperfectly, on the geo-demographic data profiling local populations. There is no parallel system that can tell us what the profile of a consortia’s ‘population’ is, and what their needs are. So the question was simple – how on earth were resources for health care in England going to be fairly distributed according to need under the GP consortia based commissioning system?
This problem had been causing considerable debate within the Department of Health, as efforts were made to see if a patient-based system could be developed that somehow took account of health demographics. It would be fair to say this issue was not exactly ‘resolved’ and whatever system had been devised would almost certainly have led to a very big disturbance in the current geographical balance of resources (which is itself problematic).
This problem has been at least partially shelved by the changes announced to the NHS reforms, as the new, new commissioning bodies will now be geographically, rather than patient, based. They will have a duty to commission for the whole population in a given area, including those not registered with GPs. But they are not going to cover the same geographical areas as current PCTs, so there is still going to be some juggling to be done with funding allocations, but at least the big disruption a switch from place to patient based funding will now apparently be avoided. Probably.
And of course there is still the problem that now the DH is going to have to allocate funds directly, without any regional or local tier, to hundreds of local commissioning bodies. That should prove ‘interesting’.