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Three market scenarios

Alisdair Stirling examines three real-life GP commissioning scenarios with the help of commissioning experts

1. Can we stick with our current integrated care pathway?

Our consortium has a really good working relationship with our hospital consultants and we have developed an integrated care pathway for COPD sufferers – we don't wish to entertain other ‘competitors' wishing to provide such a service. Will our approach survive the new world with Monitor looking to introduce more competition?

What we know

The Government has made it clear in the health white paper that it wants to encourage more integrated care via a still unspecified system of pathway tariffs.

Newly appointed Monitor chair David Bennett is reported as saying he believes competition can work with integrated care pathways, but he hasn't specified how. The recent interim report on any willing provider (AWP) from the NHS Co-operation and Competition Panel (CCP) for NHS-funded services found that just under half of PCTs were currently breaching AWP rules with routine demand-management initiatives, such as referral management schemes.

The CCP could be expected, therefore, to take a dim view of consortia trying to stick with the status quo, even if it's working well for patients.

Practical Commissioning's sister magazine Pulse reported earlier this month about consortia putting whole pathways out to tender, so this could be one way of moving with the market times.

The Department of Health view is said to be pragmatic: GPs should be transparent about their choice of provider, the thinking goes. And as long as they are seen to be open to approaches from other parties, they won't, in practice, either have to accept them or go through a long-winded procurement process in the first place.

What the experts say

Andrew Donald, chief executive for NHS Birmingham East and North, believes that GPs will be able to continue with such arrangements, post-reforms. He says part of a consortium's role will be to start to reduce the infrastructure of acute hospitals and that integrated care pathways are a good way of doing that.

‘In cases like this locally, you set up a joint board between commissioners and providers for, say, COPD. It's an arrangement for working with hospitals. It's not a question of a procurement process,' he says. ‘Where you've got big contracts you need to start using the market. But dogmatic introduction of competition won't work. Even if it wanted to, Monitor wouldn't have the time to intervene in every local case such as this.'

Dr Brian Fisher, a GP in Lewisham, south-east London, and national RCGP commissioning champion, says he doesn't understand how the AWP model could work with the type of integrated care pathways he's been involved with locally: ‘Perhaps the Government has other methods up its sleeve, but we have local evidence (in south-east London) that integrated care pathways produce excellent results. If that's the case, then why overlay it with another competitive model? It doesn't seem to make sense.'

Gerry McLean of Consulting Associates UK says he believes consortia on the ground will simply take matters into their own hands whenever they perceive any leeway in the regulations.

And if integrated care pathways are the appropriate tool for cost-effective care, consortia like the ones he currently advises will use them.

‘If there's a vacuum, they'll go ahead and fill it. There's a feeling that forgiveness is easier to get than permission,' he says.

‘A lot of GPs would like there to be a manual that says "In case of buffalo attack, here's what to do", but the other option is to not wait for instructions and just to get on with it.'

2. Will monitor allow us to make, rather than buy?

As commissioners, we may well want to decommission a fair volume of low-complexity diabetes care out of the acute sector and resource GPs, either in practices or in some sort of host organisation to provide that care, on the basis of cost-effectiveness and integration. Will Monitor permit that? Or will we have to go through a lengthy process to be an AWP or tender?

What we know

The white paper says that AWP won't be appropriate for all services – giving the example of A&E.

However, it says, the Government wants to create a presumption that all patients will have choice and control over their care and treatment and choice of AWP, wherever relevant.

Monitor is understood to be working on a list of services – analogous to the current local enhanced services – that will be able to be delivered in primary care without having to go through a tendering process.

What the experts say

‘GPs will be able to provide as well as commission as long as there is a wall between the two,' says Mr Donald. ‘But under AWP they can't be sure of any work.'

However, in a case such as low-complexity diabetes care, most of this is already done in primary care and there is a strong cost-saving argument for keeping it that way.

Monitor won't have time to adjudicate in every case like this and if commissioners can show the quality is there, the likelihood is they'll be able to continue.

‘Situations like this might be open to test. Sometimes you have to look more at co-operation than competition.'

Dr Fisher is optimistic that commissioners will just be able to get on with the job in cases such as this: ‘My understanding is that tendering will disappear increasingly.

‘I think with AWP, there will eventually be a list of providers accredited by the Care Quality Commission, assured to be safe and competent to do the job – including GP providers from which consortia can commission care.'

His fear is that patients will be able to choose from the list at any stage of their care, potentially disrupting continuity.

‘They might choose to have the diagnosis – an X-ray, for instance – in one place, treatment somewhere else, operation somewhere else, fragmenting care and making planning extremely difficult,' he says.

3. How can we ensure that consultants get sufficient training in a more fragmented NHS?

If you took, say, low-complexity hand surgery out of an acute trust and put it in the community through AWP – there are no big clinical governance issues.

But the acute sector – and commissioners – might argue that if that happens, they have no capacity to train the hand surgeons because they cut their teeth on that particular work.

What we know

GP commissioning consortia will have the power to decommission hospital services in favour of community or other providers. Hospitals will have to be prepared to adapt to their new circumstances and tailor their services to the new requirements. The health reforms are not prescriptive about training – other than saying that standards must be maintained.

According to the white paper, the NHS Commissioning Board will be charged with overseeing ‘healthcare providers' plans for training and education, checking that these reflect ‘strategic commissioning intentions'. It adds that GP consortia will provide this oversight at a local level, which suggests that consortia will have to take secondary care training issues into account when they commission.

What the experts say

Mr Donald says: ‘We'll be competing on quality – not price, so where a better-quality service can be provided outside hospital, situations like this could well arise. The NHS Commissioning Board will want to make sure there is adequate training in a hospital setting.

‘And where that means training facilities have to merge to provide the same volume of cases, they probably will.'

Dr Fisher foresees that GP consortia will have the power to affect hospital sector training and will have to take it into account in their decision making, with reference to the NHS board: ‘This is a real issue. We do need to decommission in some instances. But it will have huge implications for services in secondary care.

‘It's not yet clear how the actual process of decommissioning will work, but hospital departments will have to merge in order to preserve their training function.

‘I believe you must never close a hospital, but we have seen cases where decommissioning secondary care services – if there is a good evidence base – works to everyone's benefit.'

Alisdair Stirling is a freelance journalist

Three market scenarios