Alisdair Stirling looks at key outstanding questions posed by the landmark white paper on the future of the NHS.
The Government's white paper – Equity and Excellence: Liberating the NHS – outlines the biggest set of reforms in the NHS's 62-year history, placing GP commissioning at the centre of a complete realignment of the health service. Yet there is a lot that the paper doesn't say about how commissioning will work in the future.
The new white paper's impact on GP commissioning will be colossal. But while the document runs to 66 densely packed pages, supplemented by a 15-page letter from NHS chief executive David Nicholson and a sheaf of supporting documents, it's not a comprehensive blueprint for change.
The paper itself will be fleshed out by a succession of consultation documents. The first of these, on the new NHS outcomes framework, had already been published as Practical Commissioning went to press. Others will follow on the implementation of the new NHS Commissioning Board and GP consortiums, local democratic legitimacy in health, freeing providers, and economic regulation and the arm's length body review – all of which give the white paper a distinctly ‘greenish' tinge. These are the areas that the Government wants ideas on – and to that extent, nothing is yet set in stone and there is much detail to be filled in.
1) What will be the difference between consortiums and federations?
There are some 60 mentions of GP consortiums in the white paper but not a single mention of a GP federation. Is the much-touted GP federation, part of the RCGP's 2007 road-map for the profession, now dead? Or will it have an independent life beyond 2010?
The idea, as the RCGP developed it in 2008, was for groupings of GP practices that could bring about economies of scale by sharing back-office functions and directly employing managers and nurses to provide new services. They were to have a formal legal structure, an executive management team and a written public constitution – boxes that could all potentially be ticked by consortiums. Many observers are using the terms interchangeably.
But according to Dr Johnny Marshall, chair of the NAPC and one of David Nicholson's inner circle of GP advisers on the design and implementation of the new system, GP federations will still have a distinct role to play.
He says: ‘I think we're going to have different tiers of federations for different purposes – whether for provision or for other purposes. You might need different-sized groupings of consortiums – perhaps federations of consortiums – to interact at levels of the NHS.'
Professor Steve Field, RCGP chair has suggested that federations are more likely to provide care rather than commission it. He has also suggested that this is a potential way around the current wording of the white paper, which says that consortiums won't be able to commission care from their own GP members.
He told our sister publication Pulse: ‘We might have a single consortium covering the whole of south Birmingham or even the whole of the city, and federations could be set up just to provide NHS services, with competition between federations.'
Dr David Jenner, GP commissioning lead for the NHS Alliance, says: ‘Consortiums won't be able to commission from GP members of that consortium. That is clear from the wording as it stands, but my honest guess is that this kind of detail is not yet written. Whether federations are the way around this I don't know.'
2) Will GMS/PMS income be separate from the commissioning budget GPs receive?
The white paper deals with the two funding streams – commissioning budgets and GMS/PMS income – separately. On commissioning budgets, it says: ‘The NHS Commissioning Board will calculate practice-level budgets and allocate these directly to consortiums.'
As for GMS/PMS funding, it says that the Department of Health will ‘seek to establish a single contractual and funding model to promote quality improvement, deliver fairness for all practices, support free patient choice and remove unnecessary barriers to new provision. Our principle is that funding should follow the registered patient, on a weighted capitation model, adjusted for quality.'
Dr Jenner says: ‘That paragraph basically equates to GMS plus QOF. It will remain separate from the commissioning budget. But the crucial clue to how the GMS contract might develop is in the words "remove unnecessary barriers to new provision". To me that suggests they want to create new flexibilities, which could mean putting GMS, PMS and APMS together under something along the lines of short-term five-year, tenderable GMS contracts to allow room for people to start up new practices anywhere. Perhaps in Tesco?'
'The BMA expects little change. My reading is that there will be a big contract change in 2012 and because of the tight timescale, perhaps minor tweaks this year.'
3) What will be the incentives for GPs to take on a wider commissioning role?
The white paper talks of a commissioning outcomes framework for GP consortiums, to create powerful incentives for effective commissioning' and repeatedly mentions stronger incentives to adopt best practice, financial incentives for meeting new NICE quality standards and incentives for financial performance. However, it does not say what these will be.
According to Dr Jenner, it is clear there will be incentives for GPs involved in managing consortiums. He points to a paragraph in the white paper that states: ‘We envisage that consortiums will receive a maximum management allowance to reflect the costs associated with commissioning, with a premium for achieving high quality outcomes and for financial performance.'
'There are also non-financial incentives for GPs in being able to shape and control things and they're pretty powerful,' he adds.
But he warns that incentives could mean carrot as well as stick: ‘There's intense speculation that the new GP contract will be worth up to 20% less than PMS/GMS and that practices will have to make up the rest through commissioning.'
Dr Marshall also picked out the management allowance as a key incentive: ‘It will allow for the professionalisation of clinical leadership – which is what we've been looking for and will provide a real incentive to get involved.'
‘But we're looking for some incentives maybe built up around performance indicators for patient experience, quality of care and value for money. There's no detail yet but the NAPC will represent for that.'
4) What will the new NHS Commissioning Board look like?
This new autonomous statutory body will be established in shadow form in April next year, initially as a special health authority like NICE or the National Patient Safety Agency.
It will go live in April 2012, making allocations directly to GP consortiums for 2013/14 late in 2012. It will be accountable to the health secretary through the new NHS outcomes framework. Its main function will be to provide a national lead on commissioning for quality improvement, holding GP commissioning consortiums to account both financially and for outcomes.
According to the white paper it will be ‘a lean and expert organisation, free from day-to-day political interference'. Among other things, it will set commissioning guidelines, design model contracts and tariff structures, and host some clinical commissioning networks.
The white paper states that the board will be left to decide its own local representation. Beyond that, the board, its role and composition is one of the key areas for consultation.
But Dr Jenner believes it will have to be big. ‘It will need quite a lot of regional offices. Apart from managing at least 500 consortiums they have the other 5% of things consortiums don't do. My guess is that there could be 30 regional offices but it could be more.'
Dr Marshall says there is no more detail available on the board at present but he says even with regional offices, it could still be ‘lean' at the centre. ‘My only hope is that the board will be fleet of foot. The timescale for getting all this off the ground is tight but if you think about big commercial companies, some of them could do this in 90 days.'
In common with other boards, the NHS Commissioning Board is likely to have a chief executive and executive directors as well as a chair and non-executive directors. This means the likely involvement of the Appointments Commission and a possible way in for the private sector in non-executive director roles.
Given its large remit, it could be sub-divided into directorates. The white paper indicates that it will employ NHS managers in new roles.
5) How can any savings be spent?
According to Dr Jenner, there won't be any. ‘There are unlikely to be any freed-up resources to spare – certainly in the long run. The scale of the budgetary decisions suggests they will always need to be spent on one thing or another. My guess is that underspends will get immediately soaked up. The white paper also raises the issue of pooling risk: consortiums may need to bail out neighbouring consortiums who fail.'
‘It's not going to be like fundholding, where you could plough savings back into the practice. Frankly, I can't see incentives of that kind for member practices in this document. It's not ethical for GPs to profit from cutting costs.'
Dr Marshall agrees that savings are unlikely to benefit practices: ‘I'm pretty sure that health secretary Andrew Lansley does not see the commissioning budget as something for profit or loss. So it won't provide incentives in that sense.'
Many of the gaps in the white paper's vision will be filled in the forthcoming consultations, but in the meantime there are other outstanding questions. Dr Marshall's concerns centre on a key premise of the coalition Government's pre-white paper rhetoric, that of making the health service more locally accountable. ‘My big question is how we get to local and democratic service provision. We started from the premise of local accountability. Now we have to make sure we deliver it.'
Dr Jenner has a question too, a more fundamental one – is the Government moving too fast? ‘It's a grand and bold vision and most people don't disagree with it. But most are incredulous at the scale and pace. What the NHS Alliance is asking for is clinical credibility and outcome-based policy development. It should maybe identify the leading GP commissioners such as Nene and Wyvern and give them budgets first. Evaluate that and use the results to shape the agenda for everyone else.'
Alisdair Stirling is a freelance journalist
Key questions remain about the detail of the Government's white paper Key questions remain about the detail of the Government's white paper
