Will the GPC successfully negotiate a directed enhanced service to deliver GPs' new commissioning duties instead of altering practices' contracts to make commissioning compulsory for all?
This is a big question to which the answer might not be known, unfortunately, for some time after the White Paper consultation period ends in October.
So the replies to the queries below are based on the details the DoH has provided so far.
Q: Does our practice have to join a consortium?
All practices will need to join a consortium, with configuration depending on local agreements with their PCT.
The sooner they do it, the better, as they can work together and lead the way on commissioning, rather then being told what to do and how to do it. While there are some large practices doing practice-based commissioning (PBC) on their own, they too will have to join a consortium. This will provide the back-up and other relevant expertise they will need.
Q: What if we disagree with our nearest consortium or it doesn't want us?
Although practices may not be forced to join any particular consortium, the key here is to start a dialogue with potential consortia as soon as possible to identify how each group works together.
By doing that, practices will also be able to create the timeline for merging to establish a large enough patient population and economies of scale, in order for the consortium to carry enough weight. It needs the capability to hold budgets, tackle local acute hospitals and, indeed, benefit from collective sharing of commissioning expertise.
Leading the way is crucial. Those practices that start making arrangements sooner are likely to find like-minded people with whom to pool expertise and resources.
Q: What financial incentives will the practice get in a consortium?
The higher the risk a consortium is willing to take on, the higher the incentives and rewards must be. However, the White Paper makes clear that incentives will not always be in the form of money.
Financial incentives can, for example, be the savings made through the freeing up of resources, which are returned to the consortium for reinvestment in services, commissioning and re-commissioning, based on local community needs.
Patients must be at the centre of decisions and, in many cases, the consortium will be able to offer a much better service to patients, which is an incentive in itself.
Q: Do we have to get very involved in commissioning or can we take a back seat?
Practices will be able to choose the level of involvement they take on. However, the active involvement of each will be critical to ensure collective responsibility.
That said, some practices may prefer to leave commissioning to other active GPs, supported by skilled commissioning managers and officers.
Those delegating responsibility need to be aware that their lack of commitment/involvement may mean being led by other people's decisions. So they will also have to abide by their consortium's decisions and not ignore them.
Q: Will our consortium be able to commission provider/GPSI services from our practice?
This is already happening in many parts of the country with services such as ENT, urology, gynaecology and cardiology services, enabling patients to access a more efficient service.
Conflict of interest is the key issue here, and the consortium will need to put a process in place, agreed collectively, to tackle that. The precise arrangements for how this will happen are yet to be decided and this is a very important part of what we need to get right if GP consortia are to work.
Q: What if one of the consortium practices is performing below par?
Performance reviews and joint working will result in a system that instils co-operation rather than competition.
In existing PBC groups, where a performance review system is in place, people feel supported to make the changes necessary to improve results.
Some have a performance review group with a collective terms of reference agreement where the prime objective is to monitor and performance-manage all practices.
In a consortium, any performance panel, or other such performance review processes, will be made up of GPs, practice managers and nurses, effectively encouraging peer-to-peer review and support.
Practices can be assessed on items such as prescribing, Payment by Results (activity referrals and the associated costs) and other referrals.
Q: What if we overspend our budget at practice or consortium level?
Any overspend issues should be picked up by the consortium early on by the performance review processes. In effect, this will give practices the opportunity to work out ways to nip the problem in the bud.
At a consortium level, the clear expectation is that there will not be overspends. The NHS Commissioning Board will have reserve powers to intervene in cases of failure and consortia need to be clear about what the implications of this are.
White Paper Timeline
2010/11: GP consortia to begin to form on a shadow basis and, where they are ready to do so, take on some responsibilities from PCTs.
2011/12: A comprehensive system of shadow consortia in place, taking on increased responsibility from PCTs including quality improvement plans (QIPPs). The NHS Commissioning Board to be established in shadow form as a special health authority from April 2011. 2012/13: Formal establishment of GP consortia. NHS Commissioning Board to become an independent statutory body and to announce the budget allocations that will be made directly to consortia in 2013/14.
2013/14: GP consortia to become fully operational.
Mo Girach is special adviser on social enterprise and co-operatives to the NHS Alliance. He is currently advising a number of well-established PBC groups, including hard budgets pilots.