The form and structure of gp led commissioning consortia
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The form and structure of GP-led commissioning consortia. March 2011. The Health Bill. Government plans outlined in NHS White Paper ‘Equality and excellence: Liberating the NHS’ and the supporting consultation document ‘Equality and excellence: Commissioning for patients

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The form and structure of gp led commissioning consortia

The form and structure of GP-led commissioning consortia

March 2011


The health bill

The Health Bill

  • Government plans outlined in NHS White Paper ‘Equality and excellence: Liberating the NHS’ and the supporting consultation document ‘Equality and excellence: Commissioning for patients

  • GPC series of guides to the White Paper on the BMA website

  • Health & Social Care Bill now published


The health bill 2

The Health Bill (2)

  • Locally led commissioning– flexibility and variability in structures

  • ‘Shadow’ consortia and pathfinders being set-up

  • Unclear what work the consortia carry out themselves and what they will do in conjunction with other organisations

  • Consortia will be responsible for commissioning secondary care, mental health, maternity services and urgent care services


Timetable for change

Timetable for change

2010/11

• Clinically-led Commisioning Consortia to begin to form on a shadow basis

• 141 consorita pathfinders in place by mid-January

2011/12

• Shadow Clinically-led consortia to be in place, taking on increased responsibility from PCTs

• NHS Commissioning Board to be established in shadow form as a Special Health Authority from April 2011


Timetable for change 2

Timetable for change (2)

2012/13

• Formal establishment of Clinically-led consortia, together with indicative budget allocations

• NHS Commissioning Board to be established as an independent statutory body; SHAs to be abolished

• NHS Commissioning Board to announce (in the third quarter of 2012/13) the allocations that will be made directly to consortia for 2013/14

2013/14

• Clinically-led consortia to be fully operational, with real budgets and holding contracts with providers; PCTs to be abolished


Commissioning board

Commissioning Board

  • NHS Commissioning Board will have power to authorise the establishment of consortia; ensuring that they:

    - are of sufficient size to manage financial risk and allow for accurate budget allocations

    - have the necessary arrangements and capabilities to fulfil their statutory duties

    - provide comprehensive coverage of consortia across the country

  • Consortia may be allocated practices

  • Commissioning Board will not approve ‘cherry-picking’ of like-minded practices


Engagement with the process

Engagement with the process

  • ‘Bottom-up’ approach – requires engagement across whole profession in order to be a success

  • Engagement from a small section of enthusiasts only will not achieve aims

  • LMCs should hold meetings for all local GPs to discuss what the proposals mean for them

  • LMCs must be proactive – helping local GPs and embedding their involvement in future management structures


Possible consortia models

Possible consortia models

  • Small consortia

  • Large Consortia with locality commissioning groups

  • Federation and lead consortium model

  • Consortium service agency model


Small consortia

Small consortia

  • eg. An autonomous single consortium of around 100k patients with a direct accountability link between practices and consortium management

  • Advantages:

    - Strong sense of ownership, close relationships and effective performance management

    - Close understanding of patient needs for pathway development


Small consortia 2

Small consortia (2)

  • Disadvantages:

    - Financial risk management problems

    - Small budget variation would have more impact

    - Problems with secondary care links where acute trust is larger

    - Difficult to utilise economies of scale

    - Reduced access to best clinical leaders and skilled staff – reduced influence of best clinical leaders

    - Familiarity could lead to favouritism and accusations of bias


Large consortia with locality commissioning groups

Large consortia with locality commissioning groups

  • eg. A single autonomous consortium of around 500k patients comprised of 4-6 locality commissioning groups each of 70k – 150k patients

  • Advantages:

    - Large budget – effective financial risk management

    - Should relate well to other large organisations such as acute trusts + strong base for negotiation

    - Locality groups mean more relevance for commissioning decisions

    - Broader data available – influence commissioning decisions

    - Effective economies of scale

    - Familiar model to those acquainted with PBC

    - Extra management funding- attract better managers


Large consortia with locality commissioning groups 2

Large consortia with locality commissioning groups (2)

  • Disadvantages

    - Potentially numerous management tiers

    - More distance between actions of practice and consortium

    - These difficulties can be overcome if proper management structures are in place


Federation and lead consortium model

Federation and lead consortium model

eg. A number of consortia across a region join together as a group or federation and elect or appoint a lead consortium to undertake agreed functions on behalf of the group

  • Advantages

    - Consortia should be able to manage financial risk

    - Easy to achieve economies of scale

    - Able to commission all services for a population

    - Size may provide strong negotiating position with local authorities and acute trusts

    - Large management structure- easier to undertake statutory functions

    - Broad data available – influence commissioning decisions


Federation and lead consortium model 2

Federation and lead consortium model (2)

  • Disadvantages

    - Complicated internal governance and accountability – may add bureaucracy – level of sophistication required is rare in new organisations

    - Direct linkage between practices and consortium may be lost

    - Possible reduced sense of practice ownership

    - Potential difficulties in engaging with individual practices

    - Lead consortium may become dominant – possible tensions or disagreements


Consortium service agency model

Consortium service agency model

eg. A number of consortia join together in a group and pool a portion of their management allowance to engage a service agency to provide commissioning management support for the group

  • Advantages

    - Economies of scale may be easily achieved

    - Risk-pooling may be feasible

    - Individual consortia will retain close links with practices

    - Flexibility for small consortia- good management support without huge cost – use of highly skilled staff

    - Shares in service agency – would benefit from success

    - Potential for individual consortia to select level of service required


Consortium service agency model1

Consortium service agency model

  • Disadvantages

    - Risk that agency may not be focussed on the individual needs of each consortium. Agency may start to influence or direct the actions and directions of the consortia

    - Small consortia may have difficulty in their engagements with large acute trusts

    - Ownership of service agency could change leading to variation in performance


Consortium formation

Consortium Formation

  • Must have the support of local GPs, and be appropriate for local circumstances

  • The GPC believes that, in general, GPs should look to form large consortia to provide:

    -Good management of financial risk

    -A strong negotiating position with acute trusts and CSUs

    -A large management allowance to with which to employ the best staff

  • Not adopting this model provides that a risk that the consortium may fail in one of these key areas.


Pathfinder consortia

Pathfinder consortia

  • Early adopters or ‘pathfinders’ – allow suitable groups of practices to test different design concepts for consortia

  • There are now 141 consortia pathfinders in place

  • To join the pathfinder programme, a group of practices needs to be able to demonstrate:

    -Evidence of local GP Leadership and support

    -Evidence of LA engagement

    -Ability to contribute to the local QIPP agenda in their locality


Commissioning support units csu

Commissioning Support Units (CSU)

  • PCTs are required to join together to form about 45 - 50 clusters

  • In most cases this means 3 - 4 PCTs joining together to pool their staff and functions

  • These new clusters will be expected to establish teams to support the emerging consortia and are likely to evolve into CSUs which offer support to consortia

  • CSUs could ultimately take on devolved powers from the Commissioning Board


Transition issues

Transition issues

  • Fully operational consortia will be allocated a maximum management allowance

  • Shadow consortia funding will come from PCTs

  • GPs leading at shadow stage will be employed by PCT – must ensure they receive appropriate backfill for practice funding and for attending meetings etc.


Transition issues 2

Transition Issues (2)

  • GPs should ensure that they do not make formal agreements with PCTs at this stage, especially regarding:

    - The employment of PCT staff

    - The provision of commissioning support from CSUs

    - The functions that the consortium will undertake

    - Anything relating to the constitution of a consortium, where this has been imposed by the PCT

  • The DH will be proving guidance on all these issues in the coming months - PCTs and GPs should not act until this available.


Transition issues sessional gps

Transition issues-sessional GPs-

  • Shadow consortia must consider how to engage with sessional GPs

  • Sessional GPs offer flexibility and availability

  • LMCs should support sessional GP involvement and encourage practices to include them in the discussions


Transition issues cultural change

Transition issues-cultural change-

  • Consortia need to instil constituent practices with a sense of professionalism, ownership and peer involvement

  • PCT roles will change dramatically as they move towards abolition

  • Manager-clinician dynamic is obsolete, feuds must be forgotten to avoid encountering same problems as past organisations

  • Cultural shift towards clinician ownership of difficult decisions


Transition issues the role of the lmc

Transition issues-The role of the LMC-

  • LMCs remain local representative of the profession- commissioning proposals do not change this

  • Many LMCs already playing an active role in local development – to be encouraged

  • Should engage with all local GPs – principals, salaried and locums

  • Facilitate discussions between GPs

  • Form dialogue with local authorities, secondary care specialists, public health specialists

  • In position to mediate in any future disputes


Lmcs should be

LMCs should be:

  • Communicating regularly with all GPs in your area and encouraging their involvement in this process

  • Encouraging a two-way dialogue with GPs in your area so that, in return, you are in touch with GPs’ concerns.

  • Invite every practice to be involved in any local discussions about the formation of commissioning groups.


Ways that lmcs can support the planning process include

Ways that LMCs can support the planning process include:

  • Consider setting up a working group of interested GPs to discuss how consortia should be formed. Not ‘lead’ PBC GPs exclusively – all should have the chance to get involved. Also relevant PCT personnel and PBC managers.

  • Talk to PCTs and SHAs

  • Work with BMA Law to make sure that those involved in developing consortia take appropriate legal/financial advice + knowledge of corporate structures and responsibilities

  • LMC should offer to mediate as an "honest broker” where required.

  • Support practices and nascent consortia that are being pushed into moving too quickly, or in a direction with which they are not comfortable. If necessary, GPC can address this at a national level.


Any questions

Any Questions?


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