The White Paper- Equity and excellence- implications for

GPs

Dr Chaand Nagpaul,GP, North London

Negotiator, BMA GPs committee

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

• “Choice” consultation November

White Paper: Equity and excellence:Liberating the NHS

• We’re awaiting the government’s response to WP consultation; the final product may be different

• Much more than GP commissioning• Wholesale change to entire NHS landscape• Changing the top of the NHS• Passing control for NHS decisions away from

Ministers– towards patients and professionals

• NHS Commissioning Board “free from day to day political interference”

• GP-led commissioning consortia-accountable to NCB– with abolition of SHAs & PCTs by 2013

White Paper: Equity and excellence:Liberating the NHS

• Explicit competition agenda with private sector parity • “any willing provider”• All NHS Trusts to be FTs-greater flexibilities• Monitor - economic and competition regulator• New, expanded role of Local Authorities - Public

health, Health and Wellbeing boards• Patient Voice- HealthWatch • Patient choice and “Information revolution”• NHS Outcomes framework• £20b efficiency savings by 2014, 45% management

cuts• Workload shift from secondary to primary care

NHS Outcomes Framework

• Domains of quality measured by clinical outcomes and patient reported outcome measures (PROMS)

• National Commissioning Board to implement• Quality standards developed by NICE

– available 2011 with implementation in 2012

• 150 standards with up to 10 quality measures each - possible 1,500 targets – potentially time consuming and bureaucratic

• Create incentives for GP consortia to deliver• BMA position that process is also vital

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• Comparative provider performance data (Quality

accounts)• Comparative GP commissioner performance data• Patient access to health records- GP and other

providers• Patient voice-Healthwatch

Patient Choice - promoting competition

• Current consultation: “Greater choice and control”• 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

GP commissioning consortia

• Not GP fundholding revisited• Not PBC consortia revamped with budgets• Unchartered waters• Statutory bodies –accountable to NCB• Accountable officer and Chief Finance Officer• Hard budgets; “No bail out”• Will commission community and secondary care,

emergency services inc OOH• QIPP- £20b efficiency savings, 45% reduced

management costs• Local prioritisation/rationing – diminished role of NICE• Being asked to do what PCTs were unable to –cannot

be “more of the same”

Much more than “commissioning”• 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• Other current PCT functions?

Consortium size and configuration• Likely between 100-750k• Need GP engagement and ownership, AND

managing financial risk, low management costs, commissioning effectiveness

• Financial constraints- “no bail out”• “Small” – GP engagement +, higher management

costs -• “Large” – economies of scale +, acute hospital

commissioning +• “Large” with locality commissioning substructures• Federated with lead consortia Risk pooling arrangements Lead consortium on behalf of others Acute hospital commissioning

Consortium commissioning management functions• Financial managementFinancial planning, Budget management, Transaction processing• Information and knowledge managementPredictive demand, risk modelling and pathway design, Data

returns management, Data validation , IT systems management

• Provider managementContract negotiations and procurement, Contract performance

management, Provider payment systems, • Stakeholder engagement: patients and the public, local

authorities, secondary care and public health specialists• Consortium managementHuman resources systems for employed staff, Estates

management, corporate governance, Legal services, complaints, External auditing

Management support

• Directly employed staff by consortium:-local PCT staff with local knowledge; TUPE considerations, management cost constraints

• Service agency supporting consortia• External independent sector

commissioning support/consultancy• Need management infrastructure

discussions NOW to retain skilled local managers and staff

GP involvement

• Will affect ALL GPs• 3 tiers of GP involvement: Consortium GP leads (top table) GPs with defined commissioning roles Grassroots constituent GPs: partners, salaried,

peripatetic locums• Commissioning budgetary spend will be

affected by grassroots GPs’ clinical decisions in the consulting room

• Success of consortia will depend upon sign up, engagement and changing behaviour of grassroots GPs

Developing consortia

• Timescale is short• Detail not yet known- Andrew Lansley letter to GPs 24

September• Pathfinder sites• Don’t rush –important to get it right• Legal implications• Should await details before any formal local proposals• Start early discussion- should involve all GPs –not just

“PBC leads”• Need democratic equity of opportunity and legitimacy• Resist PCT/SHA interference in consortium formation• LMC- only statutory body representing all GPs; “honest

broker”

Shadow consortium GP leadership• Need the RIGHT people for the job• Need skills, knowledge and appropriate ethos

AND• Need support amongst constituent GPs and

practices• Opportunities for commissioning leadership skills• Election per se could result in popularity contest

vs competence• Selection followed by election?• Selection with “board of appointment” with

democratic legitimacy?• Conflicts of interest?

Peer review and performance management

• GPs leading GPs: key to WP ethos and financial management

• Consortia to “hold constituent practices to account” ; “drive up quality and improve use of NHS resources”

• “Proportion of GP practice income linked to the outcomes that practices achieve collaboratively in consortia and the effectiveness with which they manage NHS resources”

• Benchmarking practices -must make fair comparisons:

differences in practice casemix Differences in practice funding and infrastructure limitations in accuracy of practice commissioning budgets

What will be different for practices?• Working corporately: part of a greater whole• Being compared-peer review and pressure• Scrutiny of budgetary spend-referral/prescribing

management• Reducing Hospital utilisation (vs AWP choice): Referral management, pathway adherence Emergency admission reductions Expanding GP practice and community provider capacity

• Intra-practice peer review• Need to understand variation and reasons• Facilitation for outliers to improve; carrots not

sticks

What will be different for practices?• Great potential for disharmony: --within practices-between practices-between consortium board and member GPs (real

budgets, “no bail out”)• Could expel practice from consortium ?• Need for mature sensitive consortium leadership• Must maintain professionalism and patient

interest• Role of LMC as honest broker

Equity and excellence:

Liberating the NHS - BMA Response • “Critical engagement”• Remain opposed to commercialisation agenda• Oppose Monitor’s role in promoting competition• ‘GP-led commissioning groups’ –must include other

Drs• Welcome reduction in top-down targets, but

concern that being replaced by quality indicators• Support outcomes. ?PROMS, should retain process

targets• Sceptical about foundations trusts and social

enterprise• Oppose local pay determination• Oppose localised education and training• Proposals expensive at ‘time of austerity’

White Paper proposals Risks…

• Local rationing by GP consortia• GPs blamed for cuts• Damage to doctor/patient relationship• Privatisation by the front-door• Funding formula not accurate• Enough local leaders with the right skills?• Enthusiasts without a mandate setting an

inappropriate agenda

…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• Learn the lessons of PCG/PCT mergers• Learn lessons of Fundholding, commissioning, PBC

…and opportunities?

• Clinical leadership; absence of SHA/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• Can we avoid the re-creation of PCTs?

GPC guidance on theWhite Paper

• The GPC is producing a series of guidance – 6 published so far:

1. “The Principles of Commissioning – A GPC statement in the context of Liberating the NHS”

2. “Legal overview view and guidance on the commissioning proposals”

3. “The Role of Local Medical Committees in supporting the development of GP Consortia”

4. “GP consortia commissioning – initial observations”5. “The form and structure of GP-led commissioning consortia”6. “Shadow consortia, developing and electing a transitional

leadership”7. -

In summary

• Unprecedented threats• Unprecedented opportunities• “Eyes wide open” approach• Await emerging policy• Mitigate risks and threats• Influence health bill• BMA “Look after Our NHS” campaign