Press Release - Liberating the NHS - Impact on Commissioners
'This government cannot afford any risk of failure in commissioning.'
The Overview for Commissioners
Commissioners are set to play a major role in the reforms yet they have identified many areas for further clarification. These reforms will be controversial and this paper makes the point that the government cannot afford any risk of failure in commissioning.
Context
From what we can identify, there are 152 PCTs in England, some 35000 GPs and 10000 GP practices for a population of 51m. The NHS budget is £110Bn of which some £80Bn is for GP Consortia. Some commentators have suggested that there will be 500 GP Consortia which implies £160m per organisation of about 20 practices. This will be modified due to provisioning for local emergencies and disasters through a risk premium.
Local authorities will be responsible for securing the national objectives for Public Health, setting up partnerships and the JSNA. Generally instead of dealing with one PCT, they will be dealing with 3-4 GP Consortia who will be commissioning for all people plus any residual PCT functions. Does that mean changes to the Children's arrangements where DfE provide funding for certain vulnerable children?
So each GP consortium will have a lead with a consequent increase in the numbers of CEOs and Directors of Commissioning. What about all the Joint Commissioning posts between Councils and the PCTs. Will there be a joint commissioner for every GP Consortium?
With GPs taking patients from anywhere, the GP Consortia will have to be prepared to deal with a number of Councils.
In Adult Social Care, with the advent of personal budgets and substantial cost reductions in these areas, then will more cases be passed to the GP Consortia? Will they be able to handle direct payments?
Professional Development
The NHS Commissioning Board will have to address the criticisms made by the Parliamentary Health Committee report on Commissioning. Indeed, the White Paper implies an improvement but is not explicit about further actions to raise standards. It discussed workforce development and Education Commissioning but misses the point about how to address the specific workforce development of commissioners. It also makes no statement on how or if the commissioning profession will be regulated.
Recently an academic commented about the 'Taylorist' approach taken by many PCTs towards commissioning where the function is disaggregated into its constituent parts. Smaller GP Consortia will require more rounded commissioners who meet the full spectrum of skills and knowledge requirements.
This debate will affect the insurance companies particularly if employee-led organisations emerge from the embers of the PCTs.
The GP Consortia will have to be formalised and therefore issues of risk and liability, warranties and guarantees will have to be clearly stated. What changes are implied to the NHS Compensation Scheme or with the provider focus moving towards the third sector, will a centralised scheme still be appropriate under the new regulation and inspection arrangements?
GP skills will need enhanced in order to run large scale consortia and the GP contract will require modification.
It would appear that the US Health Management Organisations would be in an advanced state of preparedness due to having advanced IT which measures performance and can handle the accounting requirements. Would the Any Willing Provider rules or the Right to Request to establish a Community Enterprise be extended to the commissioning function?
Conclusions
This White Paper represents a considerable set of opportunities for commissioners as well as some real threats. We are not as naive to suggest that commissioning is the complete answer to the opportunities and problems within the NHS. We have a healthy scepticism which revolves around the issues for clarification. The opportunities include;
o Development of a key professional basis for a major funded health service;
o More closely linking clinicians and commissioners to work for the patient;
o Potential removal of bureaucracy;
o Developing robust commissioning standards and linking these to education;
o Formation of a library of best practice in commissioning;
o Achieving professional recognition;
o Extending the scope and training of the professional commissioner;
o Formation of employee-led GP Commissioning Consortia;
o Potential to use market making skills to enhance local service delivery;
o Development of enhanced relationships with Councils and the Third Sector; and
o Implementing local development of the vision on 'Liberating the NHS'.
What we can say is that our members are committed to making this work but that requires a similar commitment from the government and DH to invest in raising professional standards and recognising the efforts of commissioners.
Commissioning has a wider locus than DH and this needs to be recognised too.
The consequence of failure of the policy is considerable as local or widespread breakdown of the NHS and consequential reputational risk could lead to an electoral failure. The last government did not wish to recognise that its policies were being 'built upon sand'. This government cannot afford any risk of failure in commissioning.
Whilst the White Paper is a start for the reform process, there are a number of issues which require further clarification.
Issues for Clarification
o Is DfE planning parallel legislation for Children or does this imply Children's Social Services are again the remit of DH;
o How can £80Bn pa be awarded to GPs who are in the private sector without competition? GPs have responsibility but who has the authority to spend? The GP Consortia will do that from within or outwith the private sector.
o What organisational form and what warranties, guarantees and liabilities will these have? The implication of no bail outs means that overspending comes from the owners' pockets. The corollary is where does the profit go? So the instruction from the owner will be to underspend as downside risk is unacceptable. Will there be any compensatory mechanism? How quickly will the organisations become insolvent?
o Are there any lessons which could be learned from the shared service operations between councils?
o The first step with commissioning is to ask the service user how their needs can be met. So who asked the GP's and Commissioners if they wanted the proposed changes and what issues need to be addressed?
o What VAT and taxation implications are there - particularly for GP Consortia, the management charge and any outsourcing of the service?
o Will health commissioners be recognised as a Health Professional?
o How will the maximum management fee be determined?
o Will the GP consortia be able to get other income i.e. from special rebates or promotions from suppliers? Will they offer GP services to BUPA?
o What conflicts of interest could emerge between GP Commissioning Consortia and the GP Practices and how will these be mediated, arbitrated and regulated?
o The translation of needs to outcomes - the development of Outcome Based Assessment practices are required to enable better focus upon improving health outcomes. Who is charged with their development?
The full impact study can be accessed the IoCP web site please Click Here
Independent Commissioning Board
"if there is to be an independent commissioning board it should be charged first and foremost with developing commissioning skills in PCTs and ensuring there is an environment conductive to effective commissioning. Barriers - such as the burdensome approach to tendering and contracting - should be removed" James Gubb Director of the Health unit at Civitas, an independent social policy think tank. From an article in the Sunday Times 11th July 2010 called "Let that be , minister, it can heal the NHS"
New Membership Structure
As you are aware, one of the goals of the IoCP is to improve commissioning standards. After the recent Parliamentary Health Committee's report on Commissioning, we held a workshop to discuss the new draft National Occupational Standards from Government Skills. This innovative approach allows for the creation of a membership examination which will help to improve commissioning standards.
This will have an effect on the types of IoCP membership. Up till now, the only class of membership has been as a Founder. We have a number of proposals for changes to this arrangement tied to an entrance examination.
The National Committee agreed to an annual membership fee but this has not been charged as we had not developed a robust exam process. It is essential that we have an income stream to develop the Institute as all development work has so far been provided by members.
Membership
New members:
From the 1st July, full member entrance into the IoCP will be subject to passing the Accredited Commissioner award or through holding approved qualifications. Full details of the portfolio approach and exemptions for existing qualifications will also be published. This will involve student members submitting examples of their own work with reflective pieces linked to the skills and knowledge requirements of the National Occupational Standards.
Recognition for Approved Qualifications
Prospective members who have existing Commissioning Qualifications over NVQ5 can apply for exemption on payment of the appropriate fee.