Realising the potential of GP commissioning – enabling more cost

effective services closer to home

Tuesday 9 November 2010The King’s Fund

Dr Michael DixonChair, NHS Alliance

Question:

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

Answer: No

‘Consortia will be commissioning organisations and will not be able to provide services in their own right’ (Liberating the NHS: Commissioning for Patients)

‘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.’

‘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.’

The Problem:-

Local redesign and the transfer of services from secondary to primary care simply hasn’t happened – hospital admissions in the UK are comparable only with the US and France (and three times those of Canada).

This is because of red tape, bureaucracy and cumbersome tendering processes.

The government wishes to keep commissioning and provision separate.

Yet the real gains in redesign are often to be made by community and local GP services taking on an extended role.

Are there ways of enabling this to happen, while being able to show that public money is being best spent?

‘We propose that, wherever possible, services should be commissioned that enabled patients to choose from any willing provider.’ (Liberating the NHS)

What are the solutions?

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 the 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’.

Problems with competition and co-operation 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?

Solution 4

Open book accounting for all new services commissioned (GP, private and third sector). This makes all details of costs and profit 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.

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 stressedeczemacystitismenstrual or menopausal problems

Is integration:

of primary care services

of primary care and secondary care services

of health services initiatives on self care, personal health and community health

compatible with encouraging a market in

services and health?

One possible solution!

Umbrella provider organisations that integrate local services (provided by general practice, private sector and third sector…).

With an organisational form that is visibly for the public good – social enterprise/community interest company/not for profit.

With an open accounting system.

And trusting relationships between provider, commissioning consortium, the local patient population (and media) and the National Commissioning Board.

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