Carving a commissioning future

By Alisdair Stirling

The Government's timetable for abolishing PCTs and handing GPs control over NHS commissioning is tight and the GPC has moved swiftly to advise GPs about the transition. By Alisdair Stirling talks to the experts about what to do first

GPs could be forgiven for feeling they are being rushed into an uncertain future by the new Government. The coalition has only been in power for five months but already its white paper proposals, the most radical reform of the NHS in 60 years, are about to go before parliament.

Key details such as how much the management allowance will be are still conspicuous by their absence. But a brief – some might say cursory – consultation period has already come to a close, primary legislation is being tabled in the new health bill to go before parliament next month, and practices across England are feeling mounting pressure to form themselves into shadow commissioning consortia in less than 18 months.

The GPC's guidance on the white paper proposals has been produced in relatively short order too and advises on size, structure and legal issues.

But does all this mean GPs need to act quickly to join a consortium? Or should existing consortia be hastily joining ranks with one or several neighbours?

NAPC chair, Dr Johnny Marshall, says form should follow function and now is the time to focus on future relationships rather than becoming preoccupied about organisational structures.

‘The GPC advice is sensible. There's not much you'd fall over if you followed it. But for me the focus now should be on building relationships – who you're going to be working with – not the organisational side. That's the paradigm shift. Otherwise we may just end up reinventing what we have already with PCTs.

‘All of us can behave in a way we've already behaved. But what we need is a bit of lateral thinking. There may be solutions to come that nobody has thought of yet.'

Start talking

Dr Marshall says the first conversations for GP commissioners should take place within their individual practice.

‘It is GPs who will be taking responsibility for NHS finances. We should all start by talking within our practice, with our colleagues, nurses, receptionists, everybody, and work out what we want to do. Then talk to other practices, find common aims. Then it's a question of who do we want to work with? Let's talk to PCTs, the local authority. It's an important part of the process. It's not a governance or a structural thing. That should come at a later stage.'

New relations

The GPC states specifically that consortia should seek to involve patients via meetings or by collecting their views in order to maintain their confidence. It adds that GPs must put aside traditional rivalries and learn to work with secondary care specialists.

For Dr Donal Hynes, vice-president of the NHS Alliance, the redefining of GPs' professional relationships in the GPC guidance is the most significant part.

‘There's something very helpful about the guidance ensuring that all of this is still based on the ethical drivers of the GP's relationship with the patient. Otherwise, the reforms could destroy much of the trust between the clinician and the patient.

‘We have to take cognisance of our patients' wishes in all this. We're moving towards a new partnership and the way to prepare is to accumulate information we're going to need in redefining this relationship.

‘And if a lot of this change is to do with the change in the patient relationship, then we begin to think that consortia will work better on a small scale. Maybe we need to work on a really local level with say four or five practices to make that relationship work.

‘Of course we'll have to risk share and share backroom function, perhaps with other consortia in a federation, but if we put forming a statutory body first, it could really dampen patient enthusiasm for the reforms.'

Dr Hynes adds that another part of the Government's reforms – abolishing practice boundaries – could mould the formation of consortia. ‘It will be interesting to see what patients do if they are allowed the freedom to look at good consortia and vote with their feet. For me this new relationship we'll have with the patient is the most exciting part of all this and the GPC's recognition of this is very helpful.'

Geography

In answer to the chicken-and-egg type question of what to do first – form a consortium or decide on an area for the consortium to cover – the guidance urges GPs and PBC groups to look carefully at local boundaries. It implies that GPs not currently in PBC groups or commissioning consortia can take a proactive approach by looking at the current boundaries of their local groups, deciding where they fit in and approaching those groups about membership. The GPC guidance states that consortia may not ‘cherry pick' among local practices, recruiting, say, only low-referrers, nor may they exclude individual practices from being part of their health community.

Ensure a mandate

The guidance stresses the need for fledgling consortia to have the support of their members and calls on early adopting PBC groups in particular to consult all the practices in their area before declaring themselves a consortium. It would be improper for a small group of practices to declare themselves a consortium and then add further practices without offering them a say in the leadership and management of that consortium.

Managing risk

The guidance recommends that consortia cover populations of between 100,000 and 750,000 people, but suggests it is unlikely

a consortium covering a population of less than 500,000 people will be able to manage the financial risk. It therefore recommends all consortia should consider the benefits of working with neighbouring groups.

According to Dr David Jenner, commissioning lead for the NHS Alliance and a Mid Devon LMC representative, this is sage advice: ‘GPs will be tempted to work in small consortia. The evidence from total purchasing pilots was that the biggest ones didn't engage with GPs too well. So the temptation is to go for small consortia but you have to take account of the financial risk and bigger consortia will have more financial muscle.'

Leadership and management

As well as securing a formal mandate, the guidance says consortia need to keep their organisation flexible because responsibilities could change. It is essential the formation, governance and management of consortia be appropriate for their responsibilities.

As a first step, it advises consortia to elect a board of appointment to recruit and oversee the key executive positions, such as the accountable officer and financial officer etc. LMCs could act as external scrutineer for these elections, the guidance states. When the executives are also GPs, consortia should also decide whether they should also continue to practise.

Dr Jenner believes it makes sense to start building a new organisation from the top: ‘As with any kind of leadership, it's important to get people on side early. It's a good idea to set up an appointment board – we're looking into that locally – the board can start selecting people against the job descriptions.'

For Dr Jenner, getting the right structures in place is more important at this stage than deciding what services to commission. ‘Form should follow function. But do agree what to do with the money before you have the money. Otherwise there's a danger of being a GP version of Lord Cardigan and leading the Charge of the Light Brigade into disaster.'

Legal advice

The GPC deals with the legal side of forming consortia in a separate document. It says that as consortia will be public bodies they will be subject to all the regulations governing such bodies including Freedom of Information and public procurement rules.

Consortia will also have to consider setting up a separate provider if they wish to provide services and these will have their own board.

And the guidance urges GPs preparing to join consortia to take legal advice as a priority. ‘GPs should take appropriate legal/ financial advice and have a basic knowledge and understanding of corporate structures and responsibilities, bidding/tendering, management of commissioning and providing entities, contract law and managing budgets,' the document states.

Getting the legal side right will be crucial once consortia have formed and are beginning to get up and running, but is now the right time to turn to the lawyers? According to Dr Jenner, consortia can wait until the budgets are set before taking legal advice. ‘We're desperately short of money in the NHS at the moment and we shouldn't be spending what we do have on lawyers. What's needed is a draft national legal framework to ensure consistency, secure public interest and save everybody money.'

Help on the daunting legal processes awaiting consortia may be at hand. Andrew Lockhart-Mirams of Lockharts Solicitors, which drew up a widely adopted model PMS contract, is already working on the kind of framework Dr Jenner is calling for in partnership with Londonwide LMCs.

Mr Lockhart-Mirams told Practical Commissioning that the set of ‘rules' was comparable to a private company's memorandum of association and would be available for use around the country.

‘We don't want to leave this until January, February or March. Consortia need to be able to give consideration to their internal rules now – things like how the quality premium will be divided and how to arrange the business meetings. If you have 40 practices, you don't want to have 40 separate meetings, you'll need to think about an annual meeting with the management team. You'll also need to think about rotating members of the management board and all of that.

‘It will also cover things like what skills to buy in and how to bring in ex-PCT staff and so on.'

By Alisdair Stirling is a freelance journalist

• LMCs to have ‘midwife' role in hatching new consortia and to ensure probity in the way they are set up.
• Consortia may not ‘cherry pick' among local practices, recruiting, say, only low-referrers or excluding individual practices.
• Consortia need to ensure they have a mandate from local GPs.
• Responsibility on all GPs not to abuse their new commissioning role, must be transparent about any financial interest with all parties involved, including patients.
• Immediate move to fair shares budget setting should be opposed and replaced with a gradual transition.
• Budget-setting process to involve a risk-pooling and insurance mechanism to ensure the stability of the budgets against planned and unplanned debt such as major incidents.
• Savings to be reinvested in services – but not necessarily into primary care.
• Budgets should be for three years to avoid the perversities of in-year accounting that encourage spending towards the year end.
• Consortia likely to receive a much smaller management allowance than PCTs currently do so GPs should not make management plans they won't be able to fund.
• Advice should come from within NHS, rather than buying in external support.
• Quality premium to only be agreed in negotiation with GPC and profession. Consortia should make no calculations based on the quality premium proposal.

• Start talking – establish common aims within the practice team and with other practices, then talk to the PCT and local authority about what they want to do and what's possible.
• Establish relations with patients and consultants – GPs need good working relationships with both to create a new NHS.
• Consider local boundaries when joining or forming a consortium.
• Ensure consortium has sufficient flexibility and mandate.
• Legal advice might be better sought once budgets are in place.