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The White Paper explained: Dr David Colin-Thome answers your questions

Primary care tsar Dr David Colin-Thome is quizzed by GPs on how the White Paper will affect their practice, exclusively for Pulse.

Dr David Connolly, GP, Salisbury: Our local PCT recently agreed a five-year contract with a company for out-of-hours provision. Will consortia be bound by such a contract? If there is compensation to be paid to terminate contracts, who pays it?

GP consortia will have to look at these contracts carefully and renegotiate, terminate or vary them as they see fit. Contracts should contain clauses governing a change of commissioning organisation. These should be taken into account when GP consortia take the contracts on.

Dr Gillian Breese, GP, Llandudno, Wales: Does this White Paper apply to LHBs in Wales or health boards in Scotland? What implications does it have for the UK-wide GP contract?

Responsibility for Health Services in Wales, Scotland and Northern Ireland is devolved to their respective governments, so no, the White Paper does not affect them.

With regard to GP contractual matters, discussions with the GPC (who cover GP contract arrangements across the UK) will continue to take place as normal. There are, however, some differences already between GP contract arrangements in different countries and there is no reason why that should not continue.

Dr Gerbo Huisman, GP, Lichfield, Staffs: Will Payment by Results and fixed tariffs remain, or will there be opportunity to negotiate on pricing? Will there be a return to block contracts for certain groups of services?

The White Paper, Equity and Excellence: Liberating the NHS, makes clear that Payment by Results will be developed, extended and improved. The Department of Health will ‘design and implement a more comprehensive, transparent and sustainable structure of payment for performance so that money follows the patient and reflects quality’ (para 3.18).

The detail is still to be agreed, but there may be more scope for local flexibility on pricing. We don’t think block contracts are a good funding mechanism, but we will introduce more ‘pathway’ and ‘period of care’ tariffs, so that financial risks are better shared between commissioners and providers.

Dr Keith Hopcroft, GP, Essex: Will the ‘powerful incentives’ be paid to commissioning consortia or to member practices, and will they have to be reinvested in healthcare? Must all savings be reinvested, and if so, will they be sucked up by the commissioning budget or that of practices?

With the exception of the management allowance to cover management costs, the consortium’s commissioning budget must be used exclusively for the commissioning of patient care. It will be distinct from the income that GP practices earn under their primary medical care contract, from which they meet their practice expenses and personal income.

Subject to discussions with the BMA and the profession, a proportion of GP practice income will be linked to the outcomes they achieve and the effectiveness with which they manage financial resources. This ‘quality premium’ should be paid in the first instance to the consortium who is then free to decide how best to share it between member practices. This premium would need to be funded from within existing resources.

Dr Peter Crouch, GP, Swindon: So much patient and GP time is currently wasted with GPs in the dark about what happened at the hospital – some letters take 4-6 weeks to arrive. Will it only be clinical outcome measures that are published about hospital departments? Or will they be judged on how soon they type, check and send GPs letters?

The NHS Outcomes Framework will focus on the outcomes of care – what actually happens to the health of the patient as a result of the treatment and care they receive.

Locally, the structures and process of care will need to be monitored. But too much focus on these at a national level can distort clinical priorities and risk creating a whole system of accountability that is more concerned with the means than the end.

As the NHS becomes ever more free of top down control, you will find yourselves increasingly able to demand the kind of information you think is important from your local providers.

Dr Martin Breach, GP, St Helens, Merseyside: If PCTs are to be abolished, who will hold the GP contract? Will contracts be between practices and the commissioning consortiums – and if so, will consortiums be able to terminate practice contracts? It’s suggested that commissioning may be handled by private companies in some instances – is there a risk that this will lead to the progressive privatisation of primary care?

The NHS Commissioning Board will be responsible for all contracts with primary care providers, including GPs. At the same time, GP consortia will have a role in working with GP practices to drive up the quality of care and improve overall utilisation of NHS resources. Therefore, where appropriate, the Commissioning Board may delegate some aspects of managing primary medical services contracts to GP consortia. However, the Board will retain overall responsibility for commissioning and contractual decisions.

This is not about privatising the NHS, it is about placing the financial power to change health services in your hands – the hands the public trust most. This will reduce waste and bureaucracy as you are empowered to strip out activities that do not have appreciable benefits for your patients’ health or healthcare.

Dr Siddappa Gada, GP, Coventry, West Midlands: Are there any pilots done in any region of UK of this? Have they consulted any staff on the ground who will be running the system? Have they consulted patient groups about their views about these changes – and how will GP consortia be held accountable to patients?

Many GP consortia are already commissioning services for their local communities and they’re doing an excellent job. For example, in Bexley, Cumbria, Tower Hamlets, Somerset, Nottingham, Northants I have been impressed what has been achieved.

Primary Care Trusts will have a key role over the next two years in supporting practices to prepare for these new arrangements. We want implementation to be driven from the bottom up, with GP consortia taking on their new responsibilities as quickly as possible, with early adopters promoting best practice.

The NHS Commissioning Board will be responsible for holding consortia to account for the stewardship of NHS resources and for the outcomes they achieve.

Far from being alone, GPs will work together with the full range of clinicians and healthcare professionals to agree the best way to look after their communities. And the NHS Commissioning Board will be there to support you.

Employing good managers will be crucial. So GPs, working with other clinicians, can focus on leading, not on micro-managing the detail. And a huge part of that GP leadership is within practices.

Many GPs and other clinicians will be keen to commission, but others will mainly want to focus on running their practices. Both those tasks are hugely important and both are possible.

Last week we launched a public consultation on GP-led commissioning and the NHS Commissioning Board and I want to hear your views on how the new system should work, how we ensure patients have a better experience of the NHS, and ultimately, how we ensure better health outcomes for all.

Dr Robert Jaggs-Fowler, Barton-Upon-Humber, South Humberside: With the return of out-of-hours commissioning, will GPs get our £6,000 back as from next April? Will out-of-hours sit in a different budget pool from the rest of the commissioning pot?

Responsibility for commissioning Out of Hours services will transfer from PCTs to GP consortia in April 2013, but PCTs will be expected to work with existing practice-based commissioning groups and with shadow GP consortia in the meantime to ensure that decisions are increasingly driven by local clinical insight.

Individual GPs and practices won’t be asked to take back responsibility for providing out-of-hours services. It will remain the responsibility of the commissioner.

You will be responsible for commissioning out-of-hours services, not for providing the services themselves. As such, the sum given up in return for the opting out of out-of-hours provision under the 2004 GMS contract will not be reimbursed, but will remain part of the overall funds available to support commissioning of out-of-hours services.

The consultation on commissioning for patients provides further details on the intended arrangements for GP commissioning.

Dr Sudesh Mittal, GP, London: Will GPs be able to buy in chronic disease management services to support their member practices? Or will chronic illness remain an individual practice responsibility?

Consortia will be free to commission the services they judge will achieve the best outcomes for their community. They will be free to decide which activities they undertake for themselves and which ones they buy in, including from local authorities, the private and voluntary sectors.

At the same time, the economic regulator and NHS Commissioning Board will develop a framework that ensures transparency, fairness and patient choice.

Every GP practice will be part of a consortium and contribute to its goals. This is, of course, a major challenge. But it is also a huge opportunity for GPs to shape local healthcare and achieve the very best results for their patients.

Dr Keith Hopcroft, GP, Essex: Will the NHS Commissioning Board be able to impose special measures to stop activity if a commissioning group is overspending? And what then happens to that consortium? If it is stripped of its right to commission, who then gets the job?

The NHS Commissioning Board will have the power to intervene should a consortium be unable to fulfil its duties effectively or where there is a significant risk of failure.

We will work with the NHS to develop the criteria for intervention. The Board could make continued authorisation dependent upon remedial action and, in the last resort, take over the consortium’s commissioning responsibilities or assign them to a third party, such as a neighbouring consortium.

Dr Paul Joshi: Will there be a moratorium on PCTs awarding long-term contracts from now until commssioning groups take over, to prevent PCTs adopting a ‘scorch earth’ policy by over-spending in their final months and years?

Before awarding a contract, PCTs will have undertaken an open tender and will normally have consulted upon the services they propose to commission. PCTs should therefore continue to commission the services they believe are necessary to meet the needs of their population. Where the services go wider than that usually provided within primary care, a PCT should discuss with local GPs the appropriateness of entering into long terms contracts.

Primary care tsar Dr David Colin-Thome answers GPs’ questions Primary care tsar Dr David Colin-Thome answers GPs’ questions The White Paper explained: Dr David Colin-Thome answers your questions