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Primary care organisation size and quality of commissioning

There is uncertainty about the best size for the primary care organisations responsible for commissioning health services in England. This includes the concern that small commissioning units are more exposed to financial risk, due to their smaller populations. Smaller commissioning units may also not have sufficient expertise or the required ‘market power’ to be able to negotiate effectively with health care providers to achieve good-value contracts. Alternatively, smaller organisations may have better local engagement and responsiveness for clinicians and patients.

In a study publishedin the British Journal of General Practice, Felix Greaves and colleagues from the Department of Primary Care & Public Health at Imperial College London investigated whether there is a relationship between the size of commissioning organisations and how well they perform on a range of performance measures. This included a comparison of primary care trust (PCT) size against 36 indicators of commissioning performance, including measures of clinical and preventative effectiveness, patient centredness, access, cost, financial ability, and engagement.

They found that 14 of the 36 indicators had an association with size of the PCT and with 10 indicators, there was increasing quality with larger size. However, when population factors including deprivation, ethnicity, rurality, and age were included in the analysis, there was no relationship between size and performance for any measure. Greaves and colleagues concluded that there was little evidence to suggest that there is an optimum size for PCT performance and that the variations in PCT performance were explained by the characteristics of the populations they served. These findings suggest that configuration of clinical commissioning groups should aim to produce organisations that can function effectively across their key responsibilities, rather than being based on the size of their population alone.

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