Grasping the gauntlet of change – the challenge for GPs

A brisk timetable is being set by the Secretary of State for Health as the NHS is marched inexorably towards the brave new world where GPs are in the vanguard of shaping and driving the “what” and “how” of health service delivery. Despite some forthright objections from GP organisations, the coalition government is determined to effect a radical change in NHS services and realise its long-term vision for the NHS as set out in the White Paper ‘Equity and Excellence: Liberating the NHS’.

At the heart of the change is the shift of decision-making to be as close as possible to individual patients by devolving power and responsibility for commissioning services to local consortia of GP practices. PCTs will be wound up by 1 April 2013. This fundamental change in system architecture will bring together responsibility for clinical decisions and for the financial consequences of these decisions.

Statutory basis
The White Paper indicates that GP commissioning will be put on a statutory basis, with powers and duties set out in primary legislation, due to be published in a draft Bill early in December. Consortia of GP practices, working with other health and care professionals, and in partnership with local authorities, will commission the great majority of NHS services for their patients. However, they will not be directly responsible for commissioning services that GPs themselves provide.

The new NHS Commissioning Board will calculate fair share practice-level budgets and allocate these directly to consortia. The consortia will hold contracts with various providers and may choose to adopt a lead commissioner model. GP consortia will need to include an accountable officer, and the NHS Commissioning Board will be responsible for holding consortia to account for stewardship of NHS resources and for the outcomes they achieve. In turn, each consortium will hold its constituent practices to account against these objectives. Every GP practice will need to be a member of a consortium, as a corollary of holding a registered list of patients.

A brisk timetable
Practices will have new flexibility within the new legislative framework to form consortia in ways that they think will secure the best healthcare and health outcomes for their patients and locality. The Department has said it wants implementation to be bottom-up, with GP consortia taking on their new responsibilities as rapidly as possible and early adopters promoting best practice.

The Secretary of State announced on 21 October a programme of pathfinder consortia, which will be supported to develop their ideas and form a learning network. Andrew Lansley said: “There will be no complex approvals process. Simply show that you have local GP backing, strong clinical leadership, engagement with your local authority and are fully signed up to the Quality and Productivity agenda locally.”

GPs now need start designing appropriate arrangements to respond to this new agenda. Mr Lansley wants 2011-12 to be “a year of substantive development of consortia relationships, engagement, leadership and identification of preferred support arrangements.”

Building consensus and leadership
It seems unlikely that the government will prescribe a model for GP consortia. GPs have the opportunity to seize the initiative and craft something that works for their locality. The White Paper was not clear on whether consortia would be statutory public corporations, or could instead be independent social enterprises.

Whichever is adopted, there is merit in starting to put in place governance structures now which facilitate leadership, cooperation and decision-making across a large group of practices. This includes choosing and developing a leadership team with a clear mandate to plan for the future and defining the organisation’s mission and values.

My experience in shaping PBC consortia is that it can take two years to get buy-in from practices, populate the board and agree the work programme. There is no time to lose in starting this process to full implementation by 1 April 2013.

A key aspect of successful consortia will be their ability to drive behavioural change. In the PBC consortia I have assisted, an attractive feature for members has been an extensive programme of education and training to help influence behaviour on referrals and prescribing, coupled with an incentive scheme which rewards success. These could be crucial ways to achieve wider buy-in.

Governance issues
As stewards of public funds, consortia will need to demonstrate robust policies and procedures. A particular area of risk will be the management of conflicts of interest. Written policies will be required to ensure that GPs who have an interest in the letting of a contract to their practice or a provider in which they have a stake, must absent themselves from decision-making on this issue.

Consortia may find it beneficial to clearly separate the functions of care pathway design, from those of actually letting and managing contracts. Accountable officers will need training on their legal duties and how to manage a wide range of risks, from financial overspend to clinical incidents and compliance with equalities legislation.

Legal and commercial traps

One key risk for consortia to consider is the extent to which consortia will inherit liabilities from outgoing PCTs. These could stem from two main sources. Firstly, the cost base and liabilities associated with any staff transferring from PCTs. Consortia must consider carefully whether support services could be outsourced to mitigate this risk or instead provided in-house by former PCT staff. If the former, then TUPE Regulations could apply to transferring PCT staff. Particular care is needed in assessing the payroll, pension and other costs (such as historic claims or enhanced redundancy rights) associated with these staff.

Secondly, consortia will need to avoid unwittingly taking on any structural debt or long-term liabilities associated with contracts or assets that may transfer when PCTs are wound up in 2013.

Consortia should develop or source skills to run tender processes, let, manage and, crucially enforce, contracts with a diverse range of service providers. Advice will be required on compliance with public procurement regulations for certain types of contract.

The new goal for GPs and their commissioning consortia is to deliver a radically different health system, where GPs understand what is being spent and the outcomes being achieved; and crucially, it must cost less to run. Prospective consortia should begin preparations now, and keep an open mind on how to deliver this daunting challenge.

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