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GP-led NHS - Towards effective commissioning

John Ford draws on his experience of working with PCTs to suggest practical steps for local GP leaders.

From primary to secondary care, GPs committed to making commissioning work will have to tackle the legacy of delays in PCT decision-making (Photograph: SPL)
From primary to secondary care, GPs committed to making commissioning work will have to tackle the legacy of delays in PCT decision-making (Photograph: SPL)

Some of the steps here may have been partly achieved already in health communities where substantial powers have been devolved to primary care. In other areas, it will mean starting from scratch.

Either way, it is advisable to get thinking now.

Issues to Consider
  • Local GP leaders.
  • PCT budget allocations.
  • Deficits and surpluses.
  • Information resources.
  • Funding for pilot projects.
  • Speedier decision-making.
  • Setting of priorities.
  • Strategy and governance.
  • Implementation plan.
  • Getting hospital clinicians on side.
  • Social care relationships.
  • Conflicts of interest.
  • Getting started.

Nurture GP leaders
Encourage any existing GP colleagues who have been involved in commissioning. Finding GPs committed to making commissioning work will be difficult initially because of the legacy of delays in PCT decision-making.

You need these leaders to take control from PCTs and some may be reluctant to hand it over.

Challenge budget proposals
Do not accept that budgets for 2011/12 are predetermined by the PCT. Understanding budgets and choices open to you is the key to effective commissioning.

To mount successful challenges you need to acquire dedicated accountancy time - and to let the accountant involved know that future work is tied to the GP commissioners.

Inflation and committed growth money take up a lot of any annual growth allocation and these assumptions must be reviewed.

If you do not challenge them you will find that there is precious little funding for developing new approaches to service provision.

You also need to uncover the 'inside story' on where there are schemes not using all of their allocated budget, unrealistic assumptions about savings and surpluses to compensate for overspends. PCT savings schemes to meet budget deficits are notoriously poor at delivering their full savings.

Understanding deficits
If you are faced with a pre-existing deficit, you need to ask for previous years' analysis to establish why and when the deficit started.

There will always be areas of expenditure that, on probing, are not as 'committed' as first suggested. Budgets are often maintained against schemes that have had a slow start and used for making good deficits elsewhere. Make sure that you have access to national tariff expertise and its implications for service delivery.

Look out for hospital services budgets still allocated on a block basis (not national tariff) as there is scope to negotiate these locally.

Use your local clinical expertise to examine any substantial drug expenditure falling within block or cost per case contracts.

Securing information resources
Information analysis has been the most useful resource in many primary care-based commissioning organisations, from fundholding to practice-based commissioning (PBC).

However, you may still find delays with ad hoc data requests or those that do not fit PCT priorities. Ask yourself whether you can currently obtain the information that you need quickly and reliably as all initiatives you set in place will need measures of outcomes and patient satisfaction as well as the traditional activity and capacity measures.

Making it real
Ensure your PCT immediately makes an uncommitted ring-fenced budget available for GP commissioners to test out new approaches for primary care-based service delivery.

This does not have to be a substantial budget, but it must be wholly delegated to avoid traditional lengthy delays in PCT approvals.

It will mean you can get started on a small scale, involve colleagues in something real, and see practical results at an early stage. The opportunity for small-scale, but long-awaited, changes will encourage GP participation.

Efficient internal decision-making
Do not replicate the PCT's bureaucracy by replacing it with your own. Previous GP commissioning organisations have sometimes lost members' commitment as a result of monthly meetings that had difficulty taking decisions and uncertain chairing and subsequently become 'talking shops'.

Commissioning consortia will need to become good at defining the objectives of service improvement schemes, identifying resources to make them happen, and then letting the lead clinicians get on with it until it is time to report back. You need a methodical and disciplined approach.

Setting priorities
Make sure the consortium focuses on areas where primary care can make the most difference. There will be a number of major ongoing issues within each PCT area but the added value of GP involvement in some of them may be small.

Do not spend time on these but ensure PCT staff are delegated to deal with them. You also need to make sure that you do not spread your time and expertise too thinly.

Focus on your core objectives and do not get distracted. Your priorities will determine the skills and roles you need to acquire rather than accepting PCT staff transfers and then working out what to do with them.

Strategy development
Do not allow others to delay progress on the grounds that you do not have the necessary strategy, plans and governance in place. You need a commissioning strategy that describes what you want to achieve.

Translate your discussions into a written strategy but make it brief. The test of a good strategy is that it is easily read, and that people refer to it regularly.

You also need an implementation plan setting out key stages, resources needed (information, personnel and finance), timescale, and the monitoring needed to test the outcomes. Make sure the presentation is straightforward and to the point.

If you can refer to service improvement that has already been proven elsewhere then so much the better. However, resist the temptation to make monitoring too complicated.

Clinician to clinician dialogue
If there is one lesson to be learnt from previous commissioning activity it is that clinician to clinician dialogue and agreement between primary and secondary care is key to rapid progress.

If clinicians are agreed on what needs to happen then it can happen fast. Take the initiative and set up that dialogue, keeping it specific to the specialty in question.

Avoid being sidetracked into large amorphous GP/consultant gatherings as these tend to propagate negative thoughts.

Patient safetyThere will be people looking to demonstrate that you have failed. An area of vulnerability may be clinical governance and patient safety. However good the individual clinical expertise, there need to be systems to confirm the necessary clinical processes, training and so on - and to demonstrate competence in the case of an incident.

Ensure you have a GP colleague who can exercise leadership in this area. They must be able to buy in specialist clinical governance advice and demonstrate the relevant documentation and reporting processes.

You need a manager with experience to look after the detail and make sure the correct information is fed to the GP lead.

Relationships with social care
Develop an independent relationship with your local authority's social services adult care and children's services commissioners.

Understanding the blockages in the discharge system and how patients can be supported at home will be crucial. You also need to establish links with local voluntary organisations that can provide flexible solutions to some of the gaps in current arrangements for social care packages.

This will take time but there is evidence that sorting out effective 'downstream' care arrangements has a major impact on pressures at admissions.

Conflicts of interest
A product of the proposed changes may be greater interest in developing primary care provider services, especially within the ambit of outpatient, diagnostics, ambulatory and intermediate care.

There will be formal DoH guidance about conflicts of interest and how to avoid them.

However, check at an early stage on your organisational arrangements for GPs wishing to provide services, so there is a clear boundary and openness about the different roles, and agreement on the practical measures for dealing with this.

You do not need to lose commissioning enthusiasts who also want to be involved in providing community services.

Seize the moment
While PBC groups and PCTs discuss organisational arrangements for commissioning consortia, this should not get in the way of practical preparations, and making sure commissioning really is primary care-led.

If primary care can take the initiative now it will reduce the risk of a long period of inaction, particularly in those areas where PCTs are reluctant to 'let go'.

This should also help ensure that the most appropriate local organisational arrangements are finally selected.

  • John Ford is an independent writer with experience at director level in PCTs and social service departments, john@fr-ltd.co.uk

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