The first weeks of a new era

We asked 12 GP commissioning leads for a progress report on their activity since the white paper was published

Our experts:

• Dr Bill Tamkin (BT), Chair of Manchester, PBC South
• Dr Gurkirit Kalkat (GK), PBC cluster lead for Barking and Dagenham
• Dr Clive Henderson (CH), PBC lead of Goole, Howden and West Wolds locality in Yorkshire
• Dr Tony Brzezicki (TB), Founding chair of Combined Croydon Commissioning Consortium (C4) and interim vice-chair of the pan-Croydon PBC group
• Dr Iain Gilmour (IG), Clinical chair of Sunderland Commissioning Network
• Chris Reid (CR), Chief executive of Leodis Healthcare Leeds
• Dr Peter lves (PI), Clinical lead for the RoeHill PBC cluster in Wandsworth, London
• Dr John Ribchester (JR), Clinical lead for Whitstable Medical Practice cluster
• Paul Bearman (PB), General manager of Wyvernhealth, Somerset
• Dr Mark Dornan (MD), Chair of GatNet, Gateshead
• Dr Jim O'Donnell (JO), Slough locality PBC lead at East Berkshire PCT
• Dr Andy Harris (AH), Chair of Leodis Healthcare Leeds

What aspects of the white paper are dominating your conversations at the moment?

BT ‘We've been quite excited. We sense we could be doing real commissioning with teeth, led by clinicians of whatever hue. However, there are considerable anxieties about the enormity of the task.'

PI ‘Our main preoccupation is how to achieve the expectation of improving quality while the NHS undergoes its biggest change in 30 or 40 years with budgets that have never been so small.'

GK ‘The white paper has given us a map but hasn't given us a clear direction how to get to the destination. At the moment we are wondering about the right size of consortium and whether to merge with a neighbouring PCT group. Too small means we won't have a big enough budget to take on PCT back-office functions.'

JR ‘There is a genuine desire among local GP commissioning leads to sort things out but much frustration that there isn't enough detail yet to allow that to happen.'

CH ‘We've realised that a time imperative exists to decide the size and geography of our consortium in order to reassure and retain the best former PCT staff. Movement into alternative jobs and the private sector has already begun. The taxpayer wouldn't want to see the best staff receiving redundancy payments and leaving the NHS, only to then be rehired by private companies effecting a similar role.'

What are the first steps being taken in your area?

JR ‘We are currently looking at our options – which are either to form a large area-wide consortium with seven other local clusters, to stick to the size we have here in Whitstable, Kent (33,000 patients) or to go for a federation with the other clusters.'

‘The first option would make us more or less the size of the old health authority. Staying as we are, we'd probably be too small. But with the third option, we could have the best of both worlds. We would be looking at setting up a co-ordinating board and a consortium support organisation providing core functions such as procurement and IT. All the consortia would buy into the core functions and pay for the optional ones they want.'

GK ‘We've been mapping out what our PCT, NHS Barking and Dagenham, does – all the groups, committees and meetings – in order to identify what we need to take on. They have so many committees! Maybe that's a reason why commissioning via the PCT didn't work. We are also looking at all the key data. We want to get a measure of acute admissions and A&E attendances. We want to make sure we are not being charged for services we are not being given.'

‘We're also talking to all the member practices of the two local consortia. Ours has 115,000 patients, the other has 60,000. Merging will probably be the easiest way. There is currently a hierarchy in each cluster, so we'd have to elect a single board to get the confidence in the members.'

PB ‘Structural form is what we are looking at. We're a county-wide PBC group – 78 practices, 536,000 patients in Somerset. We thought it would now be sensible to go back to the membership and ask what they want. We need to be big for economies of scale but not lose the local element. There are localities within Wyvern and some might want to be mini commissioning consortia. The LMC is taking on a kind of "midwifery" role. It had a key role in setting up Wyvern in the first place. The strong argument for maintaining our present county-wide structure is co-terminosity with Somerset County Council – being aligned with social care boundaries.'

BT ‘We are trying to work out how to manage the transition phase between now and 2013. There's short-term pressure because any NHS Manchester PCT staff worth their salt will jump ship well before then and if we don't get ourselves organised fast, they'll go elsewhere. We want to get the structures right but we want to capture the right people.'

‘Also we need a critical mass to make it work. We've been a 26-practice consortium for three or four years – 100 GPs, 166,000 patients. If we had 300,000 or 500,000 patients we might have a bit more welly. But we'll probably stay as we are.'

‘We also need a project manager to start building structures and relationships with acute trusts and city council for example. There's no money in the system for this but we're sounding people out.'

JO ‘We're consulting with other locality leads within NHS Berkshire East to see whether they have common aims and interests or whether we want to go it alone. We have someone working with us – a former GP – helping us increase our leadership abilities and teaching us how to form partnerships. We're also working out what the core PCT responsibilities are.'

‘We figure that fair shares will probably favour us while some other areas will be penalised. But if we decide to go it alone, the dilemma is how to control outlier practices who exceed their budgets. Peer pressure doesn't work for every practice. Will we have to pick up the pieces when they fail?'

TB ‘We're setting up a virtual group for Croydon so we can protect key PCT staff. We don't want them made redundant so we have an agreement that we can allocate them to the virtual group to take us up to when we form a shadow consortium in April next year. Time is tight because redundancy letters are out this month.'

PI ‘In Wandsworth, we are currently aligned in three locality commissioning groups. We might not be able to deliver all the functions if we continue as three separate organisations. We have very locally responsive commissioners and personally I feel that would continue even if we became a single organisation.'

MD ‘Gateshead is in a good position because we're co-terminus with the PCT, the local authority and we have a single DGH for our area. Practices have voted to stay in the current consortia size – 200,000 patients. The focus now is on understanding the PCT workload and try to phase in a gradual transition.'

CH ‘At a recent gathering of GPs, our two existing PBC localities Goole, Howden and West Wolds, and Haltemprice discussed an amalgamation – and received a lukewarm reception. From my perspective, I can see the need for a large administrative body of at least the size of the existing East Riding of Yorkshire PCT, whether that be via a single large consortium/federation or a "service agency" for consortia clinicians to utilise.'

‘In the light of the GPC recognition of financial risk to consortia under 500,000 patients, I think we ought to be looking to seek partnership with elements of formerly neighbouring PCTs towards Hull and/or York. This would effect some economies of scale, retain and recruit suitably remunerated high quality staff and create bargaining power. There may be some additional benefit to what were the East Riding PCT practices in that their allocated budget per capita has historically been below its fair share levels.'

IG ‘We're really awaiting the legal framework for all this and meanwhile looking at the configuration of our PBC groups across the health authority. There's plenty of time for things to change but we're looking at how we can evolve in the interim. The thing is we've all got PBC plans we're currently involved in and it's quite a tough problem to carry those out and negotiate this at the same time.'

CR/AH ‘The three consortia in Leeds are working with the LMC and PCT on what to do about the 20 per cent of practices in Leeds that are unaligned to a commissioning group. We've also established a transitional board which is trying to establish the statutory functions of consortia and what an urgent care budget might be.

What's the timescale for your transition?

BT ‘I suspect we'll move to real budgets pilots next April – just for acutes. What's happening under Transforming Community Services is not our preferred option but we could pencil in those PCT people we need and they could be transferred to us to do commissioning work.'

PB ‘We would like to be early implementers if we can and if we know the direction of travel.'

PI ‘We're setting ourselves deadlines to keep ourselves running rather than jogging. We have a detailed operating and delivery plan based around our Joint Strategic Needs Assessment but we can't make all the decisions yet and don't want to rush into the wrong response.'

What concerns are being voiced?

BT ‘From my point of view, the PCT currently pays me for three sessions, so PBC has been a bit of a hobby. But the new white paper model makes it a full-time job. And for us to be credible among peers and colleagues we really should be seeing patients as well. There's a bit of tension around doing both.'

‘The other big thing to be sorted out is that the PCT is financially embarrassed and has to balance the books. We don't want to take on a load of debt.'

PB ‘People are worried about not knowing what we don't know. Some GPs think there is a big risk to their salaries and some are wondering to what extent we are going down the route of the US-style health management organisation.'

CH ‘The statutory body nature of PCTs carries with it a raft of obligations. These were clearly demonstrated at our recent meeting and if part of the hidden agenda was to scare GPs, it worked. Many of these functions require a different skill set than that which would interest or be best managed by clinicians.'

JR ‘I'm really keen that the detail in the white paper doesn't undo what we've achieved under PBC. The reality is that practice-based commissioning is also practice-based provision. We're not out to feather our own nest, but it works best if we also take ownership of provision.'

CR/AH ‘Our concerns are what is meant by budgetary responsibility and what will the new GP contract be like? Also there's real uncertainty over Transforming Community Services – we could be inheriting services that don't correspond with what we want. The management allowance is also a big issue. We need some clarity on that. A number of functions may have to be shared between local consortia for financial reasons.'

PI ‘At the nitty gritty level, management budgets could be a quarter of what they are currently – £12-14 per head at most, £8-10 per weighted capitation. Out of that portions may disappear off to fund central commissioning processes, so locally you may not have a budget large enough to commission effectively.'

‘But we mustn't forget the other challenge and real opportunity – integration of health and wellbeing services and community care with health. This is where the real excitement lies and in five to 10 years we could have a fully integrated service in this country and Nye Bevan will be able to rest in his grave again.'