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Emergent response

Emergent response

12 January 2011

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First, NHS Chief Executive Sir David Nicholson
predicts there will be “no great surprises” in the Department
of Health’s (DH) next steps, claiming that there was “broad
support” from nearly all parties. But while few argued
against the concept of GP-led commissioning, a huge range
of concerns were raised about the reforms and over the
suggested timescale in which they should be implemented.

The King’s Fund warned that the reforms were “too far,

First, NHS Chief Executive Sir David Nicholson
predicts there will be “no great surprises” in the Department
of Health’s (DH) next steps, claiming that there was “broad
support” from nearly all parties. But while few argued
against the concept of GP-led commissioning, a huge range
of concerns were raised about the reforms and over the
suggested timescale in which they should be implemented.

The King’s Fund warned that the reforms were “too far,
too fast”. The influential think tank urged Mr Lansley to
pilot GP commissioning first, and to place budgets with the
most advanced consortia before rolling it out gradually when others can prove they are ready.

The warning prompted the health secretary to clarify publicly that he will not delay or scale back his reforms. Mr
Lansley eventually announced groups of GPs will be invited to
bid for “pathfinder status”, which are effectively pilots, but he
is sticking to his plan to abolish all primary care trusts (PCTs),
regardless of GP consortia’s progress, by 2013.

While The King’s Fund has lobbied for a slow and steady approach, the National Association of Primary Care (NAPC) is impatient to get started. The NAPC has been pushing for these reforms for nearly a decade, and is influential – its president, Dr James Kingsland, is also the DH’s clinical lead for practice based commissioning (PBC).

Unlike the proposals set out in the white paper, the NAPC wants GP consortia to commission primary care services and hold GP practices’ contracts, meaning the profession would be effectively managing itself. The white paper proposes that GP practice contracts are held by the national commissioning
board to avoid the obvious conflicts of interest. But the
NAPC argues that GPs must be able to commission primary
care to effect change in local services. It also says a national
commissioning board would never be able to monitor
performance and data accurately across 8,000 GP practices.

Dr Kingsland believes it is “essential” that consortia can
eject poor practices from their group, which would effectively
put it out of business until it found another.
The NHS Alliance, in a contrasting response, believes the
NHS Commissioning Board should retain the responsibility
for contracting GPs.

“This would mean GP consortia act as collectives rather
than being used as local enforcers,” says the Alliance’s
chairman, Dr Michael Dixon. The NHS Alliance stresses the
importance of practices getting along and co-operating, while
the NAPC says practices that are not contributing enough to a
consortia’s commissioning should face “financial losses”.

Market concerns
The British Medical Association’s GPs’ Committee (GPC)
has remained fairly muted in these early discussions. Before
the white paper, many believed that the GPC would be the
main opponents to Mr Lansley’s plans. Surely they wouldn’t
stand for GPs taking on all PCTs’ work for no extra income?
But GPC Chairman Dr Laurence Buckman – despite
continuing to tell the press “we don’t have enough detail
to oppose anything yet” – has recently shown enthusiasm
for the proposals. “It has the potential to save the NHS
huge amounts of money,” he told MPs from the All Party
Parliamentary Group on Primary Care.

The GPC has voiced concerned that the doctor-patient
relationship could be adversely affected when GPs are in
charge of painful rationing decisions. But it will really start to
shape the reforms when contract negotiations with the DH
begin after Christmas.

The BMA’s response supports the concept of clinician-led
commissioning, but opposes the greater use of the market
as outlined in the white paper. The Association also fears
that the white paper’s proposals to move towards local pay
agreements, rather than national ones, will lead to poorer
working conditions and an uneven spread of doctors.

Public sector unions and campaign groups also want to
remove the internal market from the NHS. They see the
proposals to open the NHS up to “any willing provider” as a
route to true privatisation. But an attempt to block the white
paper’s progress by Unison, using a judicial review, failed.

‘Huge financial challenges’
The NHS Confederation is very concerned too –
understandably, because the white paper proposes that most
of its members, NHS managers, will no longer be necessary.
But their response also warns that the NHS cannot afford
to dive into these unproven reforms while at the same time
attempting to find £15-20bn in efficiency savings over the
same period. More concerning for GPs, they are convinced
the “management allowance” that consortia will receive is
likely to be insufficient for them to function properly.

“During the transition period, existing commissioners will
be distracted from the immediate task of managing the huge
financial challenges facing the NHS,” the Confederation’s
response says. “There will be a costly loss of the organisational
memory, knowledge and expertise that any new
commissioning bodies will require, as a result of management
reductions in primary care trusts.”

David Stout, Director of the NHS Confederation’s
PCT network, says that after the NHS’s management
costs are reduced by a third and are then split between
local authorities, the NHS Commissioning Board and GP
consortia, the latter will be left with “not very much at all.”
Despite its concerns about the reforms, the NHS

Confederation has drawn up the most comprehensive
plans for the white paper’s implementation, with hundreds
of practical steps to making each aspect work. They call
for “open-book accounting” among GP consortia, and a
requirement that any income a practice receives from its own
consortium should be identifiable and auditable. Like the NAPC, it calls for GP consortia to have the power to intervene
when a practice is impacting on the overall performance of
the consortium. It also argues that “federations” of consortia
could commission specialist services.
“Jockeying for power”

Another response of note came from the Local Government
Group (LLG), which represents local authorities. They
called to be made “lead commissioners” in many areas that
GP consortia will be expecting to commission: long-term
conditions, dementia services and mental health. They also
want GP consortia to be legally required to get their plans
signed off by local authorities.
The LLG were accused of “jockeying for power already”
by NHS figures following their response, which could prove  crucial as the DH decides which of the more ambiguous
PCT functions (IT, estates, safeguarding) to devolve to local
authorities and which will go to GP consortia.

One area where NHS organisations seem to have formed
a consensus is the organisation of maternity services. Most
agree that they should be commissioned by GP consortia, and
not – as proposed in the white paper – centrally. Mr Lansley
has already hinted that he is reconsidering, but says he has
“not decided yet.”

It seems likely that “federations” of GP consortia will be
able to commission specialist services, an idea generated by
both the GPC and the NHS Confederation. Mr Lansley has
backed the idea, saying it is a good way for small GP consortia
to pool risk.

Time to listen
It is thought that the white paper consultation has attracted
more than 6,000 responses. Of the GP organisations,
the NAPC and NHS Alliance are the most enthused and
influential, having championed clinical commissioning for
years. The BMA is more cautious, recognising the huge
opportunity for GPs to improve services, but concerned
about workload and privatisation. The GPC will influence the
contractual and funding technicalities at a later stage but at
the moment it seems happy with the concept.

There is undoubtedly support for clinical commissioning,
and there has not been enough strong opposition to
force the government to rethink. All of the largest NHS
organisations’ responses are constructive, with lots of
additional ideas and proposals. For once, the DH has to
listen. The white paper reforms present difficult questions
that can only be resolved by the profession itself. The
interesting question is not whether or not Mr Lansley listens,
but to whom.

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