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Emergent response


12 January 2011

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First, NHS Chief Executive Sir David Nicholson predicts there will be “no great surprises” in the Department of Health’s (DH) next steps, claiming that there was “broad support” from nearly all parties. But while few argued against the concept of GP-led commissioning, a huge range of concerns were raised about the reforms and over the suggested timescale in which they should be implemented.

First, NHS Chief Executive Sir David Nicholson predicts there will be “no great surprises” in the Department of Health’s (DH) next steps, claiming that there was “broad support” from nearly all parties. But while few argued against the concept of GP-led commissioning, a huge range of concerns were raised about the reforms and over the suggested timescale in which they should be implemented.
First, NHS Chief Executive Sir David Nicholson predicts there will be “no great surprises” in the Department of Health’s (DH) next steps, claiming that there was “broad support” from nearly all parties. But while few argued against the concept of GP-led commissioning, a huge range of concerns were raised about the reforms and over the suggested timescale in which they should be implemented.
The King’s Fund warned that the reforms were “too far, too fast”. The influential think tank urged Mr Lansley to pilot GP commissioning first, and to place budgets with the most advanced consortia before rolling it out gradually when others can prove they are ready.
The warning prompted the health secretary to clarify publicly that he will not delay or scale back his reforms. Mr Lansley eventually announced groups of GPs will be invited to bid for “pathfinder status”, which are effectively pilots, but he is sticking to his plan to abolish all primary care trusts (PCTs), regardless of GP consortia’s progress, by 2013.
While The King’s Fund has lobbied for a slow and steady approach, the National Association of Primary Care (NAPC) is impatient to get started. The NAPC has been pushing for these reforms for nearly a decade, and is influential – its president, Dr James Kingsland, is also the DH’s clinical lead for practice- based commissioning (PBC).
Unlike the proposals set out in the white paper, the NAPC wants GP consortia to commission primary care services and hold GP practices’ contracts, meaning the profession would be effectively managing itself. The white paper proposes that GP practice contracts are held by the national commissioning
board to avoid the obvious conflicts of interest. But the NAPC argues that GPs must be able to commission primary care to effect change in local services. It also says a national commissioning board would never be able to monitor performance and data accurately across 8,000 GP practices.
Dr Kingsland believes it is “essential” that consortia can eject poor practices from their group, which would effectively put it out of business until it found another.
The NHS Alliance, in a contrasting response, believes the NHS Commissioning Board should retain the responsibility for contracting GPs.
“This would mean GP consortia act as collectives rather than being used as local enforcers,” says the Alliance’s chairman, Dr Michael Dixon. The NHS Alliance stresses the importance of practices getting along and co-operating, while the NAPC says practices that are not contributing enough to a consortia’s commissioning should face “financial losses”.
Market concerns
The British Medical Association’s GPs’ Committee (GPC) has remained fairly muted in these early discussions. Before the white paper, many believed that the GPC would be the main opponents to Mr Lansley’s plans. Surely they wouldn’t stand for GPs taking on all PCTs’ work for no extra income? But GPC Chairman Dr Laurence Buckman – despite continuing to tell the press “we don’t have enough detail to oppose anything yet” – has recently shown enthusiasm for the proposals. “It has the potential to save the NHS huge amounts of money,” he told MPs from the All Party Parliamentary Group on Primary Care.
The GPC has voiced concerned that the doctor-patient relationship could be adversely affected when GPs are in charge of painful rationing decisions. But it will really start to
shape the reforms when contract negotiations with the DH begin after Christmas.
The BMA’s response supports the concept of clinician-led commissioning, but opposes the greater use of the market as outlined in the white paper. The Association also fears that the white paper’s proposals to move towards local pay agreements, rather than national ones, will lead to poorer working conditions and an uneven spread of doctors.
Public sector unions and campaign groups also want to remove the internal market from the NHS. They see the proposals to open the NHS up to “any willing provider” as a route to true privatisation. But an attempt to block the white paper’s progress by Unison, using a judicial review, failed.
The NHS Confederation is very concerned too – understandably, because the white paper proposes that most of its members, NHS managers, will no longer be necessary. But their response also warns that the NHS cannot afford to dive into these unproven reforms while at the same time attempting to find £15-20bn in efficiency savings over the same period. More concerning for GPs, they are convinced the “management allowance” that consortia will receive is likely to be insufficient for them to function properly.
“During the transition period, existing commissioners will be distracted from the immediate task of managing the huge financial challenges facing the NHS,” the Confederation’s response says. “There will be a costly loss of the organisational memory, knowledge and expertise that any new commissioning bodies will require, as a result of management reductions in primary care trusts.”
David Stout, Director of the NHS Confederation’s PCT network, says that after the NHS’s management costs are reduced by a third and are then split between local authorities, the NHS Commissioning Board and GP consortia, the latter will be left with “not very much at all.”
Despite its concerns about the reforms, the NHS Confederation has drawn up the most comprehensive plans for the white paper’s implementation, with hundreds of practical steps to making each aspect work. They call for “open-book accounting” among GP consortia, and a requirement that any income a practice receives from its own consortium should be identifiable and auditable. Like the NAPC, it calls for GP consortia to have the power to intervene when a practice is impacting on the overall performance of the consortium. It also argues that “federations” of consortia could commission specialist services.
Another response of note came from the Local Government Group (LLG), which represents local authorities. They called to be made “lead commissioners” in many areas that GP consortia will be expecting to commission: long-term conditions, dementia services and mental health. They also want GP consortia to be legally required to get their plans signed off by local authorities.
The LLG were accused of “jockeying for power already” by NHS figures following their response, which could prove crucial as the DH decides which of the more ambiguous PCT functions (IT, estates, safeguarding) to devolve to local authorities and which will go to GP consortia.
One area where NHS organisations seem to have formed a consensus is the organisation of maternity services. Most agree that they should be commissioned by GP consortia, and not – as proposed in the white paper – centrally. Mr Lansley has already hinted that he is reconsidering, but says he has “not decided yet.”
It seems likely that “federations” of GP consortia will be able to commission specialist services, an idea generated by both the GPC and the NHS Confederation. Mr Lansley has backed the idea, saying it is a good way for small GP consortia to pool risk.
It is thought that the white paper consultation has attracted more than 6,000 responses. Of the GP organisations, the NAPC and NHS Alliance are the most enthused and influential, having championed clinical commissioning for years. The BMA is more cautious, recognising the huge opportunity for GPs to improve services, but concerned about workload and privatisation. The GPC will influence the contractual and funding technicalities at a later stage but at the moment it seems happy with the concept.
There is undoubtedly support for clinical commissioning, and there has not been enough strong opposition to force the government to rethink. All of the largest NHS organisations’ responses are constructive, with lots of additional ideas and proposals. For once, the DH has to listen. The white paper reforms present difficult questions that can only be resolved by the profession itself. The interesting question is not whether or not Mr Lansley listens, but to whom.

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