Written evidence from the British Medical
Association (COM 109)
The British Medical Association (BMA) is an
independent trade union and voluntary professional association
which represents doctors and medical students from all branches
of medicine throughout the UK. With a membership of over 140,000,
we promote the medical and allied sciences, seek to maintain the
honour and interests of the medical profession and promote the
achievement of high quality healthcare.
1. EXECUTIVE
SUMMARY
1.1 Effective commissioning can improve
the range and quality of health services available to patients.
In order to facilitate this, there has to be meaningful clinical
engagement from and with both primary and secondary care.[39]
1.2 We are interested in exploring the Government's
proposals for GP-led consortia, which see GPs as an integral part
of the commissioning machinery within the NHS in England, as set
out in "Equity and excellence: Liberating the NHS".
Successful commissioning will only be achieved with GPs, secondary
and tertiary care consultants and other clinical colleagues working
together. Public Health consultants will also have a significant
role to play, as will clinical academics, in creating high-quality
care pathways.
1.3 The concept of GPs taking a leading
role in many of the NHS's commissioning decisions is not widely
understood. Some patients may view GP-led commissioning with suspicion,
particularly when their GP refers them for treatment from another
GP provider. It will be essential to develop and implement a system
that maintains patient trust and protects professional values.
This system should be as transparent as possible and assure patients
that their doctor is referring them to a particular provider purely
because it will provide the best clinical outcome.
1.4 We are concerned that the Government's
plans have the potential to accelerate a market-led approach,
creating increased transaction costs, fragmentation and competition
rather than collaboration. The current system of Payment by Results
(PbR) is not fit for purpose, encourages perverse behaviours and
is highly bureaucratic.
1.5 The winding down of Primary Care Trusts
(PCTs) and Strategic Health Authorities (SHAs) must be managed
carefully to avoid confusion and inefficiency. Both should remain
in place until the new structures are ready to operate. Steps
must be taken to prevent the loss of significant numbers of skilled
staff within both types of organisation, something which may already
be occurring. It has been reported that morale amongst PCT staff
is very low, and there has been evidence that senior staff are
already leaving, including two chief executives in Derbyshire
and North East Lincolnshire.[40]
1.6 The interface between the Public Health
Service and commissioning will be crucial. It is imperative that
there is continued public health input into commissioning and,
reciprocally, continued GP input into public health strategies.
1.7 When commissioning national and regional
specialised services, the NHS Commissioning Board should actively
seek the assistance of appropriate secondary and tertiary care
specialists and GPs from consortia. The Board will not be able
to make informed decisions without involving them.
1.8 The BMA has asked for more details from
the Government on the proposals contained within the White Paper,
since it is difficult to comment extensively on some of the proposals
until that is made available.
2. CLINICAL ENGAGEMENT
IN COMMISSIONING
2.1 We believe that collaboration rather
than competition should be the focus of the reforms. Effective
multi-professional involvement in commissioning is vital to achieve
seamless and cost-effective patient care. Greater competition
in the NHS is likely to lead to increased fragmentation of services,
and competition within and between professional groups could lead
to a reduction in the involvement of allied health professionals
in consortia.[41]
2.2 The BMA strongly supports greater clinical
involvement in the design and management of the clinical services.
Consortia will have to develop local systems and work closely
with colleagues from secondary care and public health, as well
as others such as medical academics and social care professionals,
to enable evidence-based, integrated decision-making and ensure
sensible care pathways are in place. This will help to promote
multi-professional inclusivity and support and build confidence
among healthcare professionals and patients in the decisions of
GP-led consortia. Consortia will need to design mechanisms to
resolve any conflicts that might develop along professional lines
in the course of multi-professional working.
2.3 In order to support commissioning consortia,
data must be accurate, timely, quality-checked and validated.
The data sets should include information on expenditure, referrals,
prescribing and clinical performance across secondary and community
care. It is the BMA's view that the provision of such information
to practice-based commissioners by PCTs in the past has been poor.
Consortia will only be able to commission effectively when the
relevant information is to hand.
How will commissioners address issues of clinical
practice variation?
2.4 When commissioning services, consortia
will take due account of referral patterns and patient preferences
expressed by individual practices, and where possible informed
by practice level data. They will not have a role in handling
variations in clinical practice under primary care contracts—this
will be a matter for G/PMS contracts that are the responsibility
of the NHS Commissioning Board. The BMA does have some concerns
about the lack of detail about the governance arrangements for
the provider function of GP practices. Consortia will, however,
design clinical pathways and protocols for the services they commission
and practices will presumably sign up to these. If quality is
a concern, then this would be a matter for the Care Quality Commission
(CQC).
3. HOW OPEN
WILL THE
SYSTEM BE
TO NEW
ENTRANTS?
3.1 We believe that current NHS providers
should remain the principal providers for primary and secondary
care, to ensure continuity of care, the development of productive
long-term relationships and financial sustainability. The "any
willing provider" policy, detailed in the White Paper, has
the capacity to undermine local health economies by replacing
existing multi-service natural monopolies with a plethora of smaller
units providing more limited ranges of services. This would radically
affect both the efficiency and value for money of the NHS. Where
services are not of the required standard or where the current
providers are not able to provide a service, then commissioners
will wish to look to alternative providers to do. However, we
believe that frequent, unnecessary changes of provider would be
detrimental for the reasons expressed above.
3.2 Consortia will require support from
those who already have direct experience of commissioning. Consortia
need to develop a local infrastructure of personnel who are accountable
within the commissioning process. Many of these can be drawn from
current PCT, SHA and public health staff who have local knowledge,
experience, and appropriate expertise and skills.
4. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
How will patients make their voice heard or their
choice effective?
4.1 We have concerns that the Government's
White Paper places undue and misplaced emphasis on the continuation
and extension of the patient choice agenda. This has not improved
clinical outcomes, or given patients the choices they actually
want. We support meaningful choices for patients, and the evidence
suggests that most of all, patients would want high-quality providers
close to where they live and to receive timely, competent diagnosis
and treatment, and ongoing support when necessary.
4.2 The National Association for Patient
Participation (NAPP) is currently mapping Patient Participation
Groups. This work could feed into the NHS Commissioning Board.
Where piloting and evaluation shows them to be beneficial to patient
care, appropriate Patient Reported Outcome Measures (PROMs) could
be built into contracts and published on the NHS Choices website.
Where services are commissioned from primary-care providers these
services should be required to undertake PROMs review in the same
way as the services of other providers.
4.3 Patients should be able to observe consortia
meetings and have an opportunity to submit views and ask questions,
while Patient Participation Groups should be encouraged at a practice
level. Consortia might appoint a patient or public representative,
to ensure the patient voice is at the core of the developing consortia
mode, and patient representatives might also be involved in the
creation and development of patient pathways. Consortia will also
be expected to have close links with their local authorities and
this should help to ensure both scrutiny and that the public voice
is heard.
4.4 It will be necessary for a formal process
to be developed to enable consortia to consider the views of all
relevant stakeholders and the public in relation to significant
commissioning decisions. Partnership with local authorities will
be vital to enabling this process in some areas, such as mental
health, children's services and geriatrics. The Government must
consider the time and resource constraints placed on consortia,
and the limitations this may place on any process developed.
What will be the role of the NHS Commissioning
Board?
4.5 At the moment the role of the NHS Commissioning
Board is unclear. We are concerned that the gap between a national
NHS Commissioning Board and locally based consortia will be too
great, and there is a risk that the Board could be too remote
from individual consortia for the two to be able to liaise effectively.
This will become even more of a concern if many small consortia
are formed. It may be appropriate for the Board to have local
outposts of some kind, to liaise with consortia, provided this
does not compromise efficiency savings gained through the abolition
of SHAs and does not replicate the bureaucratic performance management
functions of SHAs.
4.6 The NHS Commissioning Board, while holding
consortia to account, should also have a supportive role in helping
local consortia commission effectively and in developing ways
of enabling wider collaboration between consortia, particularly
when commissioning low volume or regional specialised services.
Training events for commissioners should be held on a regional
and national basis, as appropriate.
4.7 The Board should review local commissioning
practices to ensure that consortia-commissioned services are provided
at an appropriate and equitable level across the NHS.
What legal framework will be required to underpin
commissioning consortia?
4.8 Consortia will be public bodies and
therefore will be recognised and governed by statute. The detail
behind this has yet to be published.
4.9 It is likely that GP-led consortia will
have a multitude of legal and financial responsibilities, including
management of finances and budgets, bidding and tendering issues
and compliance with any legislation that is in place to cater
for the new processes. Practices and consortia will need to understand
the implications of managing and employing staff who work for
a future consortium, as well as any relevant employment issues
such as Transfer of Undertakings (Protection of Employment) Regulations
(TUPE), redundancies, unfair dismissal etc. This may be relevant
if, for example, current PCT functions or part of a PCT's functions
are transferred to GP consortia, leading to a transfer of relevant
staff.
4.10 As consortia will be expected to commission
services and will have the freedom to use resources to achieve
cost-effective outcomes, they will need to have knowledge of how
to tender for services legally. Consortia, as public bodies, will
be subject to the rules of public procurement.
How will commissioning interface with the Public
Health Service?
4.11 The interface between the Public Health
Service and commissioning will be crucial. It is imperative that
public health is embedded in the commissioning process. We believe
public health specialists are uniquely placed to work in partnership
with and assist GPs to make the best value commissioning decisions,
given their bird's eye view of healthcare needs and ability to
analyse health services information from a population perspective.
In addition, public health doctors are experienced at working
closely with secondary and tertiary care clinicians, to ensure
best-quality clinical outcomes, which will be of great value in
the commissioning process.
How will commissioning interface with HealthWatch?
4.12 Due to the lack of detail within the
White Paper proposals, we have been unable to give detailed consideration
to how commissioning will interface with HealthWatch. We have
highlighted to the Government that many GP practices have already
taken the initiative in this area and encouraged the development
of Patient Participation Groups. This has been of considerable
benefit to both patients and practices, and we would hope that
the roles of independent Patient Participation Groups and local
HealthWatch groups would be complementary.
5. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
How will any new structures promote the integration
of health and social care?
5.1 The BMA has urged the Government to
provide a clear definition of social care, as it is vital that
the public, commissioning groups and local authorities are aware
which services will be provided by the NHS, free at the point
of delivery, and which services will not. This would enable better
joint commissioning, help GP-led consortia to be able to invest
appropriately in preventative services, and clarify, to an extent,
the sorts of services people might need to save to pay for.
5.2 We support greater collaboration between
health and social care services[42]
and the breaking down of burdensome barriers between health and
social care that do not benefit patients. In order to create seamless
integration between health and social care, new pathways will
be required to link services to facilitate movement of patients
between different care sectors. However, the very real funding
issues associated with such moves will need to be addressed, particularly
in an environment of serious financial challenge which will be
felt even more severely in social care than in health care. We
have concerns that health funding will be used to fill the gap
in social care funding long before the benefits of a new approach
could be realised.
5.3 We would like to see a more strategic
approach to the challenges facing health and social care services
in terms of life expectancy and current health trends. Social
and environmental factors which lie outside the healthcare system
are the major cause of health inequalities and these will increase
unless the root causes are addressed. We welcome the commitment
to review the long-term care of the elderly.
6. WHAT WILL
BE THE
ROLE OF
LOCAL AUTHORITIES
IN PUBLIC
HEALTH AND
COMMISSIONING DECISIONS?
6.1 The BMA notes this year's 20% reduction
in local authority funding with grave concern.[43]
It is likely that care services provided by local authorities
will be affected by budget cuts in the coming months and years,
which will make it more difficult to commission integrated care
pathways and services and meet the wider support needs of patients.
6.2 Local authorities will play a key role
in the provision of public health and in other commissioning decisions.
The Directors of Public Health, situated in local authorities,
should be an accredited specialist in public health. As such,
they should be recognised by the local authority as the principal
officer accountable for all matters related to population health
and the principal advocate in local health systems for health
improvement and reducing health inequalities. The BMA would like
the office of Director of Public Health to be a statutory appointment
as an independent advocate for the health of a defined population.[44]
Furthermore, the Director of Public Health should be an executive
appointment reporting directly to the chief executive of the local
authority.
7. TRANSITIONAL
ARRANGEMENTS
7.1 The winding down of PCTs and SHAs must
be managed extremely carefully if confusion and inefficiency is
to be avoided in the current system's final years and months.
The task of PCTs and SHAs will be made additionally difficult
because they will be required to take on additional short-term
work to support the transition. There is a risk that, if too many
of the best managers leave their current employment too soon,
there will not only be a reduction in workforce numbers, but also
a loss of corporate memory which will leave those staff left at
PCTs and SHAs struggling to cope effectively with an increased
workload. We are extremely alarmed at the potential vacuum that
could occur. If handled poorly, there is a real risk of PCT implosion.
The BMA has grave concerns over the possibility that PCTs may
be phased out before consortia are properly established and would
suggest that PCTs should be retained until consortia are fully
operational. Ironically, where PCT management is good and there
have been good relationships between PCT and local practices,
transitional arrangements are likely to be much more straight-forward
than in areas where both management and relationships are poor.
These areas will require much greater transitional support.
8. RESOURCE ALLOCATION
How will resources be allocated between commissioners?
8.1 Consortia must have budgets that are
appropriate for their commissioning populations. Any moves towards
a "fair share" budget that is proportional to the commissioning
group's needs must be handled sensitively. Historic NHS funding
is entrenched in local health economies and any sudden move away
from this would destabilise health systems that are vulnerable
to small shifts in funding. The previous Government had implicitly
recognised this difficulty by slowing the move from historic indicative
practice-based commissioning (PBC) budgets to "fair share"
indicative PBC budgets, which were supposed to reflect more fairly
the health needs of a locality.[45]
8.2 Developing a commissioning budget that
realistically reflects the existing and likely health needs of
a local population and enables consortia to commission all of
their patients' care will be very difficult, and commissioning
budgets should move towards this goal slowly. Any budget formula
must be sufficiently sensitive, or consortia could be held responsible
for overspends which have more to do with faulty budget setting
rather than ineffective or flawed, commissioning. Budgets should
be agreed by consortia and a dispute process put in place in the
event that the budget cannot be agreed.
8.3 There should be no expectation that
an effective commissioning process will generate surplus resources
on a regular basis. Although services must be commissioned with
reference to available NHS resources, patient demand can vary
year on year and an expectation of budget surplus is unrealistic.
8.4 All debts outwith the control of consortia,
particularly structural debt tied in with private financer initiatives
(PFI), should be dealt with separately by a central fund that
top-sliced the budget allocated to the Commissioning Board.
What arrangements are proposed for risk sharing
between commissioners?
8.5 Risk management must enable consortia
to pool commissioning risk. The smaller consortia will naturally
face the greatest risks. The current proposals seem to differ
little from existing arrangements in PCTs. There appears to be
no incentive not to spend any remaining funds at the end of the
financial year, on items or short-term projects that are of little
long-term benefit, as there remains a risk that unspent money
will not be carried over into the next year.
9. SPECIALIST
SERVICES
What arrangements are proposed for commissioning
of specialist services?
9.1 When commissioning national and regional
specialised services, the NHS Commissioning Board should actively
seek the assistance of appropriate tertiary and secondary care
specialists and GPs from consortia. The Board will not be able
to make informed decisions without involving local consortia.
A mechanism is required to enable consortia to send representatives
and specialists to the Board to facilitate locally relevant decision
making. The Board should also encourage coordination between consortia
across areas within a region to ensure that the commissioning
of specialised services fits with the commissioning plans of other
consortia. It would also make financial sense to have such cross-consortia
coordination.
9.2 For the commissioning of other, more
locally based, specialist services (those which not all practices
will be able to offer and where a formal procurement process will
be necessary), it may be appropriate to establish a split in the
commissioning functions of the consortium between the designing
of a care pathway and the contracting and procurement of services.
The design of the care pathway would naturally be clinician-led,
while the procurement function could be carried out by appropriately
skilled and experienced managers employed or engaged by consortia.
They would procure the service from the most appropriate provider
with no bias towards (or against) any members of the consortium
who were also potential providers. This split would ensure that
clinicians involved in commissioning decisions had no influence
over the actual procurement of services, and as such would help
to avoid conflicts of interest.
9.3 The BMA is not convinced by the Government's
proposals that maternity services should be commissioned by the
NHS Commissioning Board and believes it would be more appropriate
for them to be commissioned at consortium level, though there
may be the need for wider oversight. Recent research by The King's
Fund highlighted that GPs' lack of involvement in maternity care
is undermining the care of pregnant women and their families and
suggested that shared care, between GPs and midwives and obstetricians,
could result in better co-ordination of care, particularly for
women with ongoing medical conditions and complicated medical
histories.
October 2010
39 The paper "BMA principles for effective and
successful commissioning" can be found online: www.bma.org.uk/employmentandcontracts/independent_contractors/commissioning_service_provision/bmaeffectcomm.jsp Back
40
"BMA warns of primary care trust implosion"
The Financial Times, Friday 1 October 2010. Available at http://www.ft.com/cms/s/0/b0c61408-ccb4-11df-a1eb-00144feab49a,dwp_uuid=debe9554-8da0-11df-b5e2-00144feab49a.html Back
41
House of Commons, Health Committee, Commissioning, Fourth Report
of Session 2009-10, Vol. 1, 2010. Back
42
Annual Representative Meeting (ARM) 126. BMA, 2000. Back
43
"Local government to bear brunt of £6.2bn cuts",
The Guardian. Monday 24 May, 2010. Available at http://www.guardian.co.uk/society/2010/may/24/cuts-local-government-loses-2bn Back
44
BMA (2010) ARM Emergency Motion 2 Back
45
Practice-based commissioning: budget guidance for 2010/1.
Department of Health, 2010. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111057 Back
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