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Business and the bill

Business and the bill

Feature: Policy
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GPs are often said to be 'the entrepreneurs of the NHS.' So when the White Paper Equity and Excellence: Liberating the NHS announced around £80bn of cash would be handed to the profession to run services, many will have seen a huge opportunity, rather than a threat.

But as the reforms become legislation in the Health Bill, there are many aspects of the new NHS architecture that remain complicated and concerning.

Where do the best business opportunities lie and what must GPs beware of before forging ahead with them?

Health Secretary Andrew Lansley's reforms will most notably transfer commissioning responsibility from PCTs to GP commissioning consortia by 2013.

Dr Angela Lennox, GP and Senior Lecturer at Leicester University, is a former Department of Health (DH) advisor and GP entrepreneur. "The development of consortia will bring lots of opportunities for GPs," she says.

"This is the obvious place for GPs to take on new roles, which will of course be funded."

From this April, emerging consortia will receive funding to pay GPs for the time they spend contributing to commissioning in the area.

John Restell, Chief Executive of manager's union Managers in Partnership, predicts there will be a number of senior roles that could pay comparable salaries to those of PCT directors. A consortium's accountable officer and director of finance will be particularly important roles as the NHS budget tightens.

A proportion of consortia's budget will also be available to buy in any support services they need. This is where the private sector is expected to profit most from the reforms, providing anything from IT, informatics, estates and asset management, or consultancy on governance and risk. Although corporate giants like KPMG and UnitedHealth UK are already providing these services, there is no reason why GPs shouldn't too if they have local solutions to share.

Though there will be new roles for GPs as commissioners, resources will be tight. Consortia will have to function on around a third of the running costs that PCTs currently receive – so any money spent on staff positions and outsourcing is likely to be restrained. There are also concerns about the 'quality premium' – the bonus paid to the most innovative and cost-effective consortia.

The BMA opposes the bonuses because it feels pressure to keep consortia budgets on track could distort GPs' clinical decisions. The government also recently signalled that quality premium cash will not be allowed to be taken out as profit but must be reinvested in services for patients.

Providing services, rather than commissioning them, may prove to be more profitable, according to Dr Johnny Marshall, Chairman of the National Association of Primary Care.
He believes GPs should look at providing new types of clinical or community service.

As GP commissioners look to move services out of hospital into the community, using 'Any Willing Provider', GPs are best placed to design them, he says.

"It's almost becoming irrelevant who provides what now. GPs should be looking to provide services in new ways that save money by preventing a cost in another place. A good example is a Warfarin-monitoring enhanced designed by GPs. It's local, creates high patient satisfaction and reduces hospital admissions."

If a service improves patient satisfaction and provides value for money alongside the aims of QIPP (the government's Quality, Innovation, Productivity and Prevention programme), "commissioners will have to look at it," says 
Dr Marshall.
Dr Lennox says there are many more opportunities in primary care. As services move out of hospital into the community, GPs should step up and help house them, 
she says.

"There are opportunities everywhere – including the estate in which we are practising.

"GPs should be looking at their own buildings and how they can accommodate the new range of community services. You can generate new income streams by working with community trusts or housing services like diagnostics." And as the NHS opens up to new providers, with more clinically-minded commissioners in charge, private companies are also looking for GPs to work with them to provide services, says 
Dr Lennox.

"There are already lots of companies looking to get closer to GPs – it's about deciding whether you want to be a provider of community services or if you want to join in partnership with a company looking to provide such services."

Dr Marshall believes the coalition government's focus on public health will also bring opportunities for GPs. Local authorities will be responsible for public health as well as social care by 2013. 

This means GPs can create services across sectors and attract funding from pooled budgets, says Dr Marshall.

"Often the benefit of a public health service may not sit in the healthcare budget – for example a 'back to work' service – and may actually take money out of the healthcare budget. If there are good relationships with local authorities, they can pool budgets with health commissioners to save money in the long-term."

If GPs have an idea for a service but are still lacking funding or support, speak to neighbouring practices, advises Dr Marshall.
"Practices federating as a group allow GPs to create services that they would not be able to provide as individuals," he says. 

There is a whole range of new roles and opportunities for GPs to contemplate. But the profession should be aware of the potential pitfalls of developing a business in the new NHS. 
Both providers and commissioners will be under the close scrutiny of economic regulator Monitor, which will ensure there is no anti-competitive behaviour or conflicts of interest.

"It therefore may be advisable to stay clear of a major role in both commissioning and provision," advises Dr Marshall.
"Providing a service beyond your own practice population will be difficult if you are commissioning in the same area. 
If you're about to set yourself up with a multi-million pound deal you should think twice about a commissioning role," 
he says.

Dr Lennox feels a big danger is that GP consortia do not evolve into the responsive, clinically-led groups they are meant to be. If Monitor's regulations prevent GPs commissioning things like enhanced services from their own practices, opportunities could also dry up, she warns.

"We need to find a solution in which there is clear governance and transparency in the new system that does not hinder excellence."

For Dr Marshall, it is important GPs find roles that suit them.  "It would be a shame if we lost our best entrepreneurs from the commissioning side because it was not as rich a seam as provision.

"Ultimately, we want the best people working for patients."

Tom Clarke

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