David Cameron has said consortia will only take on local commissioning when they are ‘good and ready'. Alisdair Stirling looks at the implications.
The removal of the April 2013 deadline was the first concession made by Prime Minister David Cameron on the health bill – and he announced it even before the Government's listening exercise report was published.
Mr Cameron said: ‘I've heard the concern that the direction is right but the pace is too fast. What if some places, some practices aren't ready? Will we just let them flounder as others prosper? No. We will make sure local commissioning only goes ahead when groups of GPs are good and ready, and we will give them the help they need to get there.'
Allowing flexibility over the ‘go live' dates for consortia creates a number of new issues for GP commissioning to work through. Which hoops will consortia keen to have budgets sooner rather than later have to jump through? And how will those less keen on embracing the reforms be persuaded to set a date?
While politics over the health bill has been dominating national headlines, for many GP commissioners on the ground there has been little choice but to carry on implementing the reforms as they attempt to avoid inheriting a deficit from their PCTs.
Professor Steve Field, head of the Government's listening exercise and former RCGP chair, said the pause in the bill has slowed progress in some areas. ‘The pause in some areas has allowed people to slow down and stop progress.
‘And what we mustn't do is let the entrepreneurs go back and be fed up and not do their entrepreneurial work. We need to actually encourage them to speed up some things while recognising that not everybody is in the right place to take it forward as quickly as others and that's a job for the commissioning board to really support.'
Despite the pause in the bill, work on setting up the NHS Commissioning Board has continued behind the scenes, according to David Stout, director of the PCT network at the NHS Confederation.
Two Pulse surveys carried out this month indicate a divide between consortium leaders and grassroots GPs. In a survey of 200 GPs, only 38% said they would still like to go live in April 2013, following removal of the deadline. But an additional survey of 20 GP consortium chairs found that 19 of them wanted to stick with the April 2013 deadline.
Holding commissioning reins
The NHS Commissioning Board is recognised as the body that will have the power to veto a consortium's go live date. Signs are emerging of plans for a new quality assurance system. Mr Stout said this process would include ‘some checking in confidence that a consortium's commissioning support set-up is fit for task'.
‘Also partly because some consortia will be young and naïve in going out and procuring support there is a notion that there needs to be a kitemark (for commissioning support organisations) or the board develops some models,' he added.
A legal technicality is that NHS Commissioning Boards cannot function until the bill is passed, so a prolonged delay would mean strategic health authorities having to manage the transition.
The question of when consortia not ready to take on commissioning responsibility in 2013 will be required to eventually do so also needs addressing, according to Mr Stout. ‘There's a fair head of steam in some places but having taken the deadline away, where's the incentive for the others?' he said. ‘And where you've got a reluctant consortium, it could go on indefinitely.'
Some say the Government should avoid the situation that has evolved with foundation trusts, with those keen on the policy going for the status straight away but some yet to show an interest.
Dr Nigel Watson, chief executive of Wessex LMCs, believes the Government will have to set a time limit for consortia to take over. ‘They'll probably need to consider a window, for example 12 months – maximum two years – and then the consortium will have to assume the responsibility. If part of the argument is the need to reduce bureaucracy, you can't have a situation where you're running PCT clusters alongside consortia, for example, for indeterminate periods. The cost would be prohibitive.'
No going back
With so much politics going on around the reforms, it's easy to overlook how much the bill has already permeated mindsets. Just a year ago, the general public had very little notion of what GP commissioning was.
Mr Stout, says: ‘The concept of GP commissioning hasn't gone. Consortia are already in existence although they will now involve a role for clinical senates. And no one to my knowledge has questioned the existence of the NHS Commissioning Board. It would appear that these are all here to stay.'
Whatever further compromises the politicians reach, the clinical commissioning genie is out of the bottle – and it's not going back in.
Alisdair Stirling is a freelance journalist