Equity and Excellence: Liberating the NHS What it means for GPs & commissioning Dr Chaand Nagpaul GPC lead Negotiat

1. Equity and Excellence:Liberating the NHS What it means for GPs & commissioningDr Chaand NagpaulGPC lead Negotiator on commissioning

2. White Paper • We’re in the middle of a consultation • BMA “critical engagement” • Opposition by Unions and others • The final product could/will be different • Much more than GP commissioning • Unprecedented wholesale change to the entire NHS landscape • Unchartered territory • Explicit competition agenda with private sector involvement and parity in commissioning and provision

3. Overview • White Paper published 12th July 2010 • “Equity and Excellence: Liberating the NHS” • Further consultation documents in July • Commissioning for Patients • Transparency in outcomes • Regulating healthcare providers • Local democratic legitimacy • Review of Arms Length Bodies • Three month consultation period

4. Headlines • Changing the top of the NHS • Passing control for NHS decisions away from Ministers • towards patients and professionals • GP-led commissioning consortia • with abolition of SHAs by 2012, PCTs by 2013 • Monitor - economic and competition regulator • All NHS Trusts to be FTs-removal of cap for private work • New & expanded role of Local Authorities in healthcare- Public health, Health and Wellbeing boards • Patient Voice- Health Watch – part of Local Authorities • £20b efficiency savings by 2014, 45% management cuts

5. Changing the top of the NHS • NHS Commissioning Board “free from day to day political interference” • Board responsible for • assessing GP commissioning consortia • holding them to account • holding GP contracts • To be established in shadow in April 2011 • 2011/12 – establish business model and staffing • Go live April 2012 • SHAs to be abolished in 2012/13

6. New Structure Government Key: Funding: Accountability: Other relationship: Dept of Health Monitor (economic regulator) Care Quality Commission NHS Commissioning Board Licensing GP Commissioning Consortia Providers Local Authorities Local partnership Contract Local HealthWatch GP Practices Patients and Public

7. GP commissioning consortia • Consortia to replace PCTs and will be statutory bodies • Will have Accountable Officer and Chief Financial Officer • Responsible to NHS Commissioning Board • Commission most services, including emergency and OOH services, except: • GMS/PMS • Pharmacy, dental, opticians, maternity • Specialised national and regional services • All practices required to join

8. GP commissioning consortia • Hold contracts with providers • May choose a lead commissioner model e.g. for dealing with large teaching hospitals • Duty to determine local health needs • Duty to promote equalities • Duty to work with local authority (public health, social care, safeguarding) • Duty of public and patient involvement • Government insists there will be ‘no bail-outs’

9. Timetable for GP commissioning consortia changes • GP consortia in place in shadow in 2011/12 • taking on increasing delegated responsibility from PCTs • Health Bill passed • Consortia responsible for commissioning in 2012/13 • Financial allocations direct to GP consortia in late 2012 • Full financial responsibility from April 2013 • PCTs abolished April 2013

10. NHS Outcomes Framework • Domains of quality measured by clinical outcomes and patient reported outcome measures (PROMS) • Effectiveness of treatment • Safety of treatment and care • Patient experience • National Commissioning Board to implement • Quality standards developed by NICE • available 2011 with implementation in 2012 • 150 standards with up to 10 quality measures • Create incentives for GP consortia to deliver • Not clear what any of this means • BMA position that process is also vital

11. Putting patients first • Shared decision making • “Nothing about me without me” • “NHS information revolution”- supporting patients to make choices and look after their own health • New online services in addition to NHS Choices • PROMS, patient experience surveys and real time feedback to rate services and departments • Undeveloped and limited evidence so far • Comparative provider performance data (Quality accounts) • Comparative GP commissioner performance data • Patient access to health records- GP and other providers

12. Patient voice • HealthWatch England to be created • “independent consumer champion”-will provide patient voice to NCB, Monitor, CQC and SoS • Local HealthWatch-views of patients integral to local commissioning across health and social care • Local HealthWatch-support LAs in promoting choice and complaints advocacy • Local HealthWatch funded by and accountable to local authorities

13. Patient Choice - promoting competition • Choice of “any willing provider” • Choice of consultant-led team (elective care 2011) • Choice of some mental health services by 2011 • Maximise use of Choose and Book • Extended maternity choice • Choice of diagnostic testing, and post diagnosis by 2011 • Choice of treatment, care in long term conditions and end-of-life care • Choice of registration with any GP practice – not limited by where a patient lives or practice boundary

14. Regulating healthcare providers • Monitor • promote competition • Investigate complaints of anti-competitive behaviour • regulate prices of NHS funded services • support service continuity • licence providers (jointly with CQC) • Intervene in event of failure including trigger special administration and regime • Will practices will need a licence from Monitor? • Care Quality Commission • licensing providers for essential safety and quality • quality inspections • take enforcement action when required

15. Education and Training • “All providers will pay to meet the costs of training and education” • Not clear if this will include practices • GP Consortia will provide local oversight of providers funding plans for training • BMA objects as this should be a central function

16. A New GP Contract? • “Proportion of GP practice income linked to the outcomes that practices achieve collaboratively in consortia and the effectiveness with which they manage NHS resources” • Quality premium paid to consortium and they decide how to apportion to practices • QOF to focus more on health outcomes not process • All funded from existing resources • Not clear how any of this will work • Local Enhanced Services probably locally commissioned • “a single contractual and funding model for GP practices” over time- nGMS2?

17. Developing GP commissioning consortia • Statutory bodies • Detail not yet known • Should await details before any formal local proposals • Legal implications • Start early discussion- should be GP led • Should involve all GPs –not just “PBC leads” • LMC-”honest broker” • Success of consortia will depend upon sign up, engagement and changing behaviour of grassroots GPs • Can continue to develop GP-led provider models

18. GP commissioning consortia – GPC view • Practices in each consortium elect a ‘board of appointment’ for CEO/AccO and FD • Consortia will require an effective governance structure • Likely size – 100k to 750k population • May link up to save money or to create service agencies • Should consider appointing capable and highly experienced former PCT managers • Commissioning budgets MUST be separate from practice budgets • Essential to work closely with secondary care clinicians

19. Commissioning as consortia • Fair shares budgets – new formula • Hard/real budgets - “No bail outs” • A “maximum management allowance” • No PCTs-GP consortia to employ or buy in commissioning support. Private sector? • Working collaboratively with other consortia: • Risk pooling arrangements • Lead consortium on behalf of others • Acute hospital commissioning • Principles of commissioning-GPC guidance

20. Commissioning- changes to PbR • NCB to design tariffs and model NHS contracts • “Best practice tariffs”-paid according to excellence of care-not average prices • No charge from Trusts for re-admission within 30 days • Currencies/tariffs for adult mental health, community services • New “pathway tariffs” • Any willing provider; private sector parity • Role of Monitor to ensure competition • Working with secondary care colleagues?

21. Commissioning enhanced services • “Essential that individual practices or groups of practices have the opportunity to provide new services (over and above the primary care services that they already have a duty to provide), where this will provide best value in terms of quality and cost”. • Consortium can commission services from one or more of its constituent practices –with transparency and safeguards • Framework to guard against real or perceived conflicts of interest

22. Commissioning-What will be different for practices? • Consortia to “hold constituent practices to account” and “drive up quality and improve use of NHS resources” • Working corporately- peer pressure, demand/referral/prescribing management • Benchmarking practices (scorecards) • Practice comparative data-must make fair comparisons • Could expel practice from consortium • Great potential for disharmony-downward financial pressures, real budgets, “no bail out” • Need for mature sensitive consortium leadership • Must maintain professionalism and patient interest • Role of LMC as honest broker

23. GPC guidance on theWhite Paper • The GPC is producing a series of guidance – 4 published so far: • The Principles of Commissioning – A GPC statement in the context of Liberating the NHS • Legal overview view and guidance on the commissioning proposals • The Role of Local Medical Committees in supporting the development of GP Consortia • GP consortia commissioning – initial observations -

24. Risks… • Damage to doctor/patient relationship • Privatisation by the front-door • Funding formula not accurate • GPs blamed for cuts • GPs accused of making excessive profit • Enough local leaders with the right skills? • Enthusiasts without a mandate setting an inappropriate agenda

25. …more risks… • Some GP Consortia will fail – what then? • How to handle inherited or new debt • PCT implosion, loss of key staff and skills • Competition v collaboration • Choice v rationing • Conflict between practices • Conflict between practices and consortium board • BMA therefore adopted position of “critical engagement” • Learn the lessons of PCG/PCT mergers • Learn lessons of Fundholding, commissioning, PBC

26. Next steps? • Work with LMC, PCT and existing PBC groups • Resist PCT/SHA interference in consortium formation • All practices/GPs in an area should be involved in discussions about future arrangements • Identify local skills and expertise • Early collaboration with local consultants and public health physicians • Use BMA advice and support guides • Respond to the White Paper consultation

27. …and opportunities? • Clinical leadership; absence of PCT hindrance • Real involvement in re-designing services and improving services for patients • Opportunity to manage and resource secondary to primary shift • New OOH services, 111 and life after NHS Direct • Developing practices • Developing meaningful partnerships between consortia, LA, hospital trusts and consultants • Reducing bureaucracy – how long will it last? • Can we avoid the re-creation of PCTs?

28. What matters now? • Rules matter: Consortium governance arrangements must be adaptable as policy develops • Size matters: Balance risk management and practice engagement • an inverted PCG/Health Authority model with regional NHS service agency • large consortium with locality sub-structure • Names matter: Local Commissioning Groups rather than GP Commissioning Consortia?

29. Any Questions?