Written evidence from the Royal College
of General Practitioners (COM 122)
1. I write with regard to the Health Committee's
Inquiry into commissioning.
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education, training, research,
and clinical standards. Founded in 1952, the RCGP has over 42,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
3. The College welcomes the opportunity
to respond to this inquiry, which has been drawn up with reference
to the College's core statement of object, vision, purpose and
values:
The Royal College of General Practitioners is
a registered charity with the object:
To encourage, foster and maintain the
highest possible standards in general medical practice and for
that purpose to take or join with others in taking any steps consistent
with the charitable nature of that object which may assist towards
the same.
A world where excellent person centred care
in general practice is at the heart of healthcare.
Our role is to be the voice for General Practice
in order to: promote the unique doctor-patient relationship; shape
the public's health agenda; set standards; promote quality and
advance the role of general practice globally.
To improve the quality of healthcare by ensuring
the highest standards for general practice, the promotion of the
best health outcomes for patients and the public and by promoting
GPs as the heart and the hub of health services.
— ensuring the development of high quality
general practitioners in partnership with patients and carers;
— advancing and promoting the academic
discipline and science of general practice;
— promoting the unique doctor-patient relationship;
— shaping the public health agenda and
addressing health inequalities; and
— being the voice of General Practice.
The RCGP is the heart and voice of General Practice
and as such:
— We protect the principle of holistic
generalist care which is integrated around the needs of and partnership
with patients.
— We are committed to equitable access
to, and delivery of, high quality and effective primary healthcare
for all.
— We are committed to the theoretical
and practical development of general practice.
GENERAL RESPONSE
4. The RCGP has responded[46]
separately to the consultations on the Government's White Paper
Equity and Excellence: liberating the NHS and to Liberating
the NHS: commissioning for patients. Our response to the Health
Committee's Inquiry should be read in the context of our overall
views on the proposed reforms to the NHS.
5. The College notes the Government's definition
of the characteristics of good commissioning, in Liberating
the NHS: commissioning for patients[47]
(paragraph 1.6), as: to ensure high-quality outcomes; maximise
patient choice; and secure efficient use of NHS resources. We
are keen to engage with these priorities and agree with the Department
of Health that GPs, as clinicians who work alongside patients
and public in the community, are in an ideal position to influence
the direction of service development in the NHS.
6. We see that Commissioning for Patients
makes a very strong case for the Government's chosen model
of GP consortia commissioning services, supported by an NHS Commissioning
Board (NHSCB). This model involves a very radical alteration in
the structures of the NHS, with many attendant costs and outcomes
which are necessarily uncertain. We would urge that other models
for commissioning services be considered. For example, some of
our members have questioned whether commissioning of services
by Primary Care Trusts (PCTs) could not be allowed to continue,
but with far greater and statutorily guaranteed involvement by
GPs and other clinicians at board level, as well as greater patient/public
involvement. This might lead to many of the benefits envisaged
in Liberating the NHS,[48]
but without some of the risks.
7. Many of our members, particularly some
of those in the early years of their careers, are enthusiastic
to take up roles in GP commissioning. They recognise the inadequacies
in the current system and are confident, as are we, that they
will be able to make better choices and achieve the goals identified
in paragraph 5 above. That enthusiasm, however, is not universal,
and is influenced by pre-existing experience with practice-based
commissioning and the successfulness or otherwise of relationships
with local PCTs. We would urge caution and flexibility in imposing
the timeline for change to the proposed new model, to ensure that
GPs in all areas are able to take on their new responsibilities,
and to ensure that examples of current good practice by PCTs are
retained.
8. If, as seems likely, the proposals in
Liberating the NHS: commissioning for patients are to be
implemented, we would urge that the Department of Health provide
much more detailed guidance on the intended structures and governance
models of GP consortia. Some of our members are reluctant or cautious
with regards to the proposals, and in part this is down to a perceived
lack of detail. GPs are being asked to stake their careers, their
practices and the wellbeing of their patients on a new structure
that has not been extensively trialled—they would find greater
detail and specificity in the proposals reassuring.
9. The funding of GP consortia will be a
critical factor in determining their success. The lack of detail
as to the funding formulas to be applied, the level of the management
allowance, the relationship between consortia and practice income,
and the potential impact of current PCT budget deficits on the
finances of nascent consortia are all matters of concern for our
members. It is difficult for us to endorse these proposals as
enthusiastically as we might whilst these issues and their consequences
remain unclear.
10. It is essential that GPs' role as commissioners
must not be allowed to detract from the crucial doctor-patient
relationship and GPs' longstanding role as advocates for their
patients. We expect GPs to conduct themselves with the utmost
probity, but there will still be the need for strict governance
rules to ensure that all commissioning decisions are open and
fully scrutinised.
11 As stated above, the College is committed
to the education of GPs and the development of the role of General
Practice. We are already actively producing material[49]
that will support GPs in better commissioning. If GP commissioning
goes ahead, we expect to be at the forefront of providing and
accrediting education and training opportunities for our members,
with the goal that all GPs, whether at the start or near the end
of their careers, and whether taking major or minor roles in commissioning
services, are supremely well equipped to meet the challenges of
this new environment.
RESPONSES TO
SPECIFIC QUESTIONS
Clinical engagement in commissioning:
— How will commissioners access
the information and clinical expertise required to make high quality
decisions about the shape of clinical services?
— How will commissioners address
issues of clinical practice variation?
— How will GPs engage with
their colleagues within a consortium and how will consortia engage
with the wider clinical community?
12. Clinical engagement is critical to the
success of commissioning both to improve quality of care and to
make savings which can fund innovation. For this to happen it
is vital that all GPs (and in fact all clinicians) are aware of
their individual and collective responsibility for resource allocation
and demand management. A small percentage of GPs will be required
to take direct leadership roles in commissioning. This is a new
demand for all, while at the same time undertaking existing roles,
including training, clinical work, and running practices.
13. New GP consortia will clearly need excellent
administrative staff. They will also need leaders who are committed
to GP commissioning and have sufficient education and ability
in this area. They will need the financial support to allow experienced
GPs to be replaced in clinical settings for sessions where they
are taken away from front-line clinical work, and this needs to
be kept to a minimum. Lead GPs will need sophisticated, multi-level
training, information and guidance from central bodies such as
the NHSCB and the RCGP.
14. Consortia will need to develop systems
for local peer review against relevant criteria—presumably
related to aspects of the Outcomes Framework and defined in partnership
with patients and the public. Each consortium will need the capacity
to collate, analyse, and compare data practice-by-practice.
How open will the system be to new entrants?
— Will care providers be free
to offer new solutions which offer higher clinical quality, better
patient experience or better value?
— Will commissioners be free
to access new commissioning expertise?
— Will potential new entrants
be free to offer alternative commissioning models?
— What arrangements will be made
to encourage the Third Sector both as commissioners and providers?
15. There are grave concerns, expressed
by many of our membership, about the level of engagement of the
for-profit sector in the re-structured NHS. We recognise that
for-profit companies may have much to bring to the NHS in terms
of efficiency and management experience. The likely involvement
of such businesses, both in providing support services to commissioning
consortia and, as a result of the "any willing provider"
stipulation, supplanting some existing primary and secondary care
providers, may undermine the essential ethos of the NHS—to
provide equitable, high quality healthcare for all, free at the
point of use. The injunction that there will be no bail-out for
failed commissioners would seem also to offer the possibility
of private companies supplanting GP consortia. The College is
open-minded with regards to engagement with the for-profit sector
but would also wish to restate the value of partnership between
GPs and existing secondary care organisations. Collaboration,
we believe, far more so than competition, is the model which will
result in the best possible outcome for NHS patients.
16. Although we understand the rationale
for some choice among healthcare providers, factors that make
for successful local healthcare, such as providing continuity
of care, effective pathways and strong relationships between primary
and secondary care will not be measured if there is a literal
application of competition rules. The commissioning framework
should also take account of these factors and be prepared to demonstrate
flexibility.
17. Under the new arrangements GP practices
will continue to be providers of primary care as independent contractors.
Practices can work together in federations, and in partnership
with other providers (including local specialists, third sector
organisations or private providers), to provide health services
commissioned by the GP consortia. These Federations could also
have a vital role in supporting GPs in the new world of health
care provision.
Accountability for commissioning decisions
— How will patients make their
voice heard or their choice effective?
— What will be the role of
the NHS Commissioning Board?
— What legal framework will be
required to underpin commissioning consortia?
— How will commissioning interface
with the Public Health Service?
— How will commissioning interface
with Health Watch?
— Where will the "buck stop"
when commissioners face hard choices?
18. We fully support the need for "no
decision about me without me", and our own best practice
aims to share decision making with all our patients. So patients
should be able to make their voice heard to individual clinicians,
to practices, and via HealthWatch. However, complete autonomy
across different providers can be costly and lead to duplication.
Many of our members have grave misgivings about the apparent emphasis
on "choice" in service provision in primary care. We
feel that the policy of free choice of GP practice, in particular,
is potentially damaging and not warranted by patient demand. We
would argue that patient choice in primary care may be better
accommodated by the development of GP Federations[50]
and other local measures. Clear and transparent procurement processes
which show that clinical decisions are not influenced by personal
gain will be essential.
19. Clearly the constitution of local HealthWatch
is critical in ensuring the patients' voice is heard. If these
groups are merely constituted so as to reflect `the same old voices',
we will miss the opportunity to reflect all groups within local
communities and risk perpetuating health inequalities and existing
failures of inclusion.
20. We agree with the need for the establishment
of the NHS Commissioning Board (NHSCB), and while the precise
division of responsibilities between this and the commissioning
consortia is not always clear, and will presumably evolve, the
broad proposals seem sensible.
21. We would envisage the NHSCB having a
collaborative and supportive relationship in this respect, based
on the sharing of information on best practice and the development
of meaningful goals related to the Outcomes Framework, rather
than a policing role.
22. In monitoring primary care performance,
it will be crucial for the NHSCB and consortia to bear in mind
particular circumstances which may impact on specific practices—for
example the vulnerability of small practices to apparent statistical
anomalies. Other factors, such as sociodemographic diversity or
rurality, also alter practice activity, and all those assessing
practice performance need a sophisticated appreciation of these
issues (hence the need for some public health competencies in
commissioning).
23. The proposals for local HealthWatch
to engage with local authorities and GP consortia, provided they
are established sensibly and with a view to being fully representative,
are a useful start as a way to get patients involved in commissioning
decisions. We would also support the inclusion of lay members
on consortia boards, and association with patient groups at practice
and consortium level, though the viability of these will depend
on the management allowance apportioned to consortia. If consortia
and the NHSCB publish full financial and other information, such
as their vision, aims and principles, and the public are educated
in the opportunities and limits of commissioning, there will be
a real opportunity for local public scrutiny and engagement with
decisions made.
Integration of health and social care
— How will any new structures
promote the integration of health and social care?
— What arrangements are proposed
for shared health and social care budgets?
24. The proposals offer GPs a greater chance
to work more closely with local authorities, social services and
specialist providers. The RCGP believes that integrated working
between health and social care is important to ensure a joined-up
and holistic approach is taken to the delivery of care in the
community and the effective reduction of health inequalities.
25. Health and social care budgets are tight
now. It is likely that they will become tighter with increased
demands and pressures on them. As pressure increases on the NHS
and social care services budgets it is ever more essential that
services are delivered as efficiently as possible. It is hoped
that greater clarification will be provided by the Government's
forthcoming proposals for the future funding of social care and
the White Paper on public health later this year.
What will be the role of local authorities in
public health and commissioning decisions?
26. We support the devolution of NHS responsibilities
to local authorities and their role, through local health and
wellbeing boards, in assisting coordination between healthcare,
public health and social care providers. These seem like sensible
measures that will increase the democratic legitimacy of healthcare
services, and GPs look forward to working with local authorities
to support public health. We are concerned, however, that at a
time of serious financial strain it may be more difficult for
local authorities to allocate the appropriate resources to this
role, and that this may result in outcomes that are less impressive,
and above all less equal, than might otherwise be hoped for.
27. There is a challenge in the proposals,
in that GP consortia may well not be coterminous with local authorities—each
consortium may need to work with the Health and Wellbeing Boards,
Directors of Public Health and HealthWatch organisations of more
than one local authority, and vice versa. This presents a bureaucratic
challenge, though not an insurmountable one if adequately funded.
How will the new arrangements strengthen commissioners
against provider interests?
28. The White Paper states that there must
be a clear separation between the commissioner and the provider.
Local specialist colleagues might be very valuable in service
redesign, but they should not be excluded from a tender under
the "any willing provider" rule. Nor should GPs who
offer a referral service within their own area be excluded as
they may provide a cost effective local service.
29. Additionally there are concerns that
consortia maybe too small to be effective in negotiating with
dominant providers. In this case, smaller population consortia
may need to join with others with shared interests, to ensure
their bargaining power is effective and to manage financial risk.
30. One of the principles underpinning commissioning,
proposed by the RCGP,[51]
is a system of trust between provider and commissioner with a
minimum amount of onerous reporting and accounting.
31. Some of our members have suggested that
consortia will need to appoint external organisations to supervise
or approve their primary care commissioning. Alternatively, a
committee elected by GPs in the consortium may be able to hold
the authority.
32. Additionally, consortia should be obliged
to report contract profiles, and publish financial and patient
satisfaction and outcome information, so that patients and the
NHSCB can hold them to account.
How will vulnerable groups of patients be provided
for under this system?
33. Many of our members do have concerns
that the proposals around commissioning consortia have the potential
to increase health inequalities within and between commissioning
areas. Health inequalities should be explicitly featured in the
proposed Outcomes Framework, with outcomes mapped across social
groups. Strong input from patient groups and local authorities
into the local Joint Strategic Needs Assessment (JSNA), if conducted
appropriately, should also give consortia goals to aim for. Additionally,
there needs to be sharing and encouragement of best practice in
this area, guided by national organisations such as the RCGP or
the Commissioning Board itself.
34. It is important that when GP commissioning
groups consider the health of their local populations they commission
appropriate services for their vulnerable citizens, this includes
the homeless, travellers, sex workers, and asylum seekers (the
inclusivity agenda). While there are good examples of care provided
to these groups across the country there are many areas where
it is poor. The White Paper, which gives GPs leadership roles
in commissioning, provides the opportunity to address this through
commissioning as well as through closer working with local government
and the third sector.
35. Another significant concern is the effective
abolition of practice boundaries implie within the White Paper
by the assertion that patients will be able to choose any GP that
they wish to see. As already argued in the College's response
to Department of Health's "Your Choice of GP" consultation,
this will have a significant impact on GP workload and continuity
of care, exacerbate existing inequalities between practices, and
potentially place a terminal strain on some, particularly rural,
local services. Clarification is needed on how geographic commissioning
would work if practice boundaries are abolished.
How will the proposed system facilitate service
reconfiguration?
Transitional arrangements
— Will the new arrangements
safeguard current examples of good practice?
— Who will drive innovation during
the transitional period?
— How will transitional costs
(redundancy etc) be minimized?
36. We would hope for a particular engagement
from the NHSCB in supporting lead GP commissioners in the initial
stages of the transfer of commissioning responsibilities. Input
at this stage could be very helpful in avoiding damaging early
errors. It should work with the RCGP and other bodies to develop
and share guidance on best practice.
37. Consortia will also need to be engaged
in providing effective education to their members, so that best
practice can be identified and shared.
38. We are sceptical, however, that the
reforms outlined in Liberating the NHS will save money, in either
the short or long term. There are always enormous costs associated
with reorganisation, in this case the redundancy costs of several
whole tiers of NHS management, as well as the likely expansion
of General Practice staff and facilities. If, as the White Paper
suggests, there will be 500 GP consortia, many of our members
fear that the necessary duplication of management and administrative
costs will actually make the new system more expensive. The loss
of GP sessions from clinical work into service development also
has major resource implications.
Resource Allocation
— How will resources be allocated
between commissioners?
— What arrangements are proposed
for risk sharing between commissioners?
— What arrangements will be made
to safeguard patient care if a commissioner gets into difficulty?
39. Consortia will need to employ support
from finance managers and accountants, for which they will need
adequate financial resources—this should not be underestimated.
And as discussed already they will need considerable education
resources, as financial risk management at the scale of consortia
is beyond the current skill set of most GPs. Beyond this, the
NHSCB should be prepared to step in quickly with support if it
looks like a consortium may be failing financially, and there
should be transparent processes for these situations so that any
risk to continuity of care is avoided. With regards to underspends,
it will be critical not to disincentivise efficiency.
40. Clarity about the budgetary commitments
of consortia, local authorities and other stakeholders, as well
as the level of existing debt which consortia will be expected
to take on, will be essential to ensure there is no collapse in
funding. The Health and Wellbeing Boards should be a viable mechanism
for managing this, and will need to be established early on to
work with consortia during the transition period. The NHSCB will
have a role in ensuring that these relationships are facilitated.
Specialist Services
— What arrangements are proposed
for commissioning of specialist services?
— How will these arrangements
interface with the rest of the system?
41. We feel that consortia will have a role
in facilitating better communication between primary and secondary
care, and developing more stable care pathways, so that standards
of referral may be improved.
42. As indicated earlier, we have concerns
that the emphasis on "any willing provider" for healthcare
will impede the development of effective co-ordinated services.
We are concerned that if consortia are obliged by Monitor, in
its role as a competition regulator, to consider all tenders for
services, it will be more difficult to form the partnerships between
primary and secondary care providers that are the absolute cornerstone
of effective healthcare.
43. Additionally, we would argue strongly
that GP commissioners should be integrally involved in the commissioning
of maternity care. The consequences of lack of GP involvement
in maternity care are discussed in depth in the recent Kings Fund
report.[52]
General Practice has a vital role in antenatal and postnatal care,
as part of the lifelong continuity of care that is central to
the NHS. Many of our members do not see why maternity services
should be primarily the domain of the NHS Commissioning Board
rather than the proposed consortia.
CONCLUDING COMMENTS
44. General Practice is the central plank
in our world-class healthcare system. The College thoroughly agrees
that it makes a great deal of sense to give GPs, with their unique
patient-centred perspective, a central role in commissioning and
directing healthcare services. Whether this is done through the
proposed consortia model, or by involving GPs more centrally in
existing models, we are confident that General Practice can rise
to the challenge and institute changes in service provision that
will improve healthcare outcomes.
October 2010
46 Royal College of General Practitioners. Response
to the Department of Health's consultation Equity and Excellence:
Liberating the NHS. London: RCGP, October 2010. http://www.rcgp.org.uk/policy/liberating_the_nhs.aspx Back
47
Department of Health. Liberating the NHS: commissioning for patient.
London: HMSO, July 2010. Back
48
Department of Health. Equity and Excellence: Liberating the
NHS. London: HMSO, July 2010. Back
49
For example, the new online course Commissioning in General
Practice: improving patient journeys launched on the RCGP
Online Learning Environment (www.elearning.rcgp.org.uk). Back
50
The RCGP has been promoting the creation of Federations of practices
since the publication of its Roadmap document in 2007 (http://www.rcgp.org.uk/PDF/Roadmap_embargoed%2011am%2013%20Sept.pdf). Back
51
Royal College of General Practitioners. Update on Commissioning
Activity. London: RCGP, September 2010. http://www.rcgp.org.uk/pdf/Update_on_Commissioning_Activity.pdf Back
52
Smith A, Shakespeare J, Dixon A. The role of GPs in maternity
care-what does the future hold? London: The King's Fund, 2010.
http://www.kingsfund.org.uk/document.rm?id=8734 Back
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