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GP Commissioning A Brave new World Dr David Jenner NHS Alliance GMS/PMS Lead
New Structure Parliament Government Key: Funding: Accountability: Other relationship: Local Authorities Local Health Watch Local partnership NHS Commissioning Board GP Commissioning Monitor (economic regulator) Care Quality Commission Licensing Contract Consortia GP Practices Patients and Public Providers
– March 2011 PCTs to involve GP practices and emerging consortia, with other clinicians, in the 2011/12 contracting round and the broader commissioning cycle from 2011/12 onwards December 2010 Initial GP consortia pathfinders identified January – March 2011 Delegated responsibilities of pathfinder consortia confirmed with PCTs January 2011 – March 2012 Further pathfinders identified and emerging consortia encouraged to become increasingly involved in commissioning and take on increasing delegated responsibilities In 2011/12 June 2011 April 2012 NHS Commissioning Board set up in shadow form as special health authority PCT clustering arrangements in place All GP practices in GP consortia and start of NHS Commissioning Board authorisation of consortia NHS Commissioning Board established, takes over relevant responsibilities SHAs abolished and responsibilities allocated to bodies in the 2012/13 architecture April 2012 – March 2013 NHS Commissioning Board to work with GP consortia that need further support to be ready to take on full statutory responsibilities April 2013 Authorised GP consortia take on full statutory responsibilities April 2013 PCTs abolished
And Right Now n n n Health Bill in parliament PCTs to form clusters with single executive team from June 2011 91% of SWSHA region covered by pathfinders Likely future consortia forms emerging as shadow forms Still need to make massive efficiency savings (QUIPP)
The Health and Social Care Bill 2011 n n n Establishes a regulated market for health care Maintains purchaser-provider spilt Introduces legal duty for commissioners to promote competition Abolishes SHAs and PCTS Establishes GP commissioning consortia Moves Public Health to Local Authorities
The Health and Social Care Bill 2011 (the players) n n n Parliament –sets annual mandate via SOS to NHSCB leads commissioners –can direct GPPC who are accountable to them GPCC –lead the local commissioning of health services to meet the national mandate
The Health and Social Care Bill 2011 (the players) n n n Local authorities –key role in providing links to social care and public health and local people through: Health and Wellbeing Boards –based in LAs set local Health and Well Being Strategy with partners in GPCC NICE –prepares quality standards and balances the cost and provision of health and social care services. (will produce 150 commissioning guides with up to ten quality statements) ? 150 new central targets by another name
The Health and Social Care Bill 2011 (the players) n n n Foundation Trusts –all NHS trusts to become FTs by 2014 Alternatives are to be social enterprise or privately managed Some FTs will inevitably be merged or acquired by others Cap on proportion income from private provision removed and this income not required to be used for the direct benefit of patients Regulated by monitor
The Health and Social Care Bill 2011 (the regulators) n n CQC –regulates all health and social care providers (GPs from 2012) Issues a certificate of registration and will levy a fee for this Has powers to withdraw registration, prosecute in courts and levy fines Will establish national Health watch to help monitor services (powers unclear) from patient’s perspective
The Health and Social Care Bill 2011 (the regulators) n n n Monitor –the financial regulator Accountable to parliament –can be directed by SOS to intervene Duty to protect and promote interests of healthcare users Duty to promote fair competition Can “designate” essential services and ensure continuous provision
Monitor (continued) n n n Will licence all providers of health care (to include GPs apparently) It can levy a fee and also require providers to contribute to a “bail out fund” It can intervene and investigate failing providers It can de-authorise failing providers It can levy fines on commissioners and providers (including NHSCB) It can demand relevant information from providers
GP Consortia n n n To be bodies corporate Minimum size two providers primary health care (GMS/PMS/APMS) Must have a constitution Each primary care provider must belong to a consortium and… Nominate one person to lead and relate to the consortium who is. . A regulated health professional
GP Consortia n n n Must apply to NHSCB for establishment Must work with HWBs and agree their annual plans with each HWB to whom they relate Must provide a representative to each HWB to whom they relate Must provide any information in any required timescale to NHSCB “Each commissioning consortium must assist and support the Board in discharging its duty under section 13 D so far as relating to securing continuous improvement in the quality of primary medical services. ”
GP Consortia n n n n Legal duty to balance budget Nominate an accountable officer (can be accountable for more than one GPCC) Constitution must include: area covered constituent practices how to deal with conflicts of interest how to ensure effective participation from each member
GP Consortia Can… n n n Merge with another consortia with approval from NHSCB Allocate any of its functions to another consortia or committees containing people who do not belong to or are employed by a consortia (i. e. NHSCB or private companies)
NHSCB Powers n n n n Hold GPCC to account Approve their constitution and establishment Allocate practices to and from a consortia Appoint and dismiss the accountable officer Dissolve the consortia Take a top slice from the consortia budget for a contingency fund Allocate a performance bonus to consortia Allocate to, (or remove from) any functions from consortia as it sees fit
GP Practices Will… n n Have to belong to consortia and nominate a lead who is a regulated healthcare professional and 24 (d) [Regulations may make particular provision]. . . for requiring a relevant contractor (GP Practice), in doing anything pursuant to the contract, to act with a view to enabling the consortium to which it belongs to discharge its functions (including its obligation to act in accordance with its constitution).
What Does This Mean n n n n Abide by constitution –yes Follow referral pathways –probably Keep to a formulary? Balance budget? Change individual patient care? Possibly! The new “contract” is likely to define this further –new GMS/PMS yet to be negotiated! Changes to GMC guidance may be needed!
What We Still Don’t Know n n Whether GPCC will be defined as “successor organisations” to PCTs (vital consequences for premises, TUPE and deficits) The allocation formula for consortia budgets (will be allocated to practice level then built up from there minus top slice to NHSCB) And any pace of change to them But we do know consortia not responsible for deficits incurred before 01/04/2011
What We Do and Don’t Know n n Exact amount of and definition of running costs (£ 25 -£ 35 per head) Whether any incentives in provider budgets for commissioning Any changes in GMS/PMS budgets to tie practices into budgetary responsibility The failure regime for consortia and practices
The Market in Future n n n Any Willing Provider Need to tender Tariff Payment by results CQUIN
Pb. R /CQUIN n n n The transactional currency and rules Pb. R driven by tariff but really means payment by activity Backed by extensive guidance and rules
Any Willing Provider n n n Means anyone can register to provide services for NHS Must be registered and licensed with Monitor and CQC Can provide services at or below tariff price Patients have free choice of AWP Consortia/practices have to offer (and be seen to offer this choice)
Any Willing Provider Pros Cons n n n No need for tenders Competition on price and service More choice for patients Allows new entrants to market Model works well where a tariff n n n Might cherry pick profit lines May not be much choice of AWP Managing and servicing multiple providers How to inform patient choice Needs an agreed tariff to work-many services still off tariff
Tariff n n n Price to be paid for NHS services Price set by Monitor, defined by NHSCB Will be a maximum price In future may be extended to community care, mental health and even primary care ? Political interference allowed in future (marginal rate emergency tariffs)
Need to Tender n n n Governed by EU regulations Default position is services need to be tendered and advertised in OCEJ Tenders not required for some services of low value (? Below 30 k) Need not apply when one provider uniquely placed to provide a service (e. g. a service requiring a provider to hold a registered list of patients) Monitor and OFT can intervene and aggrieved companies can sue!
Commissioning Roles n n n ? Mandatory in contract or as a DES (Is it right to make compulsory a role for GPs they have not been trained to do? ) Or contractual obligations to follow formularies, referral pathways and effective resource utilisation (clause 24 (d)) BMA looking for a DES and already flagged practices should not be rewarded or penalised for budget performance But all this detail still awaited and negotiations on contract start now!
And Accountability For GPs As Commissioners? n n n Professionally to GMC In statute to NHSCB To Monitor and OFT and European Competition Law on procurement and ensuring competition To HWB in commissioning plans Local and national Health watch
Accountability for GPs as Providers n n n Professionally to GMC In statute (clause 24 d) to GPCC Contractually to NHSCB To Monitor (financially) To CQC (quality) Local Health Watch (quality and pt experience)
And Then There Are the QUIPP Savings n n n n £ 20 billion by 2015 According to James Kingsland (national clinical commissioning lead) 40 p per pt per day £ 2400 per 6000 patients (average practice) per day And an ageing population And 40% reduction in management costs
And It’s Still Not In the Statute Book yet! But From 01/04/2013 we will be responsible for any debts accruing And currently c. £ 800, 000 over budget
Local Developments n n n n Mid, Exeter, Wakely and WEB consortia working more closely together NHS Devon profiling staff to support that locality Other NHS Devon localities: North Devon Southwestern Devon Torbay (Baywide –legal entity) Plymouth (Sentinel –legal entity)
What We Need to Decide Now n n n Whether to continue under current Mid Devon constitution or… Whether to commit to joint constitution with other Eastern Localities as a. . Shadow Consortium till 01/04/2013 Further configurations possible before that date PCT remains accountable till 2013
Proposed Interim Structure Eastern Board Mid Devon Exeter WEB Wakley
Feedback From Practice Visits. Issues n n n Practice data: strive to continuously improve the quality Practice budgets: check for case mix and growth Human resources: think of the consortium as well as practice needs Small practices: 10 practices have list size of less than 4, 000 - develop small practice network
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