Following the publication of Next Steps I want to spend the next few posts looking specifically at the way in which the reform programme has been developed in a number of policy areas.
The most significant remains the transfer of Commissioning to GP Consortia.
Whilst Wednesday’s reform programme still aims to leave the “end state” of GP Commissioning in a similar place to that in which it was before it was published, the tone of the way in which this is going to come about has changed.
There is a recognition that even if GP are the right people to commission NHS health care at the moment, in nearly every part of the country where this is planned to happen, the Consortia that will carry this out do not exist. So if we are going to have the principle of GP Commissioning in practice, over the next few years we are going to need the development of hundreds of real organisations to carry this out. Since very few of these organisations exist at the moment, they are going to be created from scratch.
Next steps provides us with more detail on how the Government thinks this is going to take place.
There is the nearest that this government comes to self criticism when it recognises that its previous proposals of a “big bang” approach to Commissioning - where one day NHS health care would be commissioned by PCTs and the next by GPs - will not work. Instead they want to see a programme of pathfinders that have started already with those designated last week.
There will now be a rolling programme of pathfinders from now until April 2012. The Government expectation (4.126) is that any group of practices that wishes to will be able to do so. They recognise (4.127) that they need to promote leadership development and help consortia with OD. The Operating Framework suggests that the NHS spends a sum of money on this (although whether GPs will be allowed to spend it or it will be spent by PCTs and SHAS will be interesting to see.)
All this adds up to (4.129) a carefully staged transition towards full implementation of the new commissioning arrangements. During the first year, 2011/12, emerging consortia will have the opportunity to plan how they intend to carry out their future functions. During that year they will identify those PCT staff that they want to work for them or identify other posts; engage with the NCB PCTs and SHAs to find out where there will be demand for external skills and consider how they might support consortia; manage the transfer of IT and the transfer of contacts and develop partnerships with local authorities and Healthy and Well Being boards.
Next steps contains many more references to the transfer of PCT and SHA staff to GP Commissioning consortia than were in the original White Paper. Given the likely issues in the transition period, ’NHS bosses’ (the cause of all the trouble in July) have become the saviours of the NHS by December.
There is even a recognition that by the end of March 2012 there may be some areas where the consortia are not yet ready. Under these circumstances the NCB have to create organisations to step in.
There is an interesting and potentially important issue about geography. At the moment most nascent GP consortia and certainly the ones that exist, all lie within a single boundary. Section 4.16-4.21 recommends that whilst consortia will have to perform certain geographical functions, for example access to A and E), “it would not automatically follow that every one of the practices in a consortium has to be physically located in their area, nor that all practices in a consortium have to be next to each other. 4.21
Whilst I don’t anticipate many of the immediate consortia having anything but geography as their organising focus, this will be allowed to change over time. This has very considerable implications for the future. It provides the possibility that – for example – that there could be a consortium of GPs that covers not just an area of inner London but could also be linked with inner city GPs in other cities. In this way specific commissioning expertise could be linked to specific localities to provide better expertise.
So if GP commissioning scales up to bigger organisations they are not restricted by having to be next door to each other.
Next steps also continues to argue for Consortia of varying size. They recognise that for consortia to carry out specific functions they will need to work together. The issue of size concerns the original consortia and the organisations that the consortia work with in order to commission, for example, tertiary care.
This meets Corrigan’s rule about the size of administrative boundaries – whether they are NHS or local government organisations. All administrative boundaries – however large or small the population within them is – are always either too large or too small (and frequently both). What that means in practice is that if you are a local education authority you are usually much too big to deal with, for example, nurseries or too small to have a range of sixth forms within your boundaries.
The same is true for NHS commissioning. You are either much too big to be able to work with a street by street risk register of patients, or too small to be able to commission tertiary care.
The anxiety about GP commissioning consortia is that they are too small to buy secondary or tertiary care. But the answer to this is that small consortia buy in those skills from bigger organisations. Whatever their size they buy in the skills above or below them to work with the smaller and bigger parts of the locality.
Most of next steps stress over and over again the fact that the Government is not going to tell GP Commissioners how to organise themselves. But this changes when it comes to paying for their organisations. The Bill will provide the Government with the ability to set a control total on what GP Commissioning organisations can spend on administration. So you are not going to be told what sort of organisation you can run but you are going to be told what you can spend on running it.
This is daft. A wise GP Commissioning Consortium will be able to find their way round and through this be reclassifying what they spend on what. I suspect the Government will then employ a set of inspectors to go round checking up what people are really spending their money on. This is silly and it won’t work.
In any case now the Government has announced that the new Chief Executive of the National Commissioning Board is going to be the old Chief Executive of the NHS, I suspect that the GP Commissioning Organisations will take the spend on their salaries from the starting point that the NCBs spend on his.
How many people end up earning more than the Prime Minister will be an interesting issue.