Pardon my ignorance, but I have been trying – and I confess failing – to get my head around a simple question: who owns (or rather will own) GP consortia? The legal status of these bodies may seem a bit pedantic, but it could have a fundamental affect on the dynamics of the New Model NHS. And finding out, from the 367 pages or whatever it is, of the Health and Social Care Bill is nigh on impossible.
Most people forget, if they ever knew, that GPs are not NHS employees but independent contractors. Although some work in NHS premises, many (most?) own their own buildings and single or group GP practices are small businesses. Many GPs have already done very nicely by using NHS funding – quite legally – to improve buildings and businesses that they own.
Primary Care Trusts are, on the other hand, publicly owned and controlled bodies. GP Consortia (let’s call them GPCs for short) seem to have a rather more ambiguous status. Are they public, or are they private, or some sort of hybrid?
The reason it matters of course is that if these GPCs are going to be managing 80% of the NHS budget, or £80bn in today’s budgets, what incentives will they have? If, for example, they are essentially private small businesses then there is every incentive for them to bias decisions in their favour. Because, when they are ‘commissioning’ care they could, if the system allows this, commission themselves instead of NHS Trusts to provide services. This could be either as a GPC or, presumably, as GP practices? Either way, they could stand to make money, either directly or indirectly, from such decisions.
GPCs will also have, of course, a budget for running themselves. In some cases, they will presumably be co-located with GP practices. Again, how exactly will the private interests of the GPs who own these medical businesses be kept separate from the (presumably) public GPCs?
Now I am sure most GPs are good and honest folk with only the best interests of their patients and the taxpayers at heart. But some might not be, and the temptation could be very great indeed to cream off a little of that £80bn, could it not? Especially as it could almost certainly be justified as providing better local care for patients.
But I’m sure somewhere in this gargantuan Bill, so big it can definitely be seen from space, there are a whole set of clauses and rules making sure that GPs themselves, personally, can’t benefit from controlling all that NHS money, isn’t there? I’m just worrying needlessly, aren’t I?
Colin Talbot is professor of public policy and management at the University of Manchester Business School. This post first appeared on Whitehall Watch
The issues and concerns around conflicts of interest, with GPs both commissioning and providing services have been bubbling under for a while with the introduction of practice-based commissioning. Steps are being taken to ensure adequate governance arrangements are put in place but their effectiveness will require close monitoring. The abolition of the Audit Commission threatens the effectiveness of such monitoring.
Another question which has been bothering me (mostly because no-one has even asked it) is how exactly are these proposals different from the late and not very lamented GP fundholders? (Except of course that they are going to be much bigger and control even more money.)
Will not a GP Consortium be best advised to outsource the whole business to professional admin. process managers such as Capita, Ventura, GXS etc?
This then raises queries such as:
1. Who quality controls the selection process?
2. Who determines the reward for Capita?
3. Who quality controls Capita?
4. Who sues whom if things go wrong?
5. Who decides whether something HAS gone wrong, anyway?
6. Who guards against financial rewards (cash or kind) flowing from the outsource company to the GPs?
7. Is the appointment for a fixed period or forever?
etc etc etc
There are a whole series of other questions to be considered. Firstly the role of Monitor has been highlighted by other commentators but they may inhibit GPs from commissioning from themselves without subjecting the service to competition. This points to the need for ‘chinese walls’ inside GP practices between the commissioning and contracting arms.
Secondly while £80bn sounds like a lot of money how will it be distributed between consortia? If that echoes what has happened to local authority budgets then poorer areas will lose money toward the wealthier.
Thirdly the abolition of NICE makes GP consortia vulnerable to lobbying by patient campaigns that are backed by drug companies. This could lead to spending on high profile disease at the expense of for example adolescent mental health.
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As a regular visitor to a GP’s surgery and NHS hospital I had already detected an expectation that routine services will be provided at GPs’ premises (private) so by-passing the services currently provided in the NHS hospital.
Will there be a stripping away of the routine work from public providers leaving them only with a requirement to provide for the non-routine, ‘difficult’ cases?
Hopefully a rigorous transparent contracting exercise will determine where and through which provider services will be delivered.
GP fundholding only covered certain practices and their patients. Consortia cover all practices. Also responsibility for managing contracts (or hiring managers to do so) rests at cluster level. And because of the size, most of the contracts will have to go through a full procurement process.
At a guess I’d also say that GP consortia will have less freedom than GP fundholders as they’ll be subject to the same NHS architecture as PCTs (e.g. national payment structures, a centre that won’t let go).