DH is now launching a consultation and engagement process on how the
Government should implement these proposals. The document ‘Liberating
the NHS: commissioning for patients’ provides more detail on
proposed arrangements and seeks views on a on a number of areas including:
How GP consortia and the NHS Commissioning Board can best involve
patients in improving the quality of health services
How GP consortia can work closely with secondary care, community partners
and other health and care professionals to design joined-up services
that are responsive to patients and the public
How the NHS Commissioning Board and GP consortia can best work together
to make effective and efficient commissioning decisions
How the NHS Commissioning Board can best support consortia and ensure
they achieve improvements in outcomes within NHS resources
This consultation is part of the wider White Paper consultation.
The Royal College of Physicians of Edinburgh welcomes the opportunity to respond
to the outline proposals laid out in this consultation document. This
complements the policy intentions included in the White Paper “Equity
and Excellence: Liberating the NHS”, to which the College has also responded.
The College understands and accepts the need for radical change given the
demands on the NHS at a time of financial hardship, and is committed to working
with government and other stakeholders to deliver effective change for the
benefit of patients and staff. The vision and many of the high level
policy objectives within the White Paper are very welcome, with a return to
clinical focus and local operational control, clear patient input and “joined
up” healthcare. The emphasis on clinical outcomes is also very
welcome.
Additional comments follow the questions listed in the consultation document.
- In what practical ways can the NHS Commissioning Board most effectively
engage GP consortia in influencing the commissioning of national and regional
specialised services and the commissioning of maternity services?
It
seems inevitable that the NHS Commissioning Board will require a regional
structure to create links with GP consortia and support the development of
regional services. National services may have to rely on representative
lead GP consortia and broad consultation.
Commissioning and payment of emergency services may be a particular challenge
for GP consortia in terms of needs assessment and the allocation of budgets
by population.
-
How can the NHS Commissioning Board and GP consortia best work
together to ensure effective commissioning of low volume services?
As in (1) above, a level of regional co-ordination will be required to replace
the role of the SHA and PCTs. Highly specialised services (low volume)
will require national commissioning against accurate needs assessments which
will be delivered through the local authority based “health and well
being boards”. Smaller GP consortia may struggle to commission
low volume services in the absence of the benefits of “collective risk”.
- Are there any services currently commissioned as regional specialized
services that could potentially be commissioned in the future by GP consortia?
PCTs and SHAs are best placed to respond to this question, but there may need
to be lead consortia who liaise with others across their region (as yet ill
defined) to ensure tertiary services are commissioned and available in line
with local need.
- How can other primary care contractors most effectively be involved
in commissioning services to which they refer patients, e.g. the role of
primary care dentists in commissioning hospital and specialist dental services
and the role of primary ophthalmic providers in commissioning hospital
eye services?
No specific comment.
- How can GP consortia most effectively take responsibility for improving
the quality of the primary care provided by their constituent practices?
GP consortia will have to agree within their contractual arrangements
with the NHS Commissioning Board to set and monitor quality standards (including
implementation of NICE quality standards) as applied by their constituent
practices. This
will in effect be self-monitoring which could create (or be perceived to create)
a conflict of interest, particularly as the capacity of the NHS Commissioning
Board to monitor contracts is unclear and may also rely on self-reporting. Patient
access to monitoring data will be critical to counter the perception of
self-monitoring.
- What arrangements will support the most effective relationship
between the NHS Commissioning Board and GP consortia in relation to monitoring
and managing primary care performance?
PCTs and SHAs are best placed to comment on this given current responsibilities,
but the College is anxious that effective quality assurance of GP consortia
can be achieved through a single centralised board.
- What safeguards are likely to be most effective in ensuring transparency
and fairness in commissioning services from primary care and in promoting
patient choice?
Safeguards include clear publication of the level of services, quality standards
and monitoring reports and a line of enquiry/complaint to the central NHS Commissioning
Board.
Patient choice may be a theoretical concept only if GP consortia include all
GP practices within a given locality.
Ensuring the practicality of the proposed timetable will be critical in the
short term, with the plans to abolish the PCTs by April 2013 and GP consortia
to take over commissioning as soon as local circumstances allow.
- How can the NHS Commissioning Board develop effective relationships
with GP consortia, so that the national framework of quality standards,
model contracts, tariffs, and commissioning networks best supports local
commissioning?
PCTs and SHAs are best placed to comment on this, given current responsibilities.
However, the College is unclear why maternity services have been removed from
the commissioning role of the consortia and will be handled centrally by the
NHS Commissioning Board.
Will commissioning consortia have any discretion over the services they have
responsibility to commission such that the NHS Commissioning Board will be
the “commissioner of last resort”, and will it have the capacity
to discharge this responsibility?
The national framework of quality standards as proposed is laudable but ambitious
in terms of the current status of clinical information systems and the potential
for significant duplication with current quality standards developed by professional
bodies including Royal Colleges.
- Are there other activities that could be undertaken by the NHS
Commissioning Board to support efficient and effective local commissioning?
The commissioning of training programmes in support of the new national commissioning
responsibilities would perhaps be helpful.
The NHS Commissioning Board, in partnership with Medical Education England
should ensure that the postgraduate medical training responsibilities of healthcare
providers are discharged fully in terms of compliance with education contracts
with Deaneries.
- What features should be considered essential for the governance
of GP consortia?
The governance arrangements for these new GP consortia are far from clear,
and the College would welcome confirmation of how the consortia will be held
to account for their performance, for the quality of care provided and the
financial risk in the event of failure. Questions include:
- Will they be constrained by public appointment rules for their governing
boards and required to produce annual reports as public documents?
- Will there be standard job descriptions and salary levels for executive
positions on the consortia?
- How will the Commissioning Board ensure that public funds awarded to
private companies or individual practices that may take over local commissioning
responsibilities from consortia are used appropriately and effectively?
- How will the Commissioning Board remove the possibility of conflicts
of interest for GPs commissioning (secondary care) services where they
may be a potential, competing provider?
Also, paras 3.18 and 3.19 clearly state that NHS Commissioning Board may delegate
quality monitoring of some aspects of primary care services to GP consortia. This
is of concern where GP practices may be failing in weaker consortia.
The consultation document advises that the Commissioning Board will support
the consortia by developing commissioning guidelines, model contracts and tariffs
(para 1.17), and it is unclear how prescriptive this will be given the governments
policy imperative to remove top down control.
- How far should GP consortia have flexibility to include some practices
that are not part of a geographically discrete area?
If a key aim of these changes is to create locally responsive services through
GP consortia, the addition of GP practices from outwith the area will add complexity
in terms of joint working with social care providers and will add to the administrative
burden. The parallel document “local democratic legitimacy in health” requires
local authorities to lead on health needs assessment to inform commissioning
and if consortia are not coterminous this will be difficult.
Also, it is unclear how commissioning budgets be allocated if not on a population
basis in terms of weighting for social deprivation etc. Will the proposed
legislation give the Commissioning Board the power to require independent GP
practices to join a particular consortium?
- Should there be a minimum and/or maximum population size for GP
consortia?
It would make sense for broad parameters to be set lest some areas find themselves
with multiple commissioning consortia with the potential to destabilise providers
of care and limit economies of scale.
- How can GP consortia best be supported in developing their own
capacity and capability in commissioning?
This will vary with the ambitions and interests of local GPs, and the College
anticipates many looking to buy-in commissioning expertise rather than developing
from within. This raises the issue of the deliverability of the anticipated
45% management efficiency savings.
What will be the status of any surpluses in management funds allocated by
the NHS Commissioning Board – will these funds be ring fenced for NHS
services?
- What support will GP consortia need to access and evaluate external
providers of commissioning support?
Each consortium will require expert quality monitoring staff, well developed
clinical information systems and time for the consortium board (or equivalent)
to assess monitoring data and liaise with key staff in provider units. This
will also place a significant quality monitoring burden on the provider units
to communicate and report to multiple consortia rather than a single PCT/SHA,
all of which will require funding and further development.
- Are these (paras 5.6 – 5.10) the right criteria for an effective
system of financial risk management? What support will GP consortia need
to help them manage risk?
Financial Management systems will be required by consortia to underpin their
commissioning activities, and the consultation is silent on how this will be
achieved and who will fund the IT development/equipment required to allow efficient
transactions in secondary care with (future multiple) commissioners.
The consultation makes it clear that the NHS Commissioning Board will have
the power to intervene with failing consortia (para 2.18) and the College is
concerned that this “arms length” scrutiny will be sufficiently
robust to protect patients and staff from organisational failure. Para
5.8 refers to risk management but offers no solutions to the clear risks in
the proposals, which is alarming given the proposed pace and scale of change
and the absence of pilots.
- What safeguards are likely to be most effective in demonstrating
transparency and fairness in investment decisions and in promoting choice
and competition?
The College strongly supports initiatives to improve efficiency in the NHS
but has concerns about introducing competition in healthcare where key players
may be under no obligation to provide the more challenging services and/or
where organisations could fail, leaving local patients and staff vulnerable. Similarly,
the College is unclear how much choice is expected or required by the majority
of patients, and whether this can be afforded at a time of financial constraint.
- What are the key elements that you would expect to see reflected
in a commissioning outcomes framework?
It will be important not to confuse quality standards for commissioning with
quality standards for healthcare. Commissioning standards should reflect
good value for money, effective and proportionate monitoring regimes, clear
attention to local healthcare assessments, budget management and effective
business relations with other providers.
- Should some part of GP practice income be linked to the outcomes
that the practice achieves as part of its wider commissioning consortium?
GPs will be better placed to respond, but it will be important not to
confuse effectiveness of care with the effectiveness of the commissioning
process. This
illustrates clearly the potential conflict of interest when healthcare providers
are also commissioners. However, all consortia must be held to account
for the quality of their commissioning and financial penalties will provide
an effective lever.
- What arrangements will best ensure that GP consortia operate in
ways that are consistent with promoting equality and reducing avoidable
inequalities in health?
GPs will need access to public health expertise and data to inform their local
commissioning plans. Therefore, close working with the new public health
service and local Directors of Public Health embedded within local authorities
will be critical.
- How can GP consortia and the NHS Commissioning Board best involve
patients in making commissioning decisions that are built on patient insight?
The consultation on the outcomes framework is considering how best to incorporate
patient views into the quality assurance of local services. A parallel
strand of work on health needs assessment will be required for each GP consortium.
- How can GP consortia best work alongside community partners (including
seldom heard groups) to ensure that commissioning decisions are equitable,
and reflect public voice and local priorities?
The smaller the population served by a GP consortium, the more difficult will
be the challenge of commissioning in line with the wishes of patients and simultaneously
providing comprehensive coverage for rare/highly specialised services. In
many ways, ensuring the GP consortia are coterminous with social care populations
and their public health expertise would be helpful. Whether this can
be cost-effective is debatable given the financial problems facing the smaller
PCTs in the current structure.
- How can we build on and strengthen existing systems of engagement
such as Local HealthWatch and GP practices’ Patient Participation
Groups?
No comment at this stage
- What action needs to be taken to ensure that no-one is disadvantaged
by the proposals, and how do you think they can promote equality of opportunity
and outcome for all patients and, where appropriate, staff?
PCTs operate a panel system whereby patients denied treatment can apply for
individual review. Such a system will be required by each consortia and
patients must be protected from delay in accessing treatment. The NHS
Commissioning Board will have a role in preventing postcode provision to protect
equality of opportunity, but there is potential for conflict between local
preferences and national provision of care.
- How can GP practices begin to make stronger links with local authorities
and identify how best to prepare to work together on the issues identified
above?
Securing expertise, shared information systems and management to forge essential
working relationships will be critical, and the resource implications of this
should not be underestimated.
- Where can we learn from current best practice in relation to joint
working and partnership, for instance in relation to Care Trusts, Children’s
Trusts and pooled budgets? What aspects of current practice will need to
be preserved in the transition to the new arrangements?
No comment at this stage
- How can multi-professional involvement in commissioning most effectively
be promoted and sustained?
Clearly, a medical model of commissioning would be inadequate without input
from nursing and other healthcare professions. Para
2.21 is unclear as to who will have the lead responsibility for delivering
this aim.
