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Five more big questions about the White Paper

Three months on from the publication of the Government's white paper, major questions remain about how GP commissioning will work in the future. Alisdair Stirling looks at another five key outstanding issues

The rough outline of the new Government's vision for the NHS loomed out of the Whitehall mist in July. After rumours of an election run-in and the political horse-trading of the coalition agreement, it was immediately clear that the white paper's implications for GP commissioning would be huge. But sifting the 100-plus pages of Equity and Excellence: Liberating the NHS and its supporting material for detail has revealed many more questions than answers.

GP organisations including the National Association of Primary Care, NHS Alliance, the BMA's GP committee (GPC) and the RCGP have been frantically trying to fill in the gaps during a hectic consultation period on the proposals, which ends this month (11 October). The resulting health bill is due before parliament next month, but even at this late stage much remains to be clarified.

1) Could individual practices be held responsible if a commissioning consortium fails?

The answer to this depends on whether ministers carry out their stated aim to make commissioning responsibility part of the core GP contract. The white paper itself is unclear on the matter. But GPC negotiators have said that they will resist it and will push instead for commissioning to be an optional enhanced service ( However, if they were to fail and commissioning were to be written into the core contract, GPs in failing consortia could stand to lose their ability to provide standard GP services.

Another front the GPC will be fighting on is over a clause in the consultation document Commissioning for Patients that suggests some of GPs' current income could be deducted by consortia in the form of a quality premium if they fail to meet quality standards.

But according to Dr David Jenner, commissioning lead for the NHS Alliance, the threat to enshrine commissioning responsibility in the core GP contract is the major peril: ‘This is the big one. The Conservatives were talking about this in opposition and it is still not clear whether they intend to go through with it.

‘I call it double jeopardy. It could well be that GPs who came into general practice to provide a service could lose that ability, not because they're not good at providing it, but because they've failed at something else – commissioning. Or perhaps, even, because other people in their consortium have failed.

‘Several other questions spring from this: What is the so-called failure regime if a consortium fails? Does the NHS board step in and take over the commissioning or does it go to another consortium or to private companies? The white paper makes it clear there will be no bail-out. To what extent will the accountable officer, the GP who signs the contract on behalf of the consortium, be responsible?

‘The other big question that could affect practice responsibility is will there be a central template contract for commissioning – standing orders – or will it be local and therefore potentially different in different areas?'

Dr Donal Hynes, the Alliance's vice-chair, believes the only likely change to the core contract is a simple addendum saying that to hold a list legally you must be a member of a commissioning consortium.

That would mean GPs would not lose their contracts if their consortium failed, but that a failing practice could be asked to leave a consortium and could potentially lose their list at the discretion of the NHS Commissioning Board.

‘The consortium would say that unless you shape up you can't be part of the consortium. The bottom line might be that the NHS Board would get on the phone and offer you other arrangements and maybe assign you to an independent consortium.'

Dr James Kingsland, president of the National Association of Primary Care, says that while belonging to a consortium would be made a requirement of holding a list, any major reform of the GP contract would take at least five years, so a new clause on commissioning was unlikely in the short term. ‘It won't be within the life of this Government. We will see changes, QOF will evolve, a change in the global sum to allow for new activities – but not the root and branch reorganisation this would involve.'

2) How big a challenge is it for GPs to take on the commissioning of community services and mental health?

There are no tariffs at present for either community services or mental health, but according to the white paper these are on their way and GP consortia will take over responsibility for commissioning in 2012.

In the meantime, the Transforming Community Services agenda, launched by the previous Government, is still very much live policy. PCTs have drawn up plans to make community services provision into arm's-length structures to distinguish between the commissioning and provision functions. Most PCTs have opted to transfer the provider arm of their community services to acute trusts.

But if GP consortia are to have responsibility for them in the future, wouldn't it make more sense for consortia to oversee the transformation of community services? Dr Jenner believes the logic behind the Transforming Community Services agenda itself is good: ‘That chimes perfectly with the whole thrust of the white paper, which depends on keeping the two [providing and commissioning] separate.

‘But the problem is with the pace of change. With a 1 April deadline, my PCT has to make a decision on this by the end of September. We've had go-stop-go and as a result there is not enough time for GPs to work up social enterprise or other bids to take this on. All there is time for is vertical integration with acute trusts and that will mean local monopolies.'

Dr Hynes adds that the real concern with the pace of the Transforming Community Services agenda is that acute trusts won't have the same vision of community services as GPs.

‘We could have much more dynamic community services if GPs commission them, but the problem is that they could have passed to acute trusts and been run down by the time consortia get their hands on them.

‘It's up to the Government to sort this out. Where there are strong indications declared by fledgling consortia, they should be allowed a stay of execution. It would be an opportunity for the Government to move the white paper forward.'

On mental health, a recent survey showed that two-thirds of GPs said they weren't ready to commission mental health care. Dr Jenner says that while some of the burden will be shouldered by the NHS Commissioning Board, GPs will still have a huge amount to take on.

‘This is currently commissioned on a block with no tariff but I think significant elements will fall under specialist care – forensics, in-patient secure and so on – and will be commissioned by the NHS board.

‘But it still leaves an absolutely massive area which will need organisational memory from the people who have been commissioning mental health care either in the consortia themselves or attached to them.'

3) What will be the impact on individual practices of consortia being set up as statutory public bodies?

Commissioning for Patients says: ‘We intend that consortia, once established, will be statutory public bodies.'

In Dr Jenner's view, ‘public' is the keyword here. ‘Statutory public bodies are subject to judicial review on their decisions, to freedom of information requests, public probity and the Nolan principles of standards in public life. They are also accountable to central government. The impact on individual practices is anybody's guess but that also depends on what organisational form a consortium adopts. They could be anything from social enterprises to NHS trusts.'

But could it also mean that practices themselves become statutory bodies, altering the traditional model of GPs as independent contractors to the NHS?

Dr Hynes thinks that is unlikely, but says the implications haven't yet been addressed by fledgling consortia.

‘Issues like freedom of information and duties of partnership with local authorities don't immediately lend themselves to the way GPs operate on a daily basis. Yet GPs will have to engage with this in the new world.'

‘When it comes to appointing an accountable officer, do you have a local colleague or surrender it to an independent body? You could buy in the expertise it takes to be an accountable officer, or even buy in the whole commissioning operation, and while that might seem attractive to a GP for whom statutory bodies are alien, it might in fact be a very delicate surrender of your clinical independence.'

4) How are commissioning budgets going to be set?

Commissioning for Patients says: ‘The NHS Commissioning Board will calculate practice-level budgets and allocate these budgets directly to consortia. These budgets will need to reflect an appropriate share of healthcare resources to include both people registered with practices in the consortium and local residents who are not registered with any GP practice.'

The consensus among commissioning experts is that a capitation-based fair shares formula such as the one devised by the Nuffield Trust will be used, based on the whole population of the area including non-registered patients. However, the white paper does not specify which formula is likely to be adopted.

‘God only knows what formula will be applied,' says Dr Hynes. ‘There will be winners and losers whatever happens and it will be applied nonetheless – but everyone will just have to get on with it.'

‘This is absolutely key,' says Dr Jenner. ‘We need to know what the funding formula is going to be, not just for allocations to consortia's commissioning budgets but also to the new unified GMS contracts.

‘And the question that follows from that is will budgets currently set on a historical spend basis be moved immediately to the new fair shares formula or will it happen with the pace of change. My own view is that it should happen with the pace of change.'

In Dr Kingsland's view, the ultimate would be a tailor-made allocation for each consortium. ‘I'd like one designed for Kingsland and Co and his specific package of patients. That would be the ideal. But with some 8,300 practices across the country it just couldn't be done. And no one has come up with anything new so it's going to be some kind of capitation-based formula. And there will be losers. Fair shares means winners and losers."

5) Would a quick win for commissioners be to simply commission providers to stay in budget?

The white paper makes it clear consortia will be responsible for staying within budget. A simple way of ensuring this would be to place cash limits on providers. But would that conflict with another white paper stipulation that "wherever possible" services be commissioned that enable patients to choose from any willing provider?

Dr Hynes thinks this will be possible with primary care providers but not with secondary care. ‘The way to save money – and the cost pressures are going to be huge – is by good quality, cost-effective community-based medicine, being more proactive and working more on a preventive, population-based level. Hospitals don't have the skills for that. But it should be possible with primary care providers. The any willing provider model is a separate question. We have yet to see how that will operate in practice.'

‘The answer to this will depend on how the policies end up being framed in law,' says Dr Jenner. ‘It would be good for consortia to be legally able to set cash limits for providers rather than fund unlimited demand. With the current Payment by Results system, PCTs are not legally able to do it but it would certainly make life easier for the consortia if they could.'

For Dr Kingsland, the biggest question surrounding the white paper is what scale of GP commissioning can be achieved. ‘Can we do this in every clinic, every consulting room in England? Just recreating PCTs with clinicians in charge will fail. We have to capture the spirit of the vanguard. Waste of spirit is the worst form of waste in the NHS.'

Dr Jenner has compiled a personal list of over 20 questions about the white paper, including questions over PCT debts raised by GPC chair Dr Laurence Buckman in a recent interview with our sister paper Pulse. ‘My anticipation is we won't get answers for some time,' he says. ‘The health bill will be high level – sketchy – but detail will follow later through Department of Health directives and secondary legislation. That's why it's vital for GPs to respond to the consultation process by 11 October.'

Alisdair Stirling is a freelance journalist. This piece follows on from his previous featureFive big questions about the white paper'

Five big questions about the white paper Timetable for reform

11 October: Department of Health's consultation process ends

November: Health bill to go before Parliament

By end 2010: Public health white paper

New Year: Further details to be supplied by NHS directives and secondary legislation

April 2011: Shadow NHS Commissioning Board and GP consortia

April 2012: Majority of reforms come into effect