1: Why do we need to build capacity in primary care?
JK: It's the absolute cornerstone of the whole reform agenda. If we are to continue to have a sustainable NHS free at the point of access, most contacts in general practice need to be converted into finished episodes of care. And for that, we need to build capacity in primary care.
MD: At present, we are using hospitals more than any other developed country beside the US. There has been masses of rhetoric about providing more services close to patients' homes, more conveniently and more cost effectively, but it never happens. One of the main ways to ensure it does happen is to increase the capacity of general practice.
JS: We talk so much about wanting to shift services from the acute sector into primary care, but to do that we have to make sure capacity is there in general practice. To properly tackle QIPP, we also need to think very seriously about how services are provided and that is about both additional capacity and different capacity.
This is the opportunity to put in place better co-ordinated care rooted in patients' homes or the community, and that is the principle at the heart of clinical commissioning.
2: What would you describe as the pitfalls and advantages of being able to ‘make' as well as ‘buy'?
JK: We need to demonstrate the value of the primary care, list-based system.
This reform is as much about building capacity as anything else, and from that the rest will follow. But the first thing people say to me is: ‘There is no room in our practice – how are we supposed to increase capacity?' What I am talking about is using that commissioning budget more imaginatively and repatriating the routine complex care – making it part and parcel of routine generalist care, not double-paying.
SM: Being both commissioner and provider raises issues around conflict of interest, but the best way to avoid such accusations is through increasing capacity – because rather than new income, what you do is provide additional support, additional administration or nursing support.
MD: The enormous pros of being able to make as well as buy are that it encourages movement of services from secondary to primary care and it has a chance of working where it has not worked in the past. It will also be more integrated because GPs will be commissioners and providers.
The cons are that some people will say it looks too uncompetitive. If it looks like someone is lining their pockets, it could potentially reduce trust between patients and their doctors.
JS: We know from significant research that what clinical commissioners do best is develop extended primary care or intermediate care, and they can see real opportunities for that.
Those ‘make or buy' decisions are what they have always done well. But there are practical issues that need to be considered. Clinical commissioning is based on the idea that the GP is like an agent, but we need to make sure that within that, people have a choice about care. And make or buy does require quite significant management support.
But the issue that attracts the most attention is where clinical commissioners may be commissioning or funding new work that will benefit their practice or provider company in which they have a stake.
3: What are the potential conflicts of interest, and how do we overcome them?
JK: There is a lack of understanding about conflicts of interest with make or buy and there are two different aspects to consider. One option is to set up a new provider service through creating a limited company to provide a service to replace what was in secondary care.
To do that, you have to demonstrate patient choice. If the patient was offered choice and they chose the GP, you have to then explain to the patient that they have chosen a service in which you have a financial interest.
If the correct governance system was in place, then that is the end of the conflict of interest. But I think that should be a peripheral activity – GPs being part of the any qualified provider environment – and what we should be focusing on is improving capacity.
That means taking the commissioning budget and thinking about how it can be best spent. For example, as a clinical commissioning group you could say to member practices you need to be open until 10pm and we will then reinvest what we used to fund urgent care or walk-in centres to buy in increased capacity. Our business case says it will be a better use of money.
It might be about increasing admin capacity or nursing capacity, or freeing up GP time, or putting in place a LES mechanism to do new work.
If people say that scenario is a conflict, then there is no hope for the reform agenda.
SM: Where the conflict of interest will come is if they are just seen to cherry-pick, so they need to look at whole tranches of a pathway.
The safety net in terms of conflict of interest is where the service – whether that is a LES or service-level agreement – is signed off by the commissioning board, and those involved in providing a service clearly will not be able to sign off themselves.
There is no way that conflicts of interest can be avoided, but whoever signs off on the service needs to ensure that it reduces health inequalities, produces better outcomes for the patient, that it is completely equitable, it addresses prevention and it shows cost efficiency and value for money. That is how you control your conflict of interest.
MD: If individual practices or groups of practices form a provider organisation offering something like sexual health services to local patients, then the CCG is not the provider – the practices as a federation are the provider.
It may be one of the GPs is also on the board, so clearly there will be times when people have to declare interests and leave rooms.
The more this happens the more conflict there will be, because GPs will be the commissioners and providers – and the triple conflict is that their patients will be referred to the services.
But the answer is not to make it massively bureaucratic like it has been, but get people to realise there are these conflicts.
In many cases the board will have a non-executive chair and it will be their role to make sure there is good governance.
We have got to be transparent as a CCG and seen as honest and trustworthy and not wanting to profiteer. Where there is a conflict of interest we have got to make it clear that there is one. Make sure there are notices in your surgery, making it clear there is this conflict of interest and why you are providing this service.
You also need to be upfront with patients when you are referring to the service, and suggest an alternative if possible.
JS: There won't be one-size-fits-all for governance arrangements – there never has been. We will need appropriate arrangements depending on the scale of the contract.
The NHS Commissioning Board really needs to think through how primary care commissioning is going to work and how it is going to work with CCGs to do that, because it will be cumbersome to do everything at a national level.
It is vital we have proper public or non-executive governance, but also transparency built into the contract process.
4: What should CCGs do now to create a different primary care with more capacity?
JK: Don't think that creating a strong board and well-structured CCG somehow will deliver – it is the facilitator of reform, not the reform.
The CCG has got to work out how it can consistently and accountably make sure general practice has the capacity for routine monitoring of the stable patient so we do not need the outpatient clinic.
We need action, and what I have described can be delivered with good governance – with openness and the right checks and balances in place.
MD: Many CCGs are drawing up their constitutions at the moment and there need to be clear rules about conflict of interest between providers and commissioners.
There will be guidance coming over the next few months on what governance should look like, so it is not necessary to reinvent the wheel 250 times.
Patient involvement is important – I advise everyone to set up a patient group in their practice because they can put these issues to them, and ours is very good at pointing to where they see conflicts.
Emma Wilkinson is a freelance journalist
JK: Dr James Kingsland, NAPC president
MD: Dr Mike Dixon, Chair of NHS Alliance
JS: Dr Judith Smith, Head of policy at the Nuffield Trust
SM: Scott McKenzie, Commissioning consultant
Key Points
- Most contacts in general practice need to be converted into finished episodes of care
- This requires repatriating complex routine care as well as the more straightforward outpatient-type services
- Being able to ‘make and buy' will make possible the shift from hospitals to primary care that needs to be achieved
- Conflicts of interest are inevitable, but not insurmountable
- Where there is a conflict of interest, be explicit – put signs in surgeries, tell patients you have a stake in a service, have a transparent decision-making process
- Patients are very good at identifying conflicts and every practice should ideally have a patient reference group
