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

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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

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

  • Health & Social Care Bill now published

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


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

• 141 consorita pathfinders in place by mid-January


• 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)


• 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


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

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

  • ‘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

  • Small consortia

  • Large Consortia with locality commissioning groups

  • Federation and lead consortium model

  • Consortium service agency model

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)

  • 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

  • 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)

  • 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

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)

  • 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

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 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

  • 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

  • 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)

  • 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

  • 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)

  • 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-

  • 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-

  • 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-

  • 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:

  • 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:

  • 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?

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