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Viewpoint - Take stock of GP commissioning

Jamie Foster advises GPs to assess their position on PBC and prepare themselves for changes ahead.

Integrated care organisations are likely to become increasingly important for service delivery
Integrated care organisations are likely to become increasingly important for service delivery

The critics of practice-based commissioning (PBC) are many and voluble and, with a change of government likely in several months time, GPs can expect big changes to the scheme.

Practices may find themselves rather than PCTs in the commissioning driving seat with control over real healthcare budgets. As well as PBC changes, GPs could be required to take back 24-hour responsibility for patients.

It is therefore sensible to take stock of where you are in the commissioning landscape and of any opportunities you can take up now that will strengthen your practice for challenges ahead.

Where we are now
The DoH's latest GP practice survey of PBC take-up (July 2009) suggested that nine out of 10 practices in England are in a PBC group.

But only just over half of practices were commissioning services through PBC. Only three in five practices have submitted business cases for service redesign and half of practices have seen an increase in service provision.

This indicates that, under the current PBC rules, many GP practices still have the opportunity to become more involved in commissioning services.

This is likely to continue to be the case whichever party wins the next general election. The Conservative party has recently proposed an enhanced role for PBC, with GPs being required to perform commissioning functions, possibly through federations of practices operating as consortia.

By way of encouragement, current indicative budgets would turn into real budgets.

The current policy framework offers GP practices a number of opportunities under PBC, particularly where they collaborate by forming a consortium. These include 'strategic commissioning input', cutting service management costs and winning new services contracts, integrated care and providing services via social enterprises.

By putting forward plans to reconfigure patient services across a larger geographic area, practice consortia are able to wield greater influence with PCT commissioners.

Practices in PBC groups can make the most of the relationships they develop by putting in place arrangements for shared back office support. Pooling management and administration can cut costs and bring greater efficiency. Practices in the group could set up a management company to do this.

The DoH programmes for equitable access to primary medical care and transforming community services offer a range of opportunities for GPs to bid to provide services, for example by taking on community services or new GP-led health centres.

By working together, practices can share knowledge and skills to maximise the chance of winning contracts.

Practices can also consider partnering with other bodies, perhaps as part of integrated care organisations (ICOs). A national pilot scheme is under way and ICOs are likely to become increasingly important for service delivery.

Integrated care
The DoH's most recent PBC guidance, Clinical Commissioning: our vision for practice based commissioning (March 2009), suggests that a PBC consortium could form an ICO to take on direct responsibility for an extended budget, as well as providing primary care for a registered population.

ICOs could be developed with other stakeholders such as local authorities, children's trusts and private sector providers.

The use of social enterprises for delivering services is an important part of the DoH's agenda. For example, practices could set up social enterprises to bid for contracts where this gives a greater chance of success.

A social enterprise is designed to make a profit and there is scope for some of this to be paid to the organisation's owners as well as for reinvestment into the community or into service developments.

GPs may also be able to benefit from business support and funding from the DoH's Social Enterprise Investment Fund.

Consortia: What to watch out for

Setting up a consortium for PBC and service delivery raises a number of issues:

Governance arrangements
GP practices and PCTs must ensure that their responsibilities to each other are clear, for example for provision of information by practices and payment of incentives by PCTs.

Managing conflicts of interest
It is important for GPs to ensure that potential conflicts of interest are managed where they are involved in commissioning decisions where they may benefit as service providers.

Robust arrangements for managing conflicts of interest can help to reduce the risks of contracts awarded to GPs being challenged.

Contracting
Where a contract is awarded to a consortium for service delivery, the type of contract and its terms will be important. Should it be GMS, PMS or APMS or even the standard DoH community health services contract?

Legal form
Where GPs set up a consortium, consider whether this should be done by setting up a relatively informal contractual arrangement or some type of incorporated entity (a company) that would have the benefit of limited liability.

Pensions
Whether there is access to the NHS Pension Scheme will be a major factor in any consortium organisation set up by GPs. The type of organisation and who its owners are will directly affect access to the scheme.

Time factor
The lead time for thinking through, co-ordinating and setting up a new commissioning organisation for commissioning or providing services could be significant. So, with the prospect of a new administration coming to power within the next six months, now is the time to take action to ensure you are up and running and able to maximise the opportunities presented to you.

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