GP Commissioning – A Brave New World?
Consecutive governments have wrestled with the concept of a commissioner/provider model for delivering healthcare. Conceptually the provider part of this equation is easy to identify and set up. The difficulty has been working out how to establish and run a commissioning arm.
From the time the first primary care groups had a stab at this, there has been continuing debate about the efficacy and (according to some) quality of NHS Commissioning. The last government developed the tag line “world class commissioning”. An admirable target which most would say was not reached.
The coalition government have offered their own take on commissioning, focusing much of this on the vision of handing commissioning to consortia of GPs. Some specialist services would still be commissioned by residual parts of the PCT and SHA set up that is currently in place. This scheme will probably require yet another new NHS corporate vehicle designed especially for the job. The shape of these GP consortia (which may be specific creatures of statute), their powers and remit remains to be seen. Like any administrative body, they will require some administrative staff. Sceptics might argue that if the skills currently reside in the employees of the various PCTs and SHAs, and the consortia are simply going to reemploy the
same staff to do the same job under a different badge, then this achieves little other than keeping in a job those who are seeking to “lead” this reorganisation. Another example of rearranging the deck chairs as the demographic iceberg approaches?
Early debate would suggest however that there is more to it than this. The coalition government certainly feels that GPs are better placed to commission services for their patients than administrators. Estimates of the number of GP consortia suggest that there might be 500 – 600 of these but that the number is more likely to be around 200 300 . However, it is equally estimated that the number might be as low as 50. This is to be contrasted with the number of PCTs which currently run to 151 . Given the state of the public finances and the need to effect change, it is highly likely that the coalition government’s proposals will be put into place in some form. As yet, the proposals are very sketchy but will need to cover technical issues such as:
- The legal status of the consortia
- Allocation of patients to the consortia
- Allocation of commissioning duties to the consortia
- The contractual basis upon which commissioning is to be undertaken
- The organisational structure for the consortia
- The clinical and corporate governance issues
- Access to and ownership of healthcare records
- Commissioning from the private sector
More complicated substantive policy topics to be considered and no doubt put through the political machine will be issues such as:
- Who will have day to day access to, and operational control of the healthcare budgets allocated to the consortia
- Whether the functioning, service delivery and suitability (e.g. qualifications and commercial experience) of consortia management will be regulated another role for CQC?
- Clear identification of what activities fall within commissioning, which might vary from one consortium to the next depending upon a consortium’s areas of expertise
- How and to what extent commissioning functions may be outsourced, and to whom? International healthcare companies and insurance conglomerates may well be interested in this
- Management of conflicts of interest, given that GPs may wear up to three hats – as a patient’s GP, as a manager through a consortium of a finite commissioning budget (possibly involving sticks and carrots for the GP?) and as a provider of specialist healthcare services who may be paid from the budget
- How to reconcile a GP’s primary responsibility to his or her patient with (or insulate that responsibility from?) influences felt as part of a commissioning consortium
- What should happen to budget surpluses and how will budget deficits be borne? The answers to these questions will have a powerful effect upon incentivisation of those running the consortia
- How to avoid the “gatekeeping” aspect of GP commissioning becoming, or feeling for patients like, a model that majors on budget protection (and the earning of incentive rewards?) rather than the delivery of an effective national healthcare system that is free at the point of use.
- What is a suitable level of administrative costs for consortia to incur? How is this to be controlled and regulated?
- The risk profile of consortia and the implications if they become insolvent or cease to fulfil their functions – e.g. how much liability will individual consortium members have for a consortium’s acts, omissions, financial performance and (in)solvency?
- Will there be acceptance that the incentivisation necessary to make the structure work will result in profits for someone, probably for some GPs and some commercial “for profit” entities?
- How will variations in service be managed, bearing in mind that GP consortia management teams are not likely to be elected. How will the patient population be able to influence those to whom the purse strings have been delegated by the coalition government? Are competing consortia likely to be the answer, and if so will it be like changing your electricity or gas supplier?
A brave new world awaits.
Andrew Parsons & Philip Maddock
 Financial Times 16 August 2010
 NHS Choices website 3 September 2010
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