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GPs reject call to include consultants on boards

By Mike Broad - 26th May 2011 11:02 am

GP consortium chairs are overwhelmingly opposed to any requirement to include NHS consultants on their boards, a survey reveals.

A sample of 20 chairs and chief executives of pathfinder GP consortia unanimously rejected the idea espoused recently by the Prime Minister that hospital doctors should play a bigger role in commissioning.

Consultant involvement would be a serious conflict of interest that would undermine the commissioning process, they say.

In his first major speech since the launch of the ‘listening exercise’ on the Health Bill, David Cameron recently said: “We are listening and we will make substantive changes to improve the reforms, based on what we hear.

“I do not want to pre-empt what those changes will be…But it is clear for example, that when people working in our hospitals hear the term ‘GP commissioning’, they worry it’s only GPs that are going to be involved in making decisions. Now that’s not the case, but I agree we need hospital doctors and nurses to be much more closely engaged in commissioning.”

The BMA and royal colleges agree that there should be more consultant involvement in consortia boards.

Some 18 of the 20 consortia surveyed by Pulse have non-GP representation on their boards, most commonly patients, nurses, practice managers and local council representatives. But only one currently includes a hospital doctor.

Dr Agnelo Fernandes, chair of the Croydon Healthcare Consortium, is quoted as saying: “That would be ridiculous, a total conflict of interest, as consultants are employees of their trusts which are providers. We need networks to enable good communication, but we want small, manageable boards at GP consortium level.”

The new chief executive of the NHS Confederation, Mike Farrar, told the The Guardian that consultants are not equipped to help consortia. “How can an orthopaedic surgeon represent the views of the entire secondary-care provision?” he asks.

Tags: GP consortia
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Doctors risk losing hard-earned trust of patients

By Dr Kim Price, Wellcome Trust research fellow, School of Historical Studies, University of Leicester - 26th March 2011 10:13 am

Under current coalition government proposals for GP consortia and NHS privatisation, the sliding scale of power in the doctor-patient relationship is in peril of shifting too far in favour of doctors and undermining the trust of patients.

The doctor-patient relationship is jeopardised when medical practitioners are endowed with administrative decisions that are tainted with conflict of interest or the perception of self-interest. It can lead to mistrust and medical staff being singled out for neglect while systemic problems are overlooked and allowed to endure.

General practitioner consortia are a tempting carrot for the profession, but the size of the stick remains to be seen. There is, however, historical precedent.

From 1870 until the early 1900s, the Local Government Board curtailed welfare and health expenditure and concomitantly there was a rise in cases of neglect under state medicine in the period. However, official inquiries sought individuals to blame and avoided systemic culpability - they were great show trials with a foregone conclusion: the doctor as a scapegoat.

There was a mushrooming of charges of negligence against state doctors in this period. Employment rules and duties caught them in a catch-22. They were employed part-time because it suited both employer and employee: the state could pay less but doctors retained their private practice. It led to widespread neglect, stemming from the split-prerogatives of medical officers and the economics of their employment, which meant they had to sustain a private practice to survive. They were even expected to supply drugs, medicaments and expenses out of their hopelessly low salaries.

It was a farce and doctors who worked for the pre-NHS poor law system were in a double-bind: they had to choose between their private and public patients and, needing the income from private patients, tended to gamble with their attendance on the poor. Tacit agreement was reached between state employer and poor law doctor: assistants (mostly students) were allowed to treat the poor, while the contracted doctor gave his personal care to private patients.

Unskilled attendance on the poor resulted in widespread systemic neglect. As a result, relations between doctors and patients suffered and there was a general mistrust of the state doctor.

If the doctor-patient relationship becomes seriously undermined by GP consortia and NHS privatisation it will affect health directives, policy and research. The future could once again become a place of alarmist suspicion, whereby doctors struggle to get solid medical science across to patients who have been misled by public scandals and high-profile neglect.

This blog is based on an article which appeared in The Lancet.

Tags: GP consortia
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Reconfiguration of hospital services is necessary but difficult

By Mike Broad - 8th March 2011 2:29 pm

The NHS is entering a period of unprecedented financial challenges that will result in major changes to the provision of health services. While all areas of health care will be affected, acute hospitals face particular challenges because of the high proportion of the NHS budget spent in hospitals.

Add in the need to reconfigure specialist services in many parts of the country to deliver improvements in outcomes and the requirement that all NHS trusts should become foundation trusts by 2014, and a period of fundamental service and organisational change is in prospect.

An analysis of the reconfiguration of acute hospital services in south-east London by Keith Palmer, former chair of Barts and the London NHS Trust, offers a timely and sobering contribution to the emerging debate on how service and organisational change should be taken forward across the NHS in England.

His painstaking account of the trials and tribulations of bringing together four acute hospital trusts with a history of financial problems, the challenge of funding large and long-term PFI commitments and difficulties in sustaining high-quality specialist care in hospitals in close proximity to each other offers important learning for the future.

South East London incorporates two large teaching and research hospitals (Guy’s and St Thomas’ and King’s) and four district general hospitals (Queen Elizabeth, Woolwich; University Hospital, Lewisham; Queen Mary’s, Sidcup; and Bromley Hospitals NHS Trust). The latter four hospitals have faced chronic financial and quality issues for a number of years. The reconfiguration process began in 2005. In December 2010, NHS London announced that the proposed reconfiguration met the four tests set by the government.

Here’s a summary of the report’s findings:

1. Reconfiguration of services across hospitals sites is likely to be the only way that some trusts can achieve financial balance while avoiding an unacceptable deterioration in the quality of care, given the cold financial climate, which is here for at least the next five years.

The necessary rapid growth of productivity and slower growth of hospital activity will result in excess capacity and stranded costs. Without reconfiguration, some financially challenged trusts will suffer a downward spiral of increasing deficits, declining quality of care and a further widening of the existing quality gap between the best and worst performers.

2. The large deficits and high legacy debts of financially challenged trusts with whole-hospital PFI schemes are caused in part by underfunding of fixed capital charges in Payment by Results (PbR) tariffs.

Making funding of capital charges more cost reflective would reduce the deficits of those trusts at no net cost to the NHS. It would make funding of patient care more equitable; reduce the pressures for reconfiguration across hospitals sites; reduce the current large financial leakage from the NHS; and enable more trusts to become foundation trusts sooner.

3. Reconfiguration should focus on achieving the best patient outcomes and patient experience for all NHS patients, and on narrowing the quality gap between the best and worst performers.

This is best achieved by designing reconfiguration to drive accelerated adoption of best practice models of care in as many services as possible. This in turn is best achieved by designing reconfiguration along patient pathways involving specialist/tertiary hospitals, DGHs and primary care providers.

It requires a significant change in the way emergency and network services are currently provided.

4. Competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts.

Market forces alone will rarely drive trusts into voluntary agreement to reconfigure services in ways that will improve the quality of patient care as well as drive down costs.

In many cases the most likely outcome will be continued deterioration in both the quality of care and the financial position. The NHS will have no alternative but to continue to fund their deficits or allow them to fail.

5. Strong commissioning of emergency and network services across a large catchment area is necessary to bring about major improvements in patient outcomes for all patients.

Individual PCTs in London are too small to drive major service change even when they join forces to form larger joint commissioning groups. The transfer of commissioning responsibility to even smaller GP consortia will further weaken commissioning levers to bring about service improvement across trust boundaries in major network services, such as cancer, cardiac, stroke and renal services.

Recent successes by the PCTs in reconfiguring stroke and trauma services highlight the potential of strong commissioning to bring about markedly improved patient outcomes in other network services. If this potential is to be exploited, the new NHS Commissioning Board will need to be given the statutory powers and the capability to perform the role effectively.

6. The best available means of bringing about reconfiguration along patient pathways will often be to support acquisitions of financially challenged trusts by high-performing foundation trusts.

Acquisitions of failing trusts are the logical outcome of competition and choice in healthcare services. Acquisitions by foundation trusts which have existing networks of care and high performance ratings will often be the best way to drive accelerated adoption of best practice for the benefit of all patients served by the enlarged trust.

They are also the most practicable means by which the NHS Commissioning Board can use strong commissioning powers to bring about desirable service reconfiguration locally. Concerns about adverse impacts on quality of contestable services arising from reduced competition if acquisitions do go ahead should be weighed against the deterioration in quality and loss of opportunities to improve quality if they do not.

In any event, acquisitions of financially challenged trusts (by foundation trusts or anyone else) will remain a purely theoretical option unless the Department of Health/NHS provides funding to defray the large one-off restructuring costs and agrees to refinance legacy debt.

Commenting on the report, Chris Ham, chief executive of The King’s Fund, said: “The lessons from this paper need to be acted on in a context in which ministers have emphasised that service reconfigurations should be based on support from general practice commissioners and public and patient involvement.

“They have also argued that service changes should be consistent with clinical evidence and help to facilitate patient choice. The government’s decision to bring a halt to the work being undertaken by Healthcare for London to concentrate some specialist services to improve outcomes underlines the challenges in acting on the evidence presented in this paper.

“In reality, the requirement to find up to £20 billion of efficiency savings by 2015 and to establish all NHS trusts as foundation trusts by 2014 will necessitate a stronger approach to commissioning than currently envisaged to ensure that quality is improved at the same time as costs are brought under control. The expertise of general practice commissioners needs to be married with the ability to lead complex service reconfigurations across large populations if the lessons from south-east London are to have lasting impact.”

Read the full report.

Tags: GP consortia, Reconfiguration
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Leaked letter shows how GPs could profit from reform

Channel 4 - 2nd March 2011 8:14 pm

A Channel 4 News investigation reveals that under the reforms of the NHS, GPs could end up making decisions based on profit rather than the clinical needs of the patient.

The NHS reforms plan to put up to 80% of the budget into the hands of family doctors. GP practices will form consortia and they will buy - or commission - the care.

It is widely acknowledged that not all GPs will want to run or manage the consortia. This means there is a business opportunity for private companies and already many are lining up to offer their services.

But a document leaked anonymously to Channel 4 News shows how one such company plans to work with GP consortia. What is startling about it is how it quite clearly sets out the way in which both the company, in this case called Integrated Health Partners, and the GPs, might make a profit.

It talks about plans for 5% cost savings from patient budgets, and that the less they spend, the more there is left over to share between them. It even proposes that in three to five years, the overall business should become profitable enough to attract City investors. Channel 4 established that IHP is involved with a number of consortia in Surrey.

GP commissioning: government guidance at-a-glance

By Mike Broad - 16th December 2010 11:20 am

The government’s ambition is for an NHS that puts patients first and continually improves the quality and outcomes of care for everyone. This improvement will come from devolving power to professionals, patients and carers.

By April 2013, there will be a comprehensive system of GP commissioning consortia, supported by and accountable to a new independent NHS Commissioning Board. The following is the government’s at-a-glance guidance:

1. The principle of GP commissioning

Key decisions affecting patient care should be made by healthcare professionals in partnership with patients and the wider public, rather than by managerial organisations.

GP commissioning builds on the key role that GP practices already play in coordinating patient care and acting as advocates for patients. It gives groups of GP practices financial accountability for the consequences of their decisions.

2. Granting GP consortia statutory powers and duties

The purpose of consortia being statutory bodies is to ensure that they have a separate identity from that of their member practices.

Being a statutory body means that consortia can have clear powers and duties. This will not affect the status of GPs and GP practices as providers of primary care.

The legislative framework will be designed to make sure that consortia are able to focus on improving quality of care within the resources available to them.

3. Composition of GP consortia

All holders of primary medical contracts will have a duty to be a member of a consortium for each contract they hold, i.e. for each GP practice.

Individual GPs or GP practices will not have to take commissioning and financial decisions on their own. The majority of GPs will continue focusing on providing primary care.

Membership of consortia will be flexible, with consortia able to expand, contract, dissolve or merge.

The precise size of a consortium is less important than the ability to scale up or scale down depending on the nature of the activity being undertaken.

The NHS Commissioning Board will need to be satisfied that prospective consortia, when applying to be established, have made appropriate arrangements to ensure that they can discharge their functions.

4. Robust governance arrangements

Commissioning decisions will need to reflect the healthcare needs of the practice’s registered patients together with the needs of unregistered patients for whom the consortium is responsible.

All consortia should have an Accountable Officer who need not be a GP or clinician. However, strong clinical leadership is a critical component of successful commissioning, and clinical experience will be essential in understanding how best to improve quality and outcomes.

The consortium’s Accountable Officer will be responsible for ensuring that a consortium promotes continuous improvements in the quality of services it commissions, complies with its financial duties, and provides good value for money.

All consortia will be required to have a published constitution.

Consortia will be required to make remuneration arrangements and commissioning plans public, to hold an open annual general meeting, and to publish an annual report showing the results of patient and public consultations.

5. Partnership working and public involvement

There will be increasing focus given to partnership working and the importance of multi-professional involvement in commissioning.

The NHS Commissioning Board will hold consortia to account for financial performance and outcomes, but there will also be a stronger role for local authorities in helping shape commissioning priorities, and in promoting a joint approach to improving the health and wellbeing of local communities.

There is a commitment to greater patient and public involvement within emerging GP consortia. The Health and Social Care Bill will place a duty on GP consortia and the NHS Commissioning Board to ensure that people who may receive a service are involved in its planning and development. Local Health Watch will strengthen the patient’s voice, and the enhanced role of local authorities will increase the democratic legitimacy of NHS commissioning decisions.

6. The NHS Commissioning Board

The NHS Commissioning Board will be established in shadow form as a Special Health Authority in April 2011, and as a full non-departmental public body from April 2012.

The Board will be responsible for establishing GP consortia, and in doing so will ensure that there is a comprehensive system of consortia across England. The Board will hold consortia to account, but will only have the power to intervene where there is evidence that consortia are failing or are likely to fail to fulfil their functions.

The NHS Commissioning Board will have a vital role in providing national leadership for driving up the quality of care, including safety, effectiveness and patients’ experience, and promoting choice and patient and public involvement.

The Board will need to be able to demonstrate good clinical evidence in support of its decisions, maintain effective relationships with professional bodies, and have strong internal professional leadership.

The Board will publish a business plan setting out how it intends to achieve its statutory duties, and the objectives or requirements that have been set for it by the Secretary of State. It will also publish an annual report setting out progress against both its duties and objectives and requirements.

7. Clear accountability

GP consortia will have a stronger focus on improving the quality and outcomes of care for patients. They will be under a statutory obligation to seek to reduce inequalities in access to healthcare.

The NHS Commissioning Board will draw on the national outcome goals in the Outcomes Framework to develop a Commissioning Outcomes Framework, to help hold consortia to account for promoting improvements in quality.

GP consortia will also be required to ensure that their expenditure does not exceed the commissioning budget allocated to them. There will be a clear line of financial accountability from consortia to the NHS Commissioning Board and in turn to the Secretary of State. The Board will have the powers to intervene where there is a significant risk of financial failure.

There is a need to ensure a fair approach to handling current deficits and surpluses. The expectation is that any debt will be fully resolved by the end of 2012/13. Further detail is included in the NHS Operating Framework for 2011/12.

8. Commissioning primary care

The NHS Commissioning Board will commission primary medical care services, but we are planning an explicit duty for all GP consortia to support the Board to improve the quality of these services.

It will be able to ask GP consortia to carry out some commissioning functions in relation to primary medical care on its behalf. This will mean that consortia have a core role in improving patient care across the system.

The NHS Commissioning Board will retain formal responsibility for ensuring that a practice is meeting its core contractual duties. The Care Quality Commission will be responsible for ensuring that GP practices are meeting standards of safety and quality.

9. Commissioning specialised and complex services

The NHS Commissioning Board will commission national and regional specialised services, drawing on engagement with GP consortia. The specialised services portfolio will be kept under regular review. There will be a criteria-based approach to deciding which services are ‘specialised’.

The NHS Commissioning Board will have responsibility for health services for those in prison or custody, high security psychiatric services and the current PCT duties in relation to healthcare for the armed forces and their families.

GP consortia are likely to work collaboratively with each other on particular aspects of commissioning, such as commissioning low volume services. The NHS Commissioning Board will also be able to commission some services on behalf of consortia, where this is agreed by both parties.

Responsibility for commissioning maternity services will lie with GP consortia, but with a strong role for the Board in promoting quality improvement.

10. Autonomy for the NHS with national leadership

The functions of the NHS Commissioning Board will be defined in primary legislation, rather than being at the discretion of the secretary of state through legal delegation.

Instead, the secretary of state will set a mandate for the Board, which will include the totality of the government’s requirements and expectations for the NHS over a three year period, updated annually.

Each year the secretary of state will be obliged to undertake a formal public consultation on the priorities within the mandate for the NHS Commissioning Board.

In the event of emergencies, it is vital for the government to be able to act decisively. The Board will be under a duty to ensure NHS preparedness and resilience by assuring that clear arrangements are in place.

11. GP pathfinders and managing the transition to consortia

Consortia pathfinders will test out design concepts for GP commissioning and explore how emerging consortia will best be able to undertake their future functions.

Pathfinders and other emerging consortia will work closely with PCTs to deliver the QIPP agenda.

The NHS Commissioning Board will start to establish consortia from April 2012. Once established as statutory bodies, consortia will be able to take on staff from PCTs.

In the autumn of 2012, consortia will receive notification of the budgets for which they will be statutorily accountable in their own right from April 2013 onwards.

12. Government conclusions

The proposals for GP commissioning and the NHS Commissioning Board are intended to transform the quality of care and health outcomes for patients. Day-to-day decision-making will be more sensitive and responsive to their needs and wishes.

A clear framework established and developed by the NHS Commissioning Board will promote quality, choice, patient and public involvement, and effective stewardship of public resources.

The plans are intended to unlock the benefits of GP-led commissioning, focussing on achieving a step-change in the quality of patient care, delivering better value for the taxpayer and improving the health of local communities.

Read the reaction to the consultation.

Tags: Commissioning, GP consortia
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Private referral management deal for GP consortium

Pulse - 8th December 2010 11:53 am

One of the first GP pathfinder consortia groups has signed a deal with private firm UnitedHealth UK to run a major crackdown on GP referrals.

NHS Hounslow revealed the new Referral Facilitation Service would handle all referrals, including consultant-to-consultant referrals, from February 2011.

The trusts says all 57 GP practices in the area have agreed to the consortium plans, which will see it become the first to go into fully-fledged partnership with the private sector.

The Great West Commissioning Consortium is one of the first consortia pilots.

Dr Nicola Burbidge, a GP at the Wellesley Road Surgery in Chiswick, west London and Chair of the Great West Commissioning Consortium, said: “The Referral Facilitation Service will make sure patients are seen directly by the right service, as agreed by local clinicians. GPs from the Great West Consortium have designed the referral guidelines.

“The new service will help improve understanding of what services are available locally and how to use them and we are pleased to be working with UnitedHealth UK who can give us expert support to help us deliver.”

Firms, including UnitedHealth UK, Tribal, Humana, Bupa and Aetna UK, have been talking to consortia offering to provide technology and back-office support to run referral management schemes with the looming demise of PCTs.

Re-think scale and pace of NHS reform, MPs say

By Mike Broad - 6th December 2010 7:24 pm

A cross-party group of MPs has demanded more detail on how the NHS reforms should be implemented.

The All Party Parliamentary Group on Primary Care and Public Health urges the government to rethink the scale and pace of its proposals, embodied in the white paper Equity and Excellence: Liberating the NHS. The proposals include giving GPs responsibility for commissioning services and scrapping PCTs and SHAs.

The report increases the pressure on the government to slow down the pace of the changes. Discontent within government ranks over the reforms is believed to have prompted a delay in publication of the health bill and the drafting in of Oliver Letwin, the Cabinet Office’s minister for government policy, to scrutinise the controversial plans.

The cross-party group report recommends slowing the pace of reform, approaching it in “a more measured way that will ensure continuity of management and leadership”.

It also questions the scale and disruption of the proposed reorganisation. “We have been convinced that with a few modifications to PCTs and encouraging greater local health partnerships, the vision government is seeking could be met without embarking on the radical reforms being proposed,” it says.

“The reforms such as they are will also be extremely costly, result in a drop in productivity in the NHS and there is also the real threat of losing crucial expertise that currently exists in PCTs and SHAs and we are concerned for the future of the health system if these experts are lost.”

The report is, however, supportive of the vision describing the desire to put patients and the public first and focusing on outcomes as “excellent aspirations”.

Earl Howe, Parliamentary under-secretary for health, responded: “The government is committed to strong patient and public involvement and engagement because it is essential in creating positive health behaviours and outcomes.

“Health professionals have an important role in working with and supporting patients to enable them to look after their own health and make the right decisions about their care.”

Meanwhile, the government has interpreted the significant interest among GP practices to become pathfinder consortia as a sign of support for its reforms.

Nearly 2,000 practices across the country have grouped themselves into more than 50 consortia, to test the policy, which health officials described as “overwhelming”.

Read the report’s conclusions in full.

Tags: GP consortia, Health policy
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What can polyclinics tells us about GP consortia?

By Mike Broad - 22nd November 2010 11:58 am

A wiser man than me recently said that the coalition government hasn’t learned the lessons of past reorganisations of the NHS and is intent on massive change without evidence that it will improve the service.

I’ve been making this point in ‘print’ for the past ten years - and frankly it’s starting to get boring - but the current health secretary is determined not to listen.

Just as we embark on the dissolution of 10 SHAs and 152 PCTs, and replace them with largely unpiloted GP consortia, it’s worth a quick glance at the progress of polyclinics - the flagship of the previous health administration.

They were another project that was rushed in with little testing. The government ordered 150 of them in one shape or another, allowing ‘walk in’ services for patients over a 12-hour day. The ones in London were bigger and tried to integrate diagnostic services usually found in a hospital.

They were dressed up in the language of patient choice, and yet the public weren’t demanding them (and now they’re being closed the public still don’t seem to care). In reality, they were simply a vehicle to allow private providers to enter the market and compete with GP practices.

Since the first opened in 2008, there’s little evidence to suggest they’ve revolutionised primary care. If their aim was to lower A&E attendances, they haven’t. If their aim was to bring diagnostics into the community, they haven’t. They are, in their defence, a little more accessible than a normal GP.

Is that worth the money that has been invested in them? The Department of Health pumped in £250m at the start and who knows how much they’ve cost PCTs locally.

Lansley axed the London polyclinic programme earlier this year. And many PCTs are looking to downgrade or close them. Their future will, of course, now be in GP commissioners’ hands and some believe that a number of them will continue as out-of-ours service providers.

Kieran Walshe, professor of health policy and management at Manchester Business School, believes that the current reorganisation of primary care will cost between £2bn to £3bn. This comes at a time when the NHS is supposed to be making efficiency savings of £20bn and from a government that when campaigning for office said there would be no more top-down reform.

I think there’s potential in Liberating the NHS but we’re in danger of losing the important bit - clinical empowerment - in all the rush. When are politicians going to realise that major reorganisations on politically convenient timescales don’t benefit patients?

Tags: GP consortia, Health policy, Polyclinics
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Firms to bid to run GP consortia if they fail

Healthcare Republic - 6th August 2010 2:30 pm

GP consortia are “odds-on” to fall into deficit and be taken over by private firms when they take on commissioning, according to one leading GP.

The warning comes as private companies confirm they hope to run consortia if local GPs fail. Firms are also bidding to provide data the NHS Commissioning Board will use to performance manage consortia.

Dr Kambiz Boomla, a GP in east London and lecturer at London’s Queen Mary University, said there was little evidence GPs would be able to balance constrained NHS budgets, and the DoH would replace them with private firms if they failed.

“A few years ago almost all PCTs were in financial difficulties and that was during years of growth,” he said.