In the rush to set up consortia, it's easy to miss key details. The GPC's Dr Chaand Nagpaul provides a simple checklist
Practice-based commissioning struggled to adequately engage GPs. It is vital GP commissioning consortia are set up at the outset in a culture of inclusivity, engagement and democratic opportunity.
Local areas should have already had, or be having, GP open meetings to discuss the white paper and the development of consortia.1 What follows is a checklist of the processes GPs should be going through to ensure consortia engage with practices, and gain wider political and managerial support.
Agree consortium size and configuration
Developing GP consortia should be an opportunity to develop an organisation afresh. The process should be owned by grassroots GPs, not dictated by the PCT. Practices need to consider the local health community, the proposed consortium's relationship with its practices and external organisations and its ability to manage financial risk. GP consortia will operate in an extremely financially challenging climate and the larger they are, the greater the economies of scale and ability to manage financial risk. But larger consortia might find it harder to engage GPs, which could affect their ability to manage resources. The GPC believes most will need to be between 100,000-750,000 patients, depending upon geography and demographics.2 It might be possible to have hybrid arrangements with several smaller consortia supported by a single larger management organisation, or a large consortium supporting locality substructures. Consortia will also need to collaborate with others to pool financial risk or commission some acute hospital services. One consortium might take a lead commissioning role on behalf of several.
Determine a transitional leadership
GP consortia will operate in shadow form until 2013 and willrequire transitional leadership in the interim. Leadership structures will vary according to local circumstances, but could be boards or clinical executives. This leadership will have delegated commissioning and budgetary responsibilities, and is expected to progressively take on other PCT functions. Constituent practices will want a capable, competent leadership. Equally, leaders need to command support, with confidence that their decisions are sensitive to the needs of grassroots GPs. There should be no assumptions that existing practice-based commissioning leads will take on these new positions, and should be true democratic opportunity for all local GPs, including sessional GPs. But if a transitional leadership was created solely by elections, it could deliver leaders who were popular, but might not possess the right skills for the job. It may be appropriate to require all candidates to meet certain competency requirements before being entered into an election or selection process.
Involve other GPs in lead commissioning roles
Leadership of the consortium should not be concentrated entirely within the few GPs on the top table. These lead GPs will be primarily responsible for the consortium's statutory duties, but will not have the capacity or necessarily the expertise to be involved in its wider commissioning activities. Consortia should ensure opportunities for grassroots GPs to lead in defined commissioning areas such as service redesign, pathway development, GP education or peer review. This will appeal to GPs who may have little interest in committee work, but expertise in a portfolio. It will exploit the full talent pool and widen GP leadership involvement. It is important emerging consortia identify such lead roles at the outset, as part of their development.
Ensure practices are engaged and incentivised
Practices will be the building blocks of consortia since their clinical activity will determine the budgetary spend and ability to achieve change. Practices will require internal meetings and systems to ensure consistency with consortium policy on clinical management, referrals and prescribing, while a practice commissioning lead will serve as a point of contact on consortium policy. Practices should receive identified resources for this additional work via local incentive schemes or enhanced services.
Secure management support
PCTs remain the legally accountable health body until 2013, but their management functions will be progressively devolved to shadow consortia. Clustering of PCTs, and in some areas loss of PCT staff, will require shadow consortia to quickly define the management support and infrastructure they will require. It is important shadow consortia have discussions with PCTs and identify staff with skills and local knowledge for future consortium roles. There is also the option for consortia to use management support from external bodies, perhaps from management support agencies developing from previously employed NHS managers.
Build relationships with other stakeholders
While consortia will be GP led, they will need to involve other stakeholders. There should be early dialogue with hospital consultants, since their role in redesigning services and identifying efficiencies will be vital. Consortia will need to work with community providers to improve care, and local authorities will have an expanded role, housing health and wellbeing boards and HealthWatch, a patient advocacy body. Public health doctors, who will move into local authorities, will be an invaluable resource in supporting consortia to develop evidence-based policies based on need.
Involve patients and the public
Consortia should involve patients and the public at the outset of their development and have ongoing processes for doing so. It is important the public are fully aware of both the political context and the financial constraints consortia will be operating under, so they can contribute to commissioning policy while appreciating there will be difficult decisions.
Enlist support from your LMC and GPC
The LMC should be involved at all stages of development, and used as a resource to assist the process.3 The GPC has produced a rolling series of guidance on specific aspects of consortium development, available on the BMA website.
Dr Chaand Nagpaul is a GP in Stanmore, Middlesex, and GPC lead negotiator on commissioning
