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The health White Paper: FAQs

Pulse news editor Ian Quinn provides a bluffer's guide to the health White Paper and the future of GP commissioning

What will happen to GP contracts?

As first revealed by Pulse in June, the Government plans to do away with GMS and PMS contracts and bring in a single contract for all GPs in England, which will include a new responsibility for commissioning and link pay more closely to health outcomes.

The contract is the subject of what is set to be a tumultuous round of negotiations with the GPC, already under way, with the White Paper saying the Government ‘seeks over time 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'.

Expectations of the negotiations vary drastically. The National Association of Primary Care has said it believes elements of PMS-style contracts could remain, allowing local incentives for GPs providing extra services. The NHS Alliance has warned the single funding model could open the door for use of short-term APMS-style contracts, with GPs having to re-tender every five years.

One thing nobody is expecting is a repeat of the 2004 contract outcome, which led to a substantial pay rise for the profession. These negotiations are set firmly against the backdrop of financial crisis. Yet the GPC will face the fury of its members if it is seen to cave in without winning some extra payment for taking on commissioning, as GPs are set the unenviable task of steering the NHS through extremely choppy financial waters.

How will GPs take on commissionming responsibility

The Conservatives had been talking about GPs taking on commissioning responsibility for some time, but the White Paper's radical plans still managed to take many observers by surprise.

Under the massive cull of bureaucracy, not only will SHAs be scrapped by 2012, as had been widely been reported, but PCTs will be gone too by April the following year.

All GP practices will be made to join consortiums by the autumn of 2012 - and from April 2013 will be funded directly by the new NHS Commissioning Board. On whether GPs should be beginning to form consortiums now, again there is no consensus – the NHS Alliance says yes, the BMA no. Eventually, though, the board will have the power to forcibly assign GP practices to a consortium if they have not done so themselves.

Consortiums will be able to employ staff from external organisations, such as the soon to be defunct PCTs and local authorities, with professional mangers envisaged to run them day to day rather than grassroots GPs.

The Government says not all GPs will have to be actively involved in all aspects of commissioning, but every practice will need to take on basic commissioning responsibilities, such auditing and rationalising the cost of referrals. And the move to consortiums will effectively kill the independent-contractor model of general practice, with each member practice expected to work within the same financial framework.

Indeed, the expectation is that consortiums will manage performance of member practices much more closely than PCTs currently do – and with it being considerably more straightforward to expel, and therefore close, those judged to be under-performing.

How will GP commissioning consortiums be incentivised?

Health secretary Andrew Lansley promised ‘powerful incentives' for GPs to take on the reins of commissioning, but the Department of Health's consultation document made clear these would be funded out of existing resources.

In other words, money practices currently get will come with strings attached, and how this cash is distributed looks set to become one of the most controversial of all the elements of the White Paper.

The Government says with the exception of a management allowance, to cover management costs, the consortium's commissioning budget must be reinvested exclusively in patient care.

It will be kept distinct from the income GP practices earn under their primary medical care contract, which includes practice expenses and personal income.

Yet a proportion of GP practice income will be linked to commissioning, with the DH saying GPs will be able to earn a ‘quality premium' if their consortium hits targets for clinical outcomes and financial performance set by the NHS board.

Rather than being paid to practices, this money will go to the consortium, which will have to decide how best to share it between member practices. And GP practices will lose a proportion of their existing income if their consortium overspends.

Lawyers have warned that the process of consortiums deciding how incentives should be shared will be just one of a raft of potential stumbling blocks to consortiums getting off the ground.

How will consortiums hold GP practices accountable?

The NHS Commissioning Board will be responsible for holding GP consortiums to account. It will also hold GP practice contracts, but is expected to devolve to consortiums the job of policing practice performance.

It is expected that around 70-80 % of a consortium's commissioning plans will be set from above, but the remainder will be down to individual consortiums to decide, including vital questions such as how incentives will be distributed, what the policy is on dealing with under-performance and how voting rights are distributed among practices.

Talks have already begun in some PCTs between LMC leaders and lawyers, aimed at tackling a potential legal minefield by drawing up a model contract for consortiums. But it's a complex issue, with the NHS Commissioning Board drawing up its own model contract, and likely to play a key role in attempting to resolve disputes between GPs.

Lawyers warn there could be chaos if commissioning enthusiasts end up locked in battle with GPs resistant to the Government's plans and unhappy at their peers having newfound control over them.

What happens if consortiums overspend?

Andrew Lansley has said there will be ‘no bail out' for GP consortiums, which he expects to take on the financial risk of commissioning. They may choose to insure against this risk, or to share it with a private company.

Risk will not, however, be shared with individual practices, who will not be penalised financially in the event of an overspend, other than through the loss of their quality premium.

The NHS Commissioning Board will have the power to step in if consortiums run a ‘significant risk of failure', to impose measures to limit any overspend (such as reducing referral activity), and in extreme circumstances to sanction temporary payments.

Consortiums that overspend are likely to be forced to undergo remedial action and may ultimately have their commissioning responsibilities taken away and given to someone else, such as a neighbouring consortium. Some claim this could lead to private firms being parachuted in, which the private sector will be eyeing very closely.

What happens with existing deals signed by PCTs when GP consortiums take over?

GPs will be expected to take on the huge challenge of reviewing all the contracts held by PCTs and potentially re-negotiate or terminate existing deals with a raft of NHS providers, including out-of-hours companies.

Many contracts will contain clauses governing a change of commissioning organisation, so GPs won't always be lumbered with the full burden of long-term contracts – a considerable relief, since some last up to 30 years. But GPs could be faced with legal challenges by firms, some of who have funding to dwarf any GP consortium.

GP consortiums will call the shots over future the use of management consultants, private firms running services in the community and back-office services, to name but a few.

What does the White Paper mean for private firms?

The White Paper will lead to huge new opportunities for private companies, with firms such as UnitedHealth, Tribal, Bupa and Harmoni already offering to run commissioning and accountancy services and back-office functions for GP consortiums.

Indeed, the DH's consultation document says local consortiums will have the option of either buying in support for specific services such as financial analysis, or devolving commissioning of whole services to local authorities, social enterprises or private firms.

On the provider side, privately owned practices and Darzi centres, such as those run by Virgin–owned Assura, will gain a new a stake in the direction of the NHS, being entitled to a place on GP consortiums provided they have their own list of patients.

The inclusion of Darzi centres in consortiums is also likely to thwart GP leaders' hopes of closing down the centres, widely regarded as white elephants.

On a wider front the private sector is expected to profit from many of the White Paper's elements, particularly its introduction of an ‘any willing provider' policy across the NHS.

Frequently asked questions on the health White Paper