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The form and structure of GP-led commissioning consortia

The form and structure of GP-led commissioning consortia. March 2011. The Health Bill. Government plans outlined in NHS White Paper ‘Equality and excellence: Liberating the NHS’ and the supporting consultation document ‘Equality and excellence: Commissioning for patients

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The form and structure of GP-led commissioning consortia

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  1. The form and structure of GP-led commissioning consortia March 2011

  2. The Health Bill • Government plans outlined in NHS White Paper ‘Equality and excellence: Liberating the NHS’ and the supporting consultation document ‘Equality and excellence: Commissioning for patients • GPC series of guides to the White Paper on the BMA website • Health & Social Care Bill now published

  3. The Health Bill (2) • Locally led commissioning– flexibility and variability in structures • ‘Shadow’ consortia and pathfinders being set-up • Unclear what work the consortia carry out themselves and what they will do in conjunction with other organisations • Consortia will be responsible for commissioning secondary care, mental health, maternity services and urgent care services

  4. Timetable for change 2010/11 • Clinically-led Commisioning Consortia to begin to form on a shadow basis • 141 consorita pathfinders in place by mid-January 2011/12 • Shadow Clinically-led consortia to be in place, taking on increased responsibility from PCTs • NHS Commissioning Board to be established in shadow form as a Special Health Authority from April 2011

  5. Timetable for change (2) 2012/13 • Formal establishment of Clinically-led consortia, together with indicative budget allocations • NHS Commissioning Board to be established as an independent statutory body; SHAs to be abolished • NHS Commissioning Board to announce (in the third quarter of 2012/13) the allocations that will be made directly to consortia for 2013/14 2013/14 • Clinically-led consortia to be fully operational, with real budgets and holding contracts with providers; PCTs to be abolished

  6. Commissioning Board • NHS Commissioning Board will have power to authorise the establishment of consortia; ensuring that they: - are of sufficient size to manage financial risk and allow for accurate budget allocations - have the necessary arrangements and capabilities to fulfil their statutory duties - provide comprehensive coverage of consortia across the country • Consortia may be allocated practices • Commissioning Board will not approve ‘cherry-picking’ of like-minded practices

  7. Engagement with the process • ‘Bottom-up’ approach – requires engagement across whole profession in order to be a success • Engagement from a small section of enthusiasts only will not achieve aims • LMCs should hold meetings for all local GPs to discuss what the proposals mean for them • LMCs must be proactive – helping local GPs and embedding their involvement in future management structures

  8. Possible consortia models • Small consortia • Large Consortia with locality commissioning groups • Federation and lead consortium model • Consortium service agency model

  9. Small consortia • eg. An autonomous single consortium of around 100k patients with a direct accountability link between practices and consortium management • Advantages: - Strong sense of ownership, close relationships and effective performance management - Close understanding of patient needs for pathway development

  10. Small consortia (2) • Disadvantages: - Financial risk management problems - Small budget variation would have more impact - Problems with secondary care links where acute trust is larger - Difficult to utilise economies of scale - Reduced access to best clinical leaders and skilled staff – reduced influence of best clinical leaders - Familiarity could lead to favouritism and accusations of bias

  11. Large consortia with locality commissioning groups • eg. A single autonomous consortium of around 500k patients comprised of 4-6 locality commissioning groups each of 70k – 150k patients • Advantages: - Large budget – effective financial risk management - Should relate well to other large organisations such as acute trusts + strong base for negotiation - Locality groups mean more relevance for commissioning decisions - Broader data available – influence commissioning decisions - Effective economies of scale - Familiar model to those acquainted with PBC - Extra management funding- attract better managers

  12. Large consortia with locality commissioning groups (2) • Disadvantages - Potentially numerous management tiers - More distance between actions of practice and consortium - These difficulties can be overcome if proper management structures are in place

  13. Federation and lead consortium model eg. A number of consortia across a region join together as a group or federation and elect or appoint a lead consortium to undertake agreed functions on behalf of the group • Advantages - Consortia should be able to manage financial risk - Easy to achieve economies of scale - Able to commission all services for a population - Size may provide strong negotiating position with local authorities and acute trusts - Large management structure- easier to undertake statutory functions - Broad data available – influence commissioning decisions

  14. Federation and lead consortium model (2) • Disadvantages - Complicated internal governance and accountability – may add bureaucracy – level of sophistication required is rare in new organisations - Direct linkage between practices and consortium may be lost - Possible reduced sense of practice ownership - Potential difficulties in engaging with individual practices - Lead consortium may become dominant – possible tensions or disagreements

  15. Consortium service agency model eg. A number of consortia join together in a group and pool a portion of their management allowance to engage a service agency to provide commissioning management support for the group • Advantages - Economies of scale may be easily achieved - Risk-pooling may be feasible - Individual consortia will retain close links with practices - Flexibility for small consortia- good management support without huge cost – use of highly skilled staff - Shares in service agency – would benefit from success - Potential for individual consortia to select level of service required

  16. Consortium service agency model • Disadvantages - Risk that agency may not be focussed on the individual needs of each consortium. Agency may start to influence or direct the actions and directions of the consortia - Small consortia may have difficulty in their engagements with large acute trusts - Ownership of service agency could change leading to variation in performance

  17. Consortium Formation • Must have the support of local GPs, and be appropriate for local circumstances • The GPC believes that, in general, GPs should look to form large consortia to provide: -Good management of financial risk -A strong negotiating position with acute trusts and CSUs -A large management allowance to with which to employ the best staff • Not adopting this model provides that a risk that the consortium may fail in one of these key areas.

  18. Pathfinder consortia • Early adopters or ‘pathfinders’ – allow suitable groups of practices to test different design concepts for consortia • There are now 141 consortia pathfinders in place • To join the pathfinder programme, a group of practices needs to be able to demonstrate: -Evidence of local GP Leadership and support -Evidence of LA engagement -Ability to contribute to the local QIPP agenda in their locality

  19. Commissioning Support Units (CSU) • PCTs are required to join together to form about 45 - 50 clusters • In most cases this means 3 - 4 PCTs joining together to pool their staff and functions • These new clusters will be expected to establish teams to support the emerging consortia and are likely to evolve into CSUs which offer support to consortia • CSUs could ultimately take on devolved powers from the Commissioning Board

  20. Transition issues • Fully operational consortia will be allocated a maximum management allowance • Shadow consortia funding will come from PCTs • GPs leading at shadow stage will be employed by PCT – must ensure they receive appropriate backfill for practice funding and for attending meetings etc.

  21. Transition Issues (2) • GPs should ensure that they do not make formal agreements with PCTs at this stage, especially regarding: - The employment of PCT staff - The provision of commissioning support from CSUs - The functions that the consortium will undertake - Anything relating to the constitution of a consortium, where this has been imposed by the PCT • The DH will be proving guidance on all these issues in the coming months - PCTs and GPs should not act until this available.

  22. Transition issues-sessional GPs- • Shadow consortia must consider how to engage with sessional GPs • Sessional GPs offer flexibility and availability • LMCs should support sessional GP involvement and encourage practices to include them in the discussions

  23. Transition issues-cultural change- • Consortia need to instil constituent practices with a sense of professionalism, ownership and peer involvement • PCT roles will change dramatically as they move towards abolition • Manager-clinician dynamic is obsolete, feuds must be forgotten to avoid encountering same problems as past organisations • Cultural shift towards clinician ownership of difficult decisions

  24. Transition issues-The role of the LMC- • LMCs remain local representative of the profession- commissioning proposals do not change this • Many LMCs already playing an active role in local development – to be encouraged • Should engage with all local GPs – principals, salaried and locums • Facilitate discussions between GPs • Form dialogue with local authorities, secondary care specialists, public health specialists • In position to mediate in any future disputes

  25. LMCs should be: • Communicating regularly with all GPs in your area and encouraging their involvement in this process • Encouraging a two-way dialogue with GPs in your area so that, in return, you are in touch with GPs’ concerns. • Invite every practice to be involved in any local discussions about the formation of commissioning groups.

  26. Ways that LMCs can support the planning process include: • Consider setting up a working group of interested GPs to discuss how consortia should be formed. Not ‘lead’ PBC GPs exclusively – all should have the chance to get involved. Also relevant PCT personnel and PBC managers. • Talk to PCTs and SHAs • Work with BMA Law to make sure that those involved in developing consortia take appropriate legal/financial advice + knowledge of corporate structures and responsibilities • LMC should offer to mediate as an "honest broker” where required. • Support practices and nascent consortia that are being pushed into moving too quickly, or in a direction with which they are not comfortable. If necessary, GPC can address this at a national level.

  27. Any Questions?

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