healthcare update - issue 15
Trust me, I'm a GP...
The new Coalition Government made clear its intention to
“strengthen the power of GPs to act as patient’s expert guides
through the health system” by enabling them to commission care on
their patients behalf in its Coalition agreement and confirmed this
in its NHS White Paper “Equity and excellence: liberating the NHS”
which was released in July.
Broadly, the White Paper states that GPs will be able to set up
groups of practices who would work together in a consortia to take
direct responsibility for up to £80bn of commissioning. It is
envisaged that they will also play a role in planning future
service provision and directing strategy for hospitals by
indicating what they require in the longer term.
Under the proposals outlined in the White Paper GP consortia
would be accountable for the health outcomes of the local
population, financial performance within their commissioning budget
and the quality of patient experience. The accountability of these
new GP Consortia will be assured by the creation of a new National
Commissioning Board. It is envisaged that this Commissioning Board
will also deal with commissioning of primary care and other
specialist services and take responsibility for: assessing the
achievement of health outcomes; allocating and accounting for NHS
resources; improving quality, promoting patient involvement and
choice, and tackling inequality and equality in the NHS.
Monitor will take on a an ‘economic regulator’ role reviewing
the fairness and transparency of commissioning decisions, promoting
competition and regulating private providers who wish to work with
the new GP consortia and Commissioning Board. There will also be an
extended role for local authorities in underpinning patient choice
and boosting commissioning efficiency, via the creation of new
health and wellbeing boards.
Primary care trusts and strategic health authorities are to be
abolished by 2013 and NHS providers are to lose their “preferred
provider” status.
The potential pitfalls
GP commissioning is nothing new and has been reincarnated in
several forms including GP fund holding, practice based
commissioning and total purchasing pilots over the last twenty
years. Whilst these models have reported successes in improving
primary care services they have failed to achieve a widespread
transformation of the way health services are delivered and
concerns have understandably been raised that GP commissioning will
go the same way.
Although it is envisaged that several pilots will be carried out
to test the proposed framework before the changes are implemented
the transition process will require careful management to ensure
that the delivery and standard of services continues throughout.
With a renewed emphasis on quality and patient choice the risk of
challenges by way of judicial review or otherwise, from the public
may be significantly increased.
Further there is a risk that if the appropriate processes are
not in place that any ensuing confusion could delay the resolution
of any issues threatening services and perhaps encouraging other
complaints. In particular it will be important to ensure that
consortia do not “cherry pick” the services they are going to
commission and that an effective accountability framework is in
place which holds them accountable for more than their budget
holding functions.
All of this is of course based on the premise that GPs want to
take on this responsibility and it is therefore likely that
sufficient financial incentives will be necessary as well as the
guarantee of a support network which will support GPs in taking on
these added responsibilities.
Further the proposed flexibility that GPs will have with regards
the structure of their organisations and increase in the number of
new commissioning bodies increases the risk that there will be a
lack of consistency as to commissioning approaches leading to
different prioritisation of needs and treatments which could
encourage a “locality lottery” as to the experiences the public
have.
The potential gains
The benefits of this new NHS are pre-dominantly long term and
acknowledge the fact that there will be significant upheaval in the
transition period from the traditional PCT structure to these new
GP consortia. The main benefit being of course, a reduction in
public sector spending which will be brought about by a reduction
in administration and bureaucracy with the abolition of PCTs and a
new focus on efficient and effective commissioning of services
which does not effect quality or patient safety.
Under the proposals in the White Paper the public will have the
right to choose which GP practice they sign up to. This move will
not only allow the public greater choice and allow them to move
between consortia if they believe that another consortium would
prioritise their health needs. This in turn should drive
competition between consortia to perform well and offer a range of
services based on an understanding of local need. Consortia who can
achieve this will be able to manage the risk of an adverse
reduction in their patient lists and lobby for more funds based on
their list size.
The White Paper envisages that GPs will be given the flexibility
to form consortia in “ways they think will secure the best
healthcare and health outcomes and their patients and locality”
allowing them flexibility to tailor their arrangements to their
area. This in turn may assist collaborative working between
organisations and encourage innovation.
With regards to the commissioning function of GP consortia it is
anticipated that many consortia will hire private companies to
support them in the delivery of this function. Some PCT’s have
already acknowledged this as an opportunity to set up social
enterprise models into which key staff will transfer. Even in the
absence of these social enterprise models it is likely there will
be ample employment opportunities for former PCT employees looking
to secure employment within the new GP consortia as their knowledge
of the NHS and previous law, policy and guidance will be vital in
ensuring continuity during the transition period and progress with
key NHS objectives.
The unknowns
The extent of the term ‘commissioning’ – the
range of activities which this term potentially encompasses means
that clarification is needed to establish which groups and
individuals should have responsibility for the commissioning of
which services. This will also necessitate a consideration as to
how GP's budgets can be aligned with budgets for public health,
social care and other services.
The locality that GPs will be required to cover
– this will require central co-ordination to ensure that the
population is covered appropriately
Budget allocation - a criterion for determining
how budgets are allocated to GPs. This will need to encompass
factors such as population size, local needs and long term strategy
for dealing with future needs.
Governance framework – We know that each
consortia will have an accountable officer and that the New
National Commissioning Board will hold the GP consortia to account
but it is not yet clear exactly how their performance will be
regulated and managed. Any governance framework will also need to
include procedures for ensuring effective competition between
providers and choice for patients. It will also need to ensure that
there is a procedure for resolving conflicts of interest. For
example where a GP consortia commissions care which forms part of a
care pathway within which the GPs in the consortia also
operate.
Level of risk and financial incentives – an
appropriate balance between financial and quality risks and
incentives will need to be struck to secure engagement from GPs for
taking on specific commissioning, leadership and accountability
responsibilities.
Public and patient involvement – whilst the
premise of GP commissioning is that GPs are best placed to
understand the needs of their patients there will still need to be
some form of formal involvement from patients and the public.
Further it will also be important to engage with local clinicians
to ensure that they work alongside GPs in shaping strategies for
urgent care and the management of long term conditions.
Procurement implications – PCTs, as public
bodies, are bound by the public procurement rules set out in the
Public Contracts Regulations 2006 (as amended). It is not yet clear
whether GPs will become statutory bodies and so be bound by these
rules as well. Even if they remain private companies the fact that
they receive public funding for public functions may mean that they
are bound by the rules regardless.
What next?
The White Paper places GPs and primary care at the centre of NHS
reform but it should be noted that it includes at least 20
references to further consultation before any of the proposals
contained within it are finalised.
However, whilst much of the detail of the policies seems “up for
grabs” it is anticipated that the structural changes outlined in
the White Paper will accelerate as primary care trusts and other
commissioners find it increasingly difficult to sustain services in
the face of uncertainty as to the role of their employees going
forward and the future organisation structures which will take
over.
The consultation document, “Liberating the NHS: Increasing
democratic legitimacy in health”, consulting on the proposals
outlined in the White Paper, was issued on 22 July 2010 and the
consultation will close on 11 October 2010. You can contribute to
the consultation by
visiting the DH's website.
talk to us
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The content of this update is provided for the purposes of
general interest and information. It contains only brief summaries
of aspects of the subject matter and does not provide comprehensive
statements of the law. It does not constitute legal advice and does
not provide a substitute for it.