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What should I be doing now?


12 January 2011

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The government has now published and finished
consultation on its white paper Equity and Excellence:
Liberating the NHS, and its four supporting consultation
documents: Transparency in outcomes – a framework for the NHS; Commissioning for patients; Local democratic legitimacy in health; and Regulating healthcare providers.

There is now a pause as responses to the consultation
are collated and legislation drafted to progress this highly
ambitious reform program. Practices will now look to the

The government has now published and finished
consultation on its white paper Equity and Excellence:
Liberating the NHS, and its four supporting consultation
documents: Transparency in outcomes – a framework for the NHS; Commissioning for patients; Local democratic legitimacy in health; and Regulating healthcare providers.

There is now a pause as responses to the consultation
are collated and legislation drafted to progress this highly
ambitious reform program. Practices will now look to the
response to the consultation as well as the publication of the
NHS Operating Framework for 2011/2012 and the legislation
itself, all published in mid December.

In the meantime there is much speculation over
management allowances, timescales and likely definitions
for consortia structures, but as yet no firm detail has been
announced. Indeed, at present the white paper remains
mainly a “big idea”, with very little supporting detail on
the likely future functions of GP consortia and what will be
mandated and what will not.

However, the momentum towards GP commissioning
consortia (GPCC) has started, most noticeably in primary
care trusts (PCTs) and strategic health authorities (SHAs),
where key staff are already leaving their posts. Many PCTs are
already sharing management structures and preparing for
their imminent demise.

GP practices and current practice-based commissioning
(PBC) groups are already reviewing their structure and form
to prepare for the new challenge, yet many remain sceptical
and disbelieving that change will occur quite as the white
paper outlines.

For practices and current PBC groups it is a difficult time
to prepare for what is likely (but not certain) to happen,
without detail on crucial elements of the future task.

Function before form
This is a crucial question to ask when designing and planning
likely future consortia structures, but as yet all that is clear is
the range of services GPCC are expected to commission.

Basically, this is everything apart from primary care
contracts, specialised services and for some odd (probably
political) reason, maternity services. The health secretary
has promised a review of current PCT functions and plans to
reduce these drastically before GPCC take legal responsibility
in 2013. Some, like public health, will transfer to local
authorities, some will transfer to the NHS Commissioning
Board and some will be removed by legislation – but we do
not know which, where and when!

So take care in designing any final consortia structure
now – that may need to change. Also, details of the proposed
management allowance will dictate what is affordable
(roughly £10 per patient is the current rumoured figure).

However, looking at what we do know now, ie, the scope
and size of the relevant components of the proposed
commissioning streams, the focus is clear – usually more than
50% of the budget will be spent on local acute trusts, with
around 15% on prescribing and 10% on mental health.

Whatever else you decide, the need to manage contracts
with local acute trusts should be pre-eminent in your thinking
for forming consortia.

So right now, practices should be meeting to discuss the
challenges and also checking their budget lines and their
“NHS resource footprint” to see where their NHS resources
are spent, and comparing these with others.

In the future, as now, cash will be king. Whatever is said
about quality markers and health outcomes, it is the financial
constraints that will be the biggest challenge for GPCC in an
era of flat cash in the NHS.

The NHS pathfinder programme offers possible
development and financial support to those keen to look at
taking on responsibilities from PCTs earlier, but again there is
no clear detail as yet. But why not apply anyway to your SHA
and see what transpires?

Consortia structure and size
Structure
We know from the white paper that GPCC will be statutory
public bodies. So there will have to be some central
definition of their structure, and some key roles – such as an accountable officer who may be a clinician or manager.

At present, it is probably wise to wait a while to see some
more detail before engaging legal or accountancy advice on
forming legal entities for GP consortia.

Those consortia who already are legal bodies have the
advantage of being able to employ staff directly, but if your
local PBC group is as yet not a legal entity, there is little reason
to become one now unless you wish to employ staff directly at
this time.

By the time you read this, the December publications
should be available. This will be the right time to reappraise
the situation, though there is likely to be more clarity yet not
definitive detail.

Size, form and fit
Now is also very much the time to start scoping likely future
consortia ‘fit’ with local practices: who can work with whom?
What groupings will make for effective engagement with
practices and local authorities, while being large enough to
manage risk?

There are two potential basic models here:
1. Think big as a statutory body to manage risk (a
population size of roughly 500,000), and then federate
down into small locality structures to engage with
practices but within the corporate whole.
2. Form small and lean consortia around groups of practices
that work well together and then ‘federate up’ with other
local consortia to share central functions and manage
financial risk.

As yet, there is no right or wrong answer. It is clear that
consortia size will not be centrally dictated, so scope both of
the above models and investigate further detail in December.
Working with PCTS

PCTs have already ‘woken up and smelt the coffee’ that GP
commissioning is mandated as the future direction, even
though some of them still hope and believe that their demise
may not come as soon as 2013.

But PCTs will remain accountable until then, and have
major cost savings through the QIPP (Quality, Innovation,
Productivity and Prevention) and also management cost
savings to achieve. So now is very much the time to reengage
with PCTs and look to explore how you can take on
responsibility for commissioning functions in the interim.

The key is to explore ‘interim solutions’ with the PCT
without prejudice. Find consortia functions that allow
the PCT to deploy more human and financial resources
to support GPCC and involve you more in their work
programmes.

In many cases, professional executive committees (PECs)
are being abolished and replaced with commissioning
cabinets, with lead GPs and managers from commissioning
groups helping to direct the PCT’s work programme.
Engage in the QIPP programme and help the PCT balance
its books now so that your consortia don’t start life saddled
in debt!

The key message here is to get involved and set the
agenda. Don’t let the PCT dictate your future –
consortia should be shaped and agreed by you, not imposed
from above!

Engage with local authorities
The white paper gives many new powers to local authorities:
public health, a key role in agreeing local health
commissioning plans and scrutiny through local elected
members and the public via Health Watch. Many are
ambitious about their future roles, yet have been hit hard by
budget cuts that could impact on commissioning through
cutbacks in social care funding.

Exactly how this will all work is unclear. A new public
health paper is expected in the new year, but I suggest you
build relationships now with key executives and members –
you will need to work closely with them in future, and you
will need them onboard!

Ensuring democratic legitimacy in consortia
Finally, do not forget that current commissioning groups or
commissioning legal bodies will need to refresh their mandate
with local practices before moving to statutory bodies. This
is to ensure practices feel they ‘own’ the consortia that will
play such a vital role with them in future, so some form of
democratic process will be needed.

The British Medical Association (BMA) is producing
guidance here, and local medical committees (LMCs) clearly
see their role as ensuring this, so it is worth planning how
this might work. For now, I suggest that any democratic
mandate is renewed for whatever you decide to do between
now and 2013, as the political environment and reality of
commissioning has changed radically in the last few months.

The known unknowns
Many absolutely vital questions have to be answered before
consortia can definitively plan their role. The ones that will
have to be defined centrally are as follows:
• Who will be the successor organisations, in legal terms, to
PCTs, responsible for legal and financial obligations to
;staff and through contracts – GPCC or the NHS
Commissioning Board?
• Who will be responsible for primary care IM&T budgets,
premises and hosting responsible officers?
• What exactly will the mandatory legal structure of
GPCC be?
Keep looking out for updates from the Department of
Health. This is a very fluid environment, involving “big bang
politics” – the script may change radically along the way!

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