To Make and Buy or not to Make and Buy

GP Pathfinder Consortia Development Conference – preparing for the commissioning challenges ahead

Thursday 12 May 2011The King’s Fund

Dr Michael DixonChair, NHS Alliance

Question:

Will commissioning consortia be able to ‘make’ as well as ‘buy’ services?

Answer:

‘Consortia will be commissioning organisations and will not be able to provide services in their own right.’

(Liberating the NHS: Commissioning for Patients)

‘A consortium could not make or buy all the services that the consortium is required to

commission.’

(Department of Health Guidance April 2011)

But!

All research suggests that a primary care dominated/horizontal service produces better outcomes.

Therefore GP commissioners will want to move care from hospitals to general practice and primary care.

They may have a vested interest in doing so.

A vested interest might be an important catalysing factor in something happening!

Or in other words:-

‘It is essential that individual practices or groups of practices have the opportunity to provide new services, where this will provide best value in terms of quality and cost. This will not happen if the muddled and over-bureaucratised approach that has too often characterised practice-based commissioning is allowed to continue.’

So:-

‘Further work will be taken forward in the NHS to develop a framework that allows commissioning of new services whilst guarding against real or perceived conflicts of interest.’

Meanwhile:-

A ‘reform group’ is set up by the Department of Health. Many interested parties and primary care clinicians are outnumbered by both secondary care clinicians and by managers.

An advisory group is set up at No. 10 with no primary care clinicians at all!

Increasing calls for accountability and clear governance in GP consortia.

National Commissioning Board creates its own template.

Monitor keeps silent.

What chance of the primary care-led NHS?

He is the best physician who is the best inspirer of hope

Samuel Coleridge (1772-1834)

The ‘pause’ is an opportunity for GP consortia leaders to flex their muscles.

(NHS Alliance listening exercise)

3 Hypothesis

You need competition and integration but maybe the latter trumps the former?

Profit margins in primary care are insufficient for big business – United Health/Virgin

British GPs are motivated to make a difference rather than simply make money – that is why GP commissioners have been prepared to bang their heads against the wall for so many years!

The Department of Health would strongly encourage PCTs and Pathfinders that wish to

explore innovative arrangements for commissioning of integrated care services.

‘We propose that, wherever possible, services should be commissioned that enable patients to

choose from any willing provider’

Solution 1

National templates/contracts

Under EC rules it is not compulsory to tender a service where providers are uniquely placed to provide that service. Some services (eg, organising care through complex care teams) depend on the provider having a ‘registered list’.

There could be a list of ‘enhanced services’ drawn up as national templates agreed with Monitor. GP commissioning consortia could apply to the NHS Commissioning Board to place such contracts with their practices and NHS Commissioning Board ensuring probity and value for money.

Simple but restrictive?

Solution 2

GP Practices (as practice federations) might provide non-GMS services as ‘social enterprise organisations’ or community interest companies.

Potential for co-ownership and co-production by professionals and public.

Problems with Co-operation and Competition Panel?

Solution 3

Set tariffs for primary care services and open market to any willing provider.

The current government’s preferred model, but can create conflict of interest if GPs refer patients to services provided by themselves from which they profit (GMC issues?).

Tariffs can inflate − maximum tariffs or no tariffs?

Solution 4

Open book accounting for all new services commissioned (GP, private and third sector). This makes all details of costs and profits transparent and reveals those who are loss leading or being unrealistic.

As a system for awarding contracts or simply becoming any willing provider? Flexible – or restricted to a menu of services or fixed prices?

Solution 5

Integrated care organisations – along the lines of Kaiser Permanente.

‘Make and buy’ much easier under this system. Not regarded by current government as offering sufficient competition, but, in the interests of fairness, should this not be tried out by a few who wish to?

Questions

What level of co-operation will be allowed between provider and commissioner? Friendly leverage can sometimes be the most potent means of improvement.

If foundation trusts are being allowed to run GP practices by the Co-operation and Competition Panel then isn’t it a bit rich to create red tape that stops GP practices doing work currently done in secondary care?

Does current market ideology fully understand the complexity of primary care?

• breathless• can’t sleep• pins and needles in my legs• bowel problem• general tiredness• toes• flu injection• is there a National Health diet plan?

Department of Health self help project

headachesback, joint or muscle achescolds, sore throats, viruses and virus infectionsupset tummy/irritable boweltiredness or sleep problemsanxious or feeling stressedeczemacystitis menstrual or menopausal problems

Dixon’s solution to Make and Buy!

Create a visibly inclusive GP consortium that has a strong public/lay presence.

Encourage umbrella provider organisations (co-operatives?) that integrate local services (provided by general practice, private sector and third sector…).

With an open accounting system.

Is this better or cheaper than an integrated care organisation that both commissions and provides?