4 Primary Care Commissioning
70. Since publication of the White Paper in July
2010, the Government has maintained a consistent line on separating
the commissioning of primary and secondary care services. The
Government proposes that primary care be commissioned by the NHS
Commissioning Board, and that secondary care will be commissioned
principally by local commissioning bodies. The key concern has
been to guard against the conflicts of interest that could arise
from GPs both commissioning and providing primary care services.
71. In its previous inquiry into commissioning the
Government told the Committee that it proposed that the NHS Commissioning
Board will hold GP practice contracts and will hold GPs to account
on that basis.[56] The
Government envisages that local commissioning bodies will have
a role to play in primary care commissioning in the form of helping
the Board to secure continuous improvement in the quality of primary
care.[57]
72. The Department has told us that the consortia
will undertake this function through:
[…] a collaborative approach to raising
standards in primary care. There is a considerable appetite amongst
consortia pathfinders to explore how this relationship will work,
building on existing good practice in peer-driven quality improvement.[58]
Sir David Nicholson acknowledged the complexity of
the arrangements when he told the Committee:
In terms of the way the Commissioning Board will
function, you are absolutely right that it has to function at
a national level and a relatively local level, which is a challenge
for any organisation. It is inconceivable to me that you will
have a very centralised organisation, all based in London and
Leeds.[59]
There was agreement amongst our witnesses representing
GPs that consortia would have some responsibility for performance
managing their member practices.[60]
However, Dame Barbara Hakin told us:
Of all the things that concern me in thinking
about, "How are we going to get this absolutely right?",
this is one area that still requires attention and needs to be
sorted out by working with the consortia.[61]
73. When questioned about the separation of primary
and secondary care commissioning, the Secretary of State said
"I don't think that this is likely to be a serious problem".[62]
74. With local commissioning bodies being under
the exclusive control of GPs, the Government has found itself
having to devise a system that separates the commissioning of
and provision of primary care services. The cited rationale for
this is to protect GPs from allegations of conflict of interest.
However, the Government has established that the NHS Commissioning
Board will rely on GP-led local commissioning bodies to undertake
the most significant task—that of improving primary care
provision. Given the complexity of this proposal, the Committee
has reviewed the Government's proposals for primary care commissioning.
75. The proposals to separate primary and secondary
care commissioning do not draw a clear line between both activities,
as local commissioning bodies are to have a pivotal role in primary
care commissioning. Dame Barbara was asked if there was a need
for "a single voice for commissioning the delivery of an
integrated service, both primary and secondary care" for
fear of reintroducing "a division between primary and secondary
care".[63]
She told the Committee that how primary care is delivered
has a significant impact on secondary care:
On the other hand, what you say is absolutely
right, that the difference, the kind of provision of primary care
services, is almost the start of the commissioning journey.
The way that primary care is delivered and how well it is
delivered has a huge impact on secondary care services […][64]
[…] We are back to exploring and understanding
the relationship between the Board and the consortia, not having
a situation where we have got the Board over here commissioning
primary care in isolation and the consortia commissioning secondary
care, but a commissioning architecture that works together.[65]
76. The Secretary of State echoed Dame Barbara's
point on integration when he stated to us:
We know that the best way to design those [community
based] services is with primary care and secondary care working
together, and not shift the resources into primary care and let
primary care do it and simply cut the budget at the hospital.[66]
77. Dame Barbara went on to say that, as well as
working to secure the continuous improvement of primary care,
some local commissioning bodies may have significant levels of
delegated responsibility for primary care commissioning.
Inevitably, where it is confident that consortia
are able to, the Board will delegate significant areas of this
commissioning to the consortia […] At the moment we will
need to work through how that happens and I suspect, in the final
analysis, some of it will almost need to be done on a casebycase
basis, depending on the maturity of the consortia and the ability
of the consortia to discharge some of these functions on behalf
of the Board.[67]
78. Crucially, Dame Barbara went on to say that:
You are absolutely right. Once there is confidence
in the governance arrangements of the consortia, it is much easier
to delegate authority for these issues.[68]
79. The Committee finds that the evidence provided
by the Secretary of State and officials runs counter to the direction
of policy. If integration of primary and secondary care commissioning
is important, then separating them in order to support the proposed
system architecture may cause significant harm to the commissioning
system as a whole, and should be reconsidered.
80. The Committee agrees that confidence in the
governance arrangements of local commissioning bodies is key to
them taking on greater responsibility for primary care commissioning.
The Committee considers that arguments for the complex arrangements
set out by the Government fall away if our proposals for significantly
strengthened governance in NHS Commissioning Authorities are accepted.
Given this, the Committee recommends that NHS Commissioning Authorities
should assume responsibility for commissioning the full range
of primary care—including services such as pharmacy and
dentistry as well as general practice—alongside their other
responsibilities.
56 Third Report from the Health Committee, Session
2010-11, Commissioning, HC 513-II, Ev 131 Back
57
Cm 7993, para 4.82 Back
58
Ev 117 Back
59
Q 262 Back
60
Qq 57 to 62 Back
61
Q 517 Back
62
Q 513 Back
63
Ibid. Back
64
Q 513 Back
65
Q 517 Back
66
Q 458 Back
67
Ibid. Back
68
Q 519 Back
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