Dame Barbara Hakin, the new national managing director of commissioning development at the DH, answers readers' questions about the transition of commissioning
Who will employ and manage the key support staff consortiums will need?
Subject to parliamentary approval, practices will have flexibility within the new legislative framework to form consortiums in ways they think will secure the best healthcare and health outcomes for their patients and the locality.
The white paper describes how consortiums, once established, will be statutory public bodies. It will be for consortiums to decide if they employ staff, or buy in support from external organisations.
These organisations may be local authorities, voluntary bodies or independent sector providers, and they might be brought in, for instance, to analyse population health needs and manage contracts with providers.
Commissioning comprises a broad range of functions. Some, such as service design, need local knowledge and clinical input. Others are more managerial and may be best undertaken across a number of consortiums, possibly even done only once at national level.
Different services need a different approach. But even then the same commissioning function might be delivered once only for both local services and low volume services. A good example of this is information gathering and analysis.
How do you envisage consortiums being able to negotiate skilfully with foundation trusts?
Consortiums would be likely to carry out a number of commissioning activities themselves. In some cases, consortiums may choose to act collectively, with a lead commissioner or third party negotiating and monitoring contracts with large hospital trusts or urgent care providers.
They may also choose to buy in packages of support from external organisations, including local authorities and private and voluntary sector bodies, which might include analytical activity to identify healthcare needs, support for procurement of services and contract monitoring.
What is most important is that consortiums involve relevant health and social care professionals from all sectors in designing care pathways that achieve higher quality and better integrated delivery of care to make the best and most efficient use of NHS resources – and then use economies of scale to inform commissioning functions.
I represent a rural and sparsely distributed patient population, with isolated pockets of rural deprivation that are not adequately accounted for in existing budget-setting methodology. The move towards real budgets will significantly disadvantage local patients. How will the Department of Health ensure that budgets adequately reflect the varying needs of local populations and are not calculated on inflexible fair shares formulae?
It would be for the NHS Commissioning Board, not the DH, to make allocations to GP consortiums. In doing so they would seek to ensure there is equivalent access to NHS care for equal need, given the burden of disease and disability.
The aim would be to ensure all areas have a fair share of the available resources to meet the challenges they face, perhaps because they have relatively deprived populations, older populations or some other reason.
In Suffolk, consortiums have evolved along both geographical and ideological grounds. While we feel we have local sensitivity and commission according to local needs, we are clearly not robust enough for the rough and tumble of the new world. We are exploring working in two federations but is this still too small? I see Mark Britnell, former director general of commissioning, advocates sizes similar to PCTs but many PCTs were financial disasters even in the times of growth. How do you think this will pan out?
Consortiums need to have sufficient geographic focus to be able to agree and monitor contracts for locality-based services (such as urgent care), to have responsibility for commissioning services for people who are not registered with a practice, and to commission services jointly with local authorities.
For these purposes, they need to have boundaries that interlock so that taken together they cover the entire country.
However, we do not want to be prescriptive about the size of GP commissioning consortiums. There have been widespread variations in the size and population coverage of PCTs that are currently responsible for commissioning NHS healthcare services, and there is no evidence to suggest what is the ‘optimum' consortium size.
Practices would have flexibility within any new legislative framework to form consortiums in ways they think will secure the best healthcare and health outcomes for their patients and their locality. The NHS Commissioning Board however, would need to satisfy itself that consortiums were of sufficient size to manage financial risk effectively.
It will be crucially important for the system to be locally sensitive as well as delivering economies of scale and the appropriate critical mass for the commissioning of lower-volume services. This could entail small consortiums working together or larger consortiums operating through localities. This will depend on local circumstances and clinical pathways.
The consultation document on new NHS commissioning arrangements, Liberating the NHS: Commissioning for patients, published on 22 July, seeks views on whether there should be a minimum or maximum population size for GP commissioning consortiums.
How do you think practices should currently prioritise both their internal and external development?
Practices need to think about their development as providers and commissioners and working internally, with their peers and other local partners.
Good provision in each practice is critical to commissioning and the delivery of high-quality primary care reduces unnecessary demand on secondary care and should meet local needs. Across groups of practices there may be opportunities for shared provision.
Some practices and individual GPs might wish to be much more keenly involved in consortium business, taking lead roles in service redesign or becoming a key part of the governance structure such as undertaking the accountable officer role. For these practices and GPs, broader development will be required. The National Leadership Council is working with GPs and consortiums across the country to identify these needs and help to meet them.
All over the country there are pockets of brilliant commissioning. But there is a definite weakness in scaling up the projects that work. I recognise that we have the NHS innovation and development institute and SHA commissioning networks but I think we need something more. Do you envisage a more proactive way of expanding and disseminating success?
The NHS faces a challenging future to manage financial pressures and the continually increasing demand for improvement in quality of services. It is therefore critically important that best practice, innovative ways of working and new technologies are not only identified and adopted locally, but are shared and spread across the NHS.
Over the past year, new initiatives have been launched to encourage both the simple front-line innovations that will make a practical difference to how services are provided, and greater adoption and diffusion in the NHS. For example, Regional Innovation Funds (£20m a year), which have generated over 2,000 applications with funds being 10 times oversubscribed, are supporting innovation at the front line. NHS Evidence (a search engine for evidence in health and social care www.evidence.nhs.uk) offers service providers and commissioners easy access to quality-assured evidence.
To enable innovation to flourish in the new landscape, we need a fundamental change in the way people work. With a focus on greater decentralisation, more freedom for NHS trusts, greater responsibility for GPs and more control of decision-making for patients, the challenge for the NHS will be to create the right incentives to encourage the service-wide development of innovative provision.
At the heart of this is strong leadership – both clinical and managerial at all levels in the system – to identify and tackle the behaviours and cultures that stand in the way of innovation. The changes set out in the white paper provide a unique opportunity for GP consortiums to take the lead and push innovation forward
Dame Barbara Hakin
