By Alisdair Stirling
Government plans in the white paper could hand local authorities a major role in GP commissioning. By Alisdair Stirling looks at the small print.
Much of the intense discussion concerning the white paper Equity and Excellence: Liberating the NHS has concerned the fundamental reorganisation of the NHS and radical reform of GP commissioning that it sets out. But the document and its supporting consultation papers also set out a parallel revolution for local authorities that could have a significant effect on the way GP commissioning works.
The wording in the white paper itself suggests that local authorities will simply be mopping up PCTs' health improvement functions, allowing them to be abolished once GP consortia and the new NHS Commissioning Board take over their NHS commissioning functions. However, the consultation document Local Democratic Legitimacy in Health specifies a slew of proposals that could give local authorities a major role in determining the activities of GP commissioning consortia and even in policing them.
Tellingly, health secretary Andrew Lansley recently told the Commons health select committee: ‘The most significant statement in the white paper is not that we are going to have GP commissioning, but that we are going to ally it with a strategic role for local authorities.'
In broad outline, local authorities will:
• lead Joint Strategic Needs Assessments (JSNAs) of health and care needs
• support public and patient involvement and the exercise of patient choice
• promote joined-up commissioning of local NHS services, social care and health improvement
• lead on local health improvement and prevention activity.
The first three of these new responsibilities will all directly affect the operation of GP consortia. But the extent to which consortia will be affected depends on whether or not the Government decides to give local authorities statutory powers to force consortia to work in partnership with them.
JSNAs
JSNAs are assessments of the health and wellbeing needs of the population in a local area. It has been a statutory duty since 2007 forPCTs and local authorities to undertake them.
The consultation document makes it clear GP consortia will be responsible for making healthcare commissioning decisions informed by the JSNA. But the key change is that local authorities will now take the lead on these. According to Robin Lorimer, an independent management consultant with a background in commissioning for health and social care design, this could present a major challenge for GP consortia. ‘World class commissioning was based on the JSNA so it won't be that different, but local authorities will now have the lead. Consortia are going to have to try to operate within the quality framework and the JSNA and that might be difficult for GPs to adapt to.'
Local involvement
The Government plans to set up a national body called HealthWatch England as part of the Care Quality Commission. Local Involvement Networks (LINks) will be replaced by local HealthWatch organisations funded by local authorities, which will act as consumer champions across health and care and could have extra functions including helping people to choose a GP practice and funding.
The white paper doesn't specify what the relationship between local HealthWatch groups and GP consortia will be and, according to Professor Chris Drinkwater, president and public health lead for the NHS Alliance, GP consortia could find themselves negotiating with the local HealthWatch over service redesigns. ‘Making hard choices about what is and isn't provided will be part of the job of consortia and is bound to be contentious, so they will have to go out and consult the public. But will HealthWatch be a critical friend or an enemy in cases like this? Consortia could find themselves up against powerful lobby groups challenging what they want to do.'
Health and wellbeing boards
The Government wants to ‘create stronger institutional arrangements within local authorities to support partnership working across health and social care and public health'. Rather than leave it up to commissioners and local authorities to devise their own arrangements, the Government states in the consultation document that it would prefer to introduce a law making it a duty for GP commissioning consortia to work in partnership with local authorities.
Subject to consultation, this would be done via Health and Wellbeing boards in each local authority, which would undertake the JSNA, decide on pooled budgets between consortia and local authorities and undertake a scrutiny role in relation to major service redesigns currently held by Overview and Scrutiny Committees. Consortia would be expected to be represented on these boards.
According to Professor Drinkwater, responsibility for NHS commissioning would nominally rest with the consortia and the NHS Commissioning Board, but local authorities would have a statutory right to influence NHS commissioning and commissioners would have a reciprocal right to influence health improvement, reducing health inequalities and social care.
‘It might be a cynical view, but giving Health and Wellbeing boards statutory powers – teeth, in other words – could make things difficult for consortia. They could be forced to shape their plans much more to what local authorities want to see.'
From a local government perspective, however, the proposed integration makes perfect sense. The Local Government Association (LGA) represents 422 member authorities across England and Wales and is already talking with the RCGP and NHS Confederation about how to bring local government and the NHS closer together.
Alyson Morley, the association's senior policy consultant, says local authorities are the natural candidate to take the lead on local health issues. ‘We can't work in silos anymore and someone has to take the lead at a local level and I feel very strongly it should be local councils. If they don't do it, it's very difficult to know where the leadership is going to come from.'
The boards would bring together the local authority leader or elected mayor, social care representatives, NHS commissioners, local government and patient champions such as local HealthWatch representatives as well as representation from the NHS Commissioning Board where necessary.
In addition the Health and Wellbeing board would have an important role in enabling the NHS Commissioning Board to assure itself that GP consortia are ‘adequately engaging and involving the public in planning services and considering any proposed changes in how those services are provided'.
‘There is a carefully designed tension between the two,' says Mr Lorimer. ‘It's the Government's way of restoring the democratic deficit under its Big Society umbrella and it will certainly create a challenge for GP consortia. Consortia will be able to have more influence on community services but local authorities will have strong views on any changes.'
Health and Wellbeing boards would also have powers to engage external expertise to resolve conflicts – for example a clinical expert, the Centre for Public Scrutiny or the Independent Reconfiguration Panel. In exceptional cases GP consortia could find their plans being referred to the NHS Commissioning Board or secretary of state.
Budgets
Consortia will also have to accommodate local authorities' agendas when it comes to pooled budgets. Ms Morley says: ‘The NHS budget is ringfenced but that doesn't mean the NHS doesn't have to put its hands in its pocket for social care. There is an expectation from the department that the NHS will put resources into social care.'
Mr Lorimer agrees: ‘I understand that the NHS chief executive has said that's acceptable. But research shows that if you invest more in local authority services, you cut NHS spending. It runs counter to NHS culture – but it's true.'
Culture
In the 1940s, when the NHS was created, GPs resisted working with local councils in favour of the independent contractor status that they have enjoyed ever since. So will there be a clash of cultures bringing the two together now? Professor Bob Hudson, public policy analyst at the University of Durham, believes the two parties have more in common than they think: ‘Both councils and GP consortia are in the same business of public welfare, they are in the same business of reducing admissions, treating more people in the community and of being cost-effective. These are win-wins for both sides. They will be able to pool knowledge too.
‘They also have a common interest in taking on foundation trusts and they'll find that much easier if they work together and have some sensible discussions about boundaries. If they opt for co-terminosity you'll have two big organisations with greatly enhanced commissioning clout.'
Professor Drinkwater says: ‘The strength of local authority commissioners is that they have a longer and stronger track record of commissioning, procurement and contract management than NHS commissioners. In the new world they will also be the only body able to join up funding streams for adult social care, public health and NHS GP commissioning funds. They also have the added advantage of local democratic legitimacy.
‘The downside is that their knowledge and understanding of the NHS and health care is limited and they tend to be in awe of specialists and their local acute trusts.'Might small consortia find it hard to stand up to larger local authorities?
Professor Drinkwater says the picture is more complex than that: ‘Many large local authorities have the same tensions about a local neighbourhood focus versus a whole city approach as consortia. Newcastle City Council, for instance, seems fairly comfortable at the moment with three separate GP groups covering the east, the west and the north of the city. I suspect pressure to form larger consortia will come from the Department of Health and the National Commissioning Board rather than from local authorities themselves.'
For Mr Lorimer, how the plans will work in practice depends on the will among both sides to collaborate: ‘It's a steep learning curve for local authorities as well as GPs. It will be interesting to see if GPs are interested in working with local authorities. They are not the only gatekeepers in the NHS any more.'
By Alisdair Stirling is a freelance journalist.
Alyson Morley Commissioning revolution
