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What’s agreed – and what’s not?

With major changes ahead for clinical commissioning, Alisdair Stirling sets out the common ground between the coalition partners and highlights the potential battlegrounds

The radical policies agreed by the Conservatives and the Liberal Democrats in forming their coalition are beginning to take shape with the swift publication of the parties' policy document The Coalition: Programme for Government.

That document sets out some broad principles that will guide the development of primary care commissioning – but there are many details that remain to be settled.

We set out the agreed policy principles and assess the potential for blood on the carpet as the Tories and the Liberal Democrats thrash out the details and push through the necessary contractual and organisational changes.

Commissioning budgets will be devolved to GPs

What the coalition document says:

‘We will strengthen the power of GPs as patients' expert guides through the health system by enabling them to commission care on their behalf.'

Sticking points:

The coalition document echoes the Tory election pledge almost word for word. The Liberal Democrats did promise to put front-line staff in charge of their own ward or unit budgets but it is not clear whether GP commissioning budgets is what they had in mind.

There is also the question of whether or not these will turn out to be ‘real' budgets as proposed by the Tories in their manifesto and also whether the GP provider and commissioning contracts will be combined.

What the experts say:

According to Dr David Jenner, PBC co-lead for the NHS Alliance and a GP in Cullompton, Devon, strategic health authorities have already been briefed that PBC groups will get management budgets to spend on IT and contracting and commissioning support that they can buy from the PCT or private companies or develop in house at their discretion. But it is not yet clear whether the commissioning budgets will be ‘real'.

‘And the tricky bit – and where we need detail - is if GP practices fail to balance the books, they might lose the right to hold their GP provider (GMS and PMS) contract if they are combined. Get set for a major run-in with the profession if they are.'

Dr Johnny Marshall, chair of the NAPC and a GP in Buckinghamshire, says: ‘This is the talk of the town. The reality of the budgets depends on accountability and responsibility, which will mean big changes for GPs.

‘The money has to come with those otherwise they won't be real budgets. The detail has not been publicly announced but we are trying to input into the discussions to ensure that GPs are given the full range of powers to commission as well as the money.'

Look out for:

Swift progress in negotiations. The new Government is said to be ‘very open' to solutions to make this work as swiftly as possible.

New independent board to draw up commissioning guidelines

What the document says:

‘We will establish an independent NHS board to allocate resources and provide commissioning guidelines.'

‘We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS.'

Sticking points:

The Liberal Democrats wanted a much more local level of control on commissioning through elected local boards. While sources close to the negotiations are saying there is ‘no friction' over these two aspirations, it is not yet clear what the new board will do, let alone how it might relate to local governance.

Established in 2004, Monitor is the independent overseer of NHS foundation trusts and is a non-departmental public body that determines whether NHS trusts are fit to become foundation trusts, and ensures they comply with conditions such as being well led and financially robust once established.

Monitor can intervene in the running of trusts if they fail on these criteria. How Monitor evolves in this new role and how much say it will have over GP commissioning is still to be decided.

What the experts say:

Dr Jenner says: ´The new GP contract will be between the practice and the NHS board. SHAs are going to become the local office of the NHS board.'

Dr Marshall says: ‘It looks as if Monitor will expand its role to something equating to the Competition and Co-operation Panel. Whether this is one of the quangos the new Government wants to do away with remains to be seen.'

Look out for:

What happens to the Competition and Co-operation Panel in the next wave of coalition quango-bashing by the Treasury´s new Efficiency and Reform group.

GP contract renegotiated to reflect change in GPs' commissioning status

What the policy document says:

‘We will renegotiate the GP contract.'

Sticking points:

What the new document doesn't say is that the new contract is likely to be between the practice and the new health board – rather than the PCT – and is likely to give GPs commissioning responsibility for all routine, non-elective and out-of hours care.

There is no reason to believe the Liberal Democrats will oppose this plan but the devil, as always, will be in the detail.

Before the election, the Tories employed cancer specialist Professor David Kerr of Oxford University to plan the transition to a new GP contract over an estimated two-year period post-election, and the plan was for GPs to operate in commissioning clusters covering populations of between 100,000 to 150,000 patients.

And the new Government is likely to demand much more onerous outcome measures in individual GP contracts to reflect the shift in commissioning emphasis, although it's still not clear where the Liberal Democrat members of the coalition stand on this.

The document also states: ‘We will measure our success on the health results that really matter – such as improving cancer and stroke survival rates or reducing hospital infections.' This is not as specific a pledge as was made in the Tory manifesto, which said that payment for health initiatives would be made according to ‘how successful they are in improving health'.

The Tories' drive for greater transparency and payment by results, including greater use of PROMs and patients using outcome data to inform who provides care for them, appears to have been watered down.

However, the coalition agreement does leave the door open for greater transparency: ‘We will publish detailed data about the performance of healthcare providers online so everyone will know who is providing a good service and who is falling behind.'

Meanwhile, the GPC is insisting there will be no radical overhaul of the GP contract, leaving the Government facing a huge challenge to push such changes through the negotiating process.

What the experts say:

‘The GP contract is going to start including the quality of service you provide and the quality your patients experience,' Dr Marshall says. ‘This is what we've been saying we'd like. Pre-election, the Tories certainly wanted clinical and financial accountability for GPs but we don't yet know how tempered that will be by the coalition. I think we will start to see much greater transparency and emphasis on outcomes.'

Dr Jenner says: ‘I think it will be a major revision of the GP contract. I suggest non outcome-based targets will go, with a GP survey as a means of payment with results posted online. The commissioning responsibility will be exercised through consortia PBC arrangements with a minimum population of 150,000.'

Look out for:

A draft GP contract from the Department of Health within weeks rather than months – followed by protracted and heated negotiations with GP leaders.

PCTs will retain some commissioning roles

What the document says:

‘The local PCT will act as champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs.'

Sticking points:

The Tories and Liberal Democrats appear to be singing from the same hymn sheet on this point, with a renewed focus on public health and a greater input for patients.

What the experts say:

Dr Johnny Marshall says: ‘PCTs are likely to retain responsibility for specialist and tertiary commissioning – for example, coronary artery bypass grafting. It wouldn't make much sense to devolve those down to GP level. There will be different paces of change in different areas, so PCTs will continue to fill in in areas where GPs are getting up and running.'

Dr Jenner says: ‘PCTs – possibly reduced to 30 in number – will be responsible for public health, specialist commissioning for cancer, heart surgery, renal dialysis and back office support for PBC groups.'

Look out for:

An expanded role for patients in PCT-based commissioning. The coalition has agreed: ‘We will ensure there is a stronger voice for patients locally through directly elected individuals on the boards of their PCT.' It is not clear how this will work.

Out-of-hours to undergo change

What the document says:

‘We will develop a 24/7 urgent care service in every area of England, including GP out-of-hours services, and ensure every patient can access a local GP'

Sticking points:

Tory insiders have told Practical Commissioning that the new health secretary Andrew Lansley won't tell GPs when to open their surgeries. It will be up to each practice to decide when to open and to commission out-of-hours and weekend care from other providers.

There is a difference of opinion on GP out-of-hours. The Liberal Democrats wanted to ensure GPs were directly involved in providing out-of-hours care. But the Tories want to see GPs commissioning the care they don't provide themselves.

What the experts say:

Dr Jenner says: ‘There are likely to be 24/7 non-elective services for urgent care in each patch – probably a mixture of walk-in centres and acute visiting centres accessed via a 111 number, with an opportunity for GPs to be part of that and with out-of-hours providers moving into in-hours urgent care provision.'

Dr Marshall says: ‘GPs will have a greater say in the commissioning of out-of-hours care rather than taking it back on themselves. It makes sense for GPs to decide themselves how best to provide the cover.'

Look out for:

GP out-of-hours commissioning forming part of the coalition's brave new world.

Guaranteed provider role for the private and third sectors

What the document says:

‘We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and voluntary providers.' And further:´We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers.'

Sticking points:

This was not a Liberal Democrat policy. And Liberal Democrats generally, and especially those on the left of the party, are likely to be suspicious of private sector involvement.

Pre-election, they wanted elected local health boards to be able to commission services for local people from a range of different provider types, including staff co-operatives, on the basis of a level playing field in any competitive tender, ending any current bias in favour of private providers.

Look out for:

A slow but steady blurring of the public/private status of providers.

Alisdair Stirling is a freelance journalist

Focus on...commissioning under a coalition government