Consortia forecast

Beyond requiring every GP practice in the
country to belong to a commissioning consortium, the
Health and Social Care Bill is far from prescriptive about
the development of GP commissioning. There are few
requirements for consortia in terms of size, structure or
geographical coverage.

This lack of prescription and rapid pace of change
makes it difficult to predict what will happen over the next
four years. If pathfinder consortia are indicative of future

This lack of prescription and rapid pace of change
makes it difficult to predict what will happen over the next
four years. If pathfinder consortia are indicative of future
developments, we are likely to see around 300 consortia Beyond requiring every GP practice in the
country to belong to a commissioning consortium, the
Health and Social Care Bill is far from prescriptive about
the development of GP commissioning. There are few
requirements for consortia in terms of size, structure or
geographical coverage.

This lack of prescription and rapid pace of change
makes it difficult to predict what will happen over the next
four years. If pathfinder consortia are indicative of future
developments, we are likely to see around 300 consortia
ranging in size from clusters of two or three practices
covering fewer than 50,000 people to groups of several
hundred practices covering more than 500,000 patients.

Whether such variety in size will endure in the longer
term is up for debate. Learning from the US suggests that as
medical groups increase in size, they can struggle to retain
the engagement of their members.(1) This would suggest that
we might see increasing numbers of small groups of likeminded practices breaking away from larger consortia.

Conversely, learning from primary care trusts (PCTs), and practice-based commissioning (PBC) suggests that larger commissioning bodies have more influence over providers than smaller entities whose patients represent a negligible proportion of the provider's income.

Although there is no 'ideal' population size for a commissioner, it is thought that anything under 100,000 would make the management of risk of a global budget very difficult.(2) If we follow this line of argument, we are likely to see the emergence of larger GP consortia.

The question is whether consortia covering populations
of more than 500,000+ patients will be able to maintain crucial intraconsortium relationships and engagement.

Previous research has found that commissioning is most
effectively undertaken at a number of scales.(3) As such, we
are likely to see the emergence of cross-consortia groupings
which will make decisions best taken at a large scale. At the
same time, we are likely to see the creation of groups of
practices within consortia taking responsibilities for decisions
best taken at a local level.

However, different arrangements are likely to arise
according to local context. What works for an inner city
is unlikely to work for a rural area. Some consortia may
seek to retain alignment with a single local authority while others might straddle two or more local authorities. The
other key influence will be the extent to which the NHS
Commissioning Board (NCB) uses powers given to it in the
Bill to shape consortia and their internal structures.

What can we learn from PBC?
The accepted narrative about commissioning in the English
NHS is that it is 'weak'. Commissioning (at PCT and PBC
levels) has been branded ineffective, weak and passive by
successive reports, most critically by the House of Commons
Committee in March 2010. This report concluded that
commissioners have failed to bring about significant shifts
in activity from the acute sector, made little progress in
dampening demand and not succeeded in redressing the
imbalance of power between commissioners and providers.
Whether GP consortia will be more effective than previous.

incarnations of commissioning depends on a multitude of
factors, ranging from whether GPs will be equipped with the
necessary skills to whether the various elements of the wider
system operate as intended. Experience of PBC offers some
insight into the risks and opportunities which we will soon see
played out as pathfinders develop.

Governance and accountability
Clear accountability and governance structures within and
between consortia, and between consortia and with NCB,
will be central to the success of GP commissioning. Under
PBC, weak accountability meant that PCTs struggled to hold
GPs to account. The misalignment of financial risk and
reward meant that PCTs carried the financial risk of decisions
made by GPs. Indicative budgets did little to influence the
behaviour of a GP who chose not to engage with PBC. Under
the new arrangements it will be compulsory for a GP practice
to hold a real budget and to carry the financial risk for the
commissioning of all but a few specialist services. The hope
is that this will make them more aware of their referral
behaviour and lead to better use of resources. What remains
unclear at present is whether consortia, which will manage
the budgets of constituent practices, will have sufficient
powers to hold practices to account. There is also uncertainty
over how the NCB will hold consortia to account in practice.

The assurance framework is currently in development and it
will be critical that this framework allows the NCB to identify
early warnings of failure.

GPs, as both commissioners and providers of care,
will inevitably face conflicts of interest. Under PBC, PCTs
struggled to deal with conflicts of interest and, in response,
imposed increasingly cumbersome business case approval
processes.(4) Consortia will need to strike a careful balance
between implementing robust governance structures that
protect against financial failure and developing cumbersome
bureaucratic processes that stifle innovation.
One of the key lessons from PBC was that permissiveness
can lead to delays and tensions as different parties at the
local level struggle over roles and responsibilities.(5) GP
commissioning arguably allows an even greater level of
permissiveness and there is a lack of clarity over roles,
responsibilities and lines of accountability between consortia,
the NHSCB, local authorities, public health and Health and
Wellbeing Boards (HWBs). For instance, the responsibility for
ensuring coordination of commissioning has been assigned
to health and wellbeing boards but, with no direct line of
accountability from GPs to HWBs, it is not clear what powers
they will hold to enforce this.

Clinical engagement and relationships
The response to the Pathfinder initiative suggests that there
is a high level of engagement among GPs. What remains to
be seen is whether enough GP leaders will emerge to take
forward cross-consortia collaboration and large-scale service
redesign. PBC relied heavily on a small number of enthusiasts
– and, in some areas, the PCT – to drive it forward.

The reforms aim to inject real clinical involvement into
commissioning in an attempt to harness engagement.
Learning from studies of PBC demonstrate the importance
of relationships between GPs. King's Fund research into PBC
found that clusters making the most progress were those that
had come together voluntarily, consisting of like-minded GPs
with established relationships rather than those operating in
structures imposed by the PCT. The new arrangements allow
these natural groupings to emerge but one potential problem
is that some may not be large enough to manage risk.

One concern highlighted by many is the fact that the
focus so far is on GP commissioning, with the emphasis very
much on the GP. The same was true of PBC, which was very
much seen as a GP-only pursuit. The Bill, which currently
requires only that consortia obtain relevant 'advice' from
other professions risks missing a valuable opportunity
for integration across professional and organisational
boundaries. The loss of coterminous health and social care
boundaries is likely to put at risk progress made to integrate
services.

Reprovision of services versus strategic redesign
One positive impact of PBC was the development of
expanded primary care services and this is something that
GP commissioning could and should nurture. However, with
a few exceptions, GPs pursued the small-scale re-provision of
hospital-based services in their practices (eg, haematology)
at the expense of pursuing strategic and transformational
change. GPs largely left PCTs to lead such strategic change.(5)

The government's proposals do not make clear who will
be responsible for leading strategic change across consortia.
If cross-consortia alliances (as described above) emerge, they
will need to be of sufficient size and weight to lead change
and influence powerful providers. There is no requirement
for GPs to develop such structures and it is not clear whether
allowing them to emerge organically will be effective.

Skills: capacity and capability
A survey of practice-based commissioners found that 80%
felt they lacked some or all the necessary skills to be an
effective commissioner.(4) This skills deficit is likely to be
exacerbated because of the extended scope of roles and
responsibilities. Indeed, the most striking observation from
a recent simulation event (6) was the scale of the personal
and organisational development challenge. Although some
consortia will feel ready to take on real budgets very soon,
many will need to learn a range of new skills – from technical
data analysis and financial management through to contract negotiation and influencing. Leadership will be a critical skill
in bringing about successful collaborative working and in
driving large-scale strategic change.
Although there will be opportunities to buy in support,
GPs will be inexperienced users of such external support.

Research into the use of external support by PCTs suggests
that consortia will need to develop a good understanding
of what commissioning is and what skills they feel they are
lacking in order to use such support effectively.7 The creation
of PCT clusters, which may now survive beyond 2013, will be a
valuable source of support to emerging consortia. Many PCT
staff will seek to form their own support agencies that are
commissioned by GPs. In other cases, consortia might seek to
directly employ some (possibly former PCT) staff.

In addition to specific skills, a cultural shift is required:
GPs will need to accept that their responsibilities extend
beyond the proximal concerns of their clinical practice to the
health of the population for whom they commission services.

What does this add up to?
Although PBC provides insight into the risks and
opportunities that lie ahead, it should be acknowledged that
the reforms will create a very different system and GPs will be
taking on a range of new responsibilities. Unlike under PBC,
GPs will be managing real budgets; competing for patients;
contending with the Any Willing Provider policy and all the
transactional intricacies that that will entail; and, crucially,
they will be taking on some of the rationing powers previously
held by NICE – to name but a few. Limited central guidance and prescription, whilst opening up opportunities for local
innovation, runs the risk of duplicating time and effort. The
most immediate challenge is skilling-up GPs to take on their
new role and, particularly given the ambitious time-scale, the
scale of personal and organisational development should not
be underestimated.

Finally, it should not be forgotten that GPs will not just
be undertaking a significant shift in their responsibilities but
will be doing so during a time of unprecedented financial
constraint. The question remains whether they will be able
to meet the financial challenges while also grappling with
their new roles. As to whether consortia will offer more of
a challenge to dominant providers than their predecessors,
only time will tell.

References
1. Smith J, Walshe K (2004). Big business: the corporatization
of primary care in the UK and the USA. Public Money &
Management, vol24, no 2, pp87-96 Smith J (1999). 'Setting
budgets for general practice in the new NHS'. British Medical
Journal, vol 318, pp 776–9.
2. Smith J, Thorlby R (2010). Giving GPs budgets for
commissioning: what needs to be done? London: Nuffield
Trust.
3. Smith J, Curry N, Mays N, Dixon J (2010). Where next for
commissioning in the English NHS? London: The Nuffield Trust.
4. Wood J, Curry N (2009). Practice-based commissioning two
years on: Moving forward and making a difference? London:
The King's Fund.
5. Curry N, Goodwin N, Naylor C, Robertson R (2008). Practicebased
commissioning: Reinvigorate, replace, or abandon?
London: The King's Fund.
6. Imison C, Curry N, McShane M (Forthcoming).
Commissioning for the future: the learning from a
simulation of the health system in 2013/14. London: The
King's Fund.
7. Naylor C, Goodwin N (2010). Building high-quality
commissioning. What role can external organisations play?
London: The King's Fund.