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Lansley’s hopes rest on 200 GP consortia

By Richard Hoey

There's a fair bit of variation, but the pathfinders have coalesced around the size of a small PCT, says Pulse editor Richard Hoey

It's been a big week for health secretary Andrew Lansley's commissioning reforms, with the announcement of the 52 pathfinders providing something he himself has seemed reluctant to give – some good, concrete detail.

The idea of GPs taking over £80bn of NHS budget feels rather less pie in the sky when you can view a real-life map marked with the explorers of this challenging but potentially exciting new landscape.

So what does the make-up of the pathfinders tell us about the likely progress of GP commissioning? Well, firstly, this really does have the feel of a pilot programme, designed to tentatively test out the various options, even if the Department of Health would rather describe it as the first stage of a rollout.

Sure, a bit of variation to suit local circumstances is natural and fits the zeitgeist. But let's assume for a moment that there is some purpose at all to organisational theory, and that the thinking behind commissioning can't be so relativist that all answers are equally right and equally wrong.

If that is the case, then commissioning groups varying in size from 18,000 patients to 672,000 can't both represent the future, and presumably at least one of those models will have to be discarded in future as either too small and risky, or too bulky and bureaucratic.

If pathfinders are indeed pilots, as the GPC has always argued they should be, then it makes NHS South Central look ever more ridiculous for asserting that half of all its practices should be members of one by April, and all of them a year later.

If every GP is expected to find a path, expect lots of different routes to be trampled, some of them to some fairly out of the way places. Fortunately, not all SHAs have found the term ‘pathfinder' so hard to understand.

Still, tentative or not, these pathfinders do tell us quite a lot about where commissioning is going. The average size is 36 practices covering a population of 248,000 patients, with just over half covering populations within 100,000 of this.

The 52 announced so far cover about a quarter of England's population, which means we could be heading for about 200 across the country, to succeed the current set-up of 151 PCTs.

Compare that 200 figure with the original proposal that there would be 500 consortia covering 100,000 patients each. It suggests the GPC's warning – that consortia might need populations of 500,000 to cope with financial risk – has had some effect.

I'd expect the final number to be a bit fewer than 200. If the GPC is onto anything at all, then those really very small consortia must surely only be there as valuable experiments, rather than with the serious expectation of sticking around in this form for the long term.

I'm speculating, but I'd imagine groups will be more likely to group together than they will be to split up, particularly as some look just a little bit too small to be co-terminus with local authorities, which is likely to mean pressure to get just a bit bigger.

So, the reforms are starting to take shape. We have consortia forming of about the same size as, although maybe a little bit smaller than, PCTs.

Mr Lansley has set out the path to GP commissioning and it looks a road some GPs at least will feel able to travel. The real question is whether the destination will be dramatic and exciting enough to be worth the arduous journey.

Richard Hoey, Pulse editor