Written evidence from the Royal College
of General Practitioners (CFI 30)
1. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. Founded in 1952, it has over 42,000 members who are committed
to improving patient care, developing their own skills and promoting
general practice as a discipline. We are an independent professional
body with enormous expertise in patient-centred generalist clinical
care. Through our General Practice Foundation, established by
the RCGP in 2009, we maintain close links with other professionals
working in General Practice, such as practice managers, nurses
and physician assistants.
2. 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:
OBJECT
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.
OUR VISION
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 patient - doctor relationship;
shape the public's health agenda; set standards; promote quality
and advance the role of general practice globally.
OUR PURPOSE
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.
We will do this by:
— 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.
OUR VALUES
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
3. We believe that good commissioning is about
being a good GP. It is about understanding the impact of clinical
decisions on the public's health and purse, understanding the
need to practice safely, effectively and in an evidence based
manner and about understanding how the needs of patients can be
best served through the design of services that meet their needs.
4. In addition, we believe that good commissioning
is about engaging in clinical dialogues with colleagues in health
and social care, and establishing effective channels of communication
between patients, the public and elected representatives. The
RCGP has already advocated the potential advantages of cross-practice
working in its work on federated practice.[67]
5. However, as indicated in a snapshot survey
carried out by the RCGP in January 2011, more than half of GPs
who responded are concerned that the proposed health reforms will
not lead to improvements in care for patients. Over 50% disagreed
that the proposed model of GP commissioning would create a patient-led
NHS. The poll attracted more than 1,800 responses.
RESPONSES TO
SPECIFIC QUESTIONS
The Committee believes it is essential for clinical
engagement in commissioning to draw from as wide a pool of practitioners
as is possible in order to ensure that it delivers maximum benefits
to patients. GPs have an essential role to play as the catalyst
of this process, and under the terms of the Government's changes
they, through the commissioning consortia, will have the statutory
responsibility for commissioning. They should, however, be seen
as generalists who draw on specialist knowledge when required,
not as the ultimate arbiters of all commissioning decisions. The
Committee therefore intends to review the arrangements proposed
for integrating the full range of clinical expertise into
the commissioning process. (Paragraph 96)
6. The RCGP are concerned about the potential
split in the NHS reforms between GPs as commissioners and others
as providers. We recognise the need to work with our specialist
colleagues, other members of the healthcare team, patient groups,
social care professionals and managers to provide safe, effective
and evidence based solutions to meet patients' healthcare needs.
The College also agrees engagement with the wider clinical community
is essential, but accepts that GPs as commissioners will have
to take a lead role.
7. We think that consortia can 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.
8. The College is already working to improve
integrated working between general practice and the mental health
sector. We strongly support the recently established Joint Commissioning
Panel for Mental Health (JCP-MH). This is an initiative between
the Royal College of Psychiatrists, the Royal College of General
Practitioners, the Association of Directors of Adult Social Services,
the NHS Confederation, Rethink, Mind and the National Survivor
and User Network. It will publish a practical framework for mental
health commissioning in April 2011 aimed specifically at those
commissioning during the current transition from PCT to GP Consortia.
9. Time for the development of appropriate skills,
abilities and experience are essential if GPs are to play these
lead roles and deliver high quality services in a changing healthcare
system. To do this, GPs will require the right support and resources
to assist their professional development. The RCGP will provide
guidance, education and training opportunities, and ensure the
sharing of good practice to assist our members to develop the
necessary skills to lead effective clinical primary care within
the context of GP consortia and commissioning groups if these
pass into law.
10. To demonstrate our support for clinician-led
commissioning, RCGP has developed the RCGP Centre for Commissioning
with its funding partner - the NHS Institute for Innovation and
Improvement to equip GPs, practices and GP consortia with the
skills, competencies and expertise required to deliver effective
healthcare commissioning which ensures patient-focused, safe,
high quality healthcare and improved local health outcomes.
11. Our principles for effective commissioning,
laid out in the new RCGP Commissioning Competency Framework, provide
an excellent platform for clinicians and managers across all sectors
to build an even better NHS. The Commissioning Competency Framework
is supported by a new programme of education, training and organisational
development support.
12. It is important to bring on the next generation
of GP clinical leaders. Enhanced opportunities in the early years
of GP training would allow GPs to gain a better understanding
of commissioning, prepare for advocacy, service development and
leadership roles in their local community.
Although the Committee understands the value of
the separation of the commissioner and provider functions
it believes it is important that this function separation is not
allowed to obstruct the development of high quality and cost
effective service solutions. We therefore intend to review
the arrangements proposed in the Bill for reconciling these
conflicts. (Paragraph 102)
13. The RCGP recognises the risk of conflicts
of interest if GPs are to be both commissioners and providers.
However, we believe GPs can manage the provider and the commissioner
roles as long as there is strong governance. Many GPs have a special
interest which can make a major contribution to care pathways
and efficient use of resources. All GPs who are providers will
also be part of commissioning consortia and it would also be a
serious loss of expertise if we cannot use GPs to provide services
that the NHS Commissioning Board would wish to commission. The
situation can be resolved through excellent governance systems
and transparency. Lay representation will be important to assist
identification of any serious conflict of interests and maintain
transparency.
14. Innovation is critical to deliver better
services for patients and deliver the cost savings the NHS requires.
To deliver this innovation GPs should not be constrained from
developing new provider offers which can be commissioned from
their consortia if that is the best way of ensuring high quality
services for patients
15. One of the principles underpinning our values
for effective commissioning is the importance of a trusting and
collaborative relationship between commissioners and providers.
That is part of what it means to put patients at the heart of
the system - deliberately removing artificial boundaries and obstacles
to a cohesive and cooperative NHS.
16. 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.
Creative solutions require a collaborative process, and that's
how we can deliver better services and outcomes for our patients.
The Committee agrees that local engagement with
the commissioning of primary care services is important and therefore
welcomes this development. The potential conflict of interest
between consortia and local primary care providers does however
remain. We therefore intend to review the arrangements proposed
in the bill for the commissioning of primary care services.
(Paragraph 104)
17. As discussed above, we recognise concerns
around the potential conflict of interest between consortia and
providers. Some of our members have suggested that consortia will
need to appoint external representatives to assist in the scrutiny
of their primary care commissioning. A committee elected by GPs
in the consortium may be able to hold the authority.
18. Dentists and optometrists will be providers
as well as commissioners, and we can foresee a synergy of interests
in developing services in the community wherever possible. There
are already cases of local opticians collaborating with Practice
Based Commissioning groups, and we expect this approach to develop.
The commissioning of services that either work
across [health and social care] boundaries, or are intimately
linked is therefore an issue to which the Committee attaches great
importance, and we intend to review the effectiveness of
the structures proposed in the Bill which are designed to safeguard
co-operative arrangements which already exist and promote the
development of new ones. (Paragraph 107)
19. The commissioning of services that work across
boundaries or are linked is welcomed. There is huge potential
to meet people's needs more effectively and promote the best use
of public resources through close working relationships between
local authorities and the NHS, to further integrate health with
social care, and wider services. Crucial to the maintenance and
success of these relationships will be the assembly, analysis
and sharing of examples of best practice. This should be informed
by patient experience
20. A vital part of this will be the availability
of public health information - this can be a powerful driver to
commissioning, but only if there is accurate collation and analysis
of patient data, and effective communication and data sharing
between commissioners and local authorities.
21. As outlined in our response to "Liberating
the NHS: An Information Revolution"[68],
General Practice leads the way in collecting
comprehensive data. When secondary care and other organisations
record data as effectively, and standards for interoperability
are established and implemented, the potential is there for information
to be a vital tool in assisting commissioning for service development.
22. The use of information across organisational
boundaries, and hopefully the coordination of care which will
follow, will be of use to most service users, but particularly
for those with long term conditions, who may currently experience
distress and frustration at the lack of "joined-up thinking".
The co-ordination of care across different organisations is particularly
important in chronic co-morbid conditions.
We intend to review the arrangements proposed
in the Bill to enable commissioning consortia to address these
issues [cross-area collaboration by consortia in reconfiguring
services] effectively; this will include a review of the ability
of the new system to encourage commissioning consortia to
cooperate in achieving the benefits to patients which may be available
from major service reconfiguration. (Paragraph 110)
23. While consortia are likely to carry out a
number of commissioning activities themselves, in some cases,
they may choose to act jointly, for instance by adopting a lead
commissioner model to negotiate and monitor contracts with shared
providers such as large hospital trusts or urgent care providers.
As well as joint working between consortia to commission certain
services, consortia may also choose to buy in support from external
organisations, including Local Authorities and private and voluntary
sector bodies.
24. However, the RCGP has serious concerns that
GP commissioning will create a postcode lottery and greater health
inequalities. Some consortia will provide certain services that
others will not, or cannot afford. The poorer, less mobile patients,
and those with multiple chronic medical problems such as the elderly
and frail, as well as those in remote and rural areas where choice
will continue to be relatively limited, can be expected to lose
services. The RCGP would wish to see emerging consortia having
official encouragement to work collaboratively with their specialist
colleagues and tariffs for integrated care being designed and
supported by appropriate contracts.
The Committee intends to review the arrangements
proposed in the Bill for enabling consortia to reconcile this
potential conflict [between patient choice and commissioning]
by enhancing patient choice at the same time as delivering the
consortium's clinical and financial priorities. (Paragraph 115)
25. We know that many patients value being given
access to information and choices about their healthcare, and
that a culture of shared decision-making (SDM) can be empowering
for patients. There is evidence that appropriate SDM can improve
adherence, lifestyle change and service usage, and the RCGP has
championed this approach for some time.
26. However, there seems to be a major contradiction
between the proposed right of patients to choose from "any
willing provider" and the expectation on commissioning consortia
to put energy into developing excellent local services which integrate
care pathways: integrated care models from the USA align rather
than divide providers. The current emphasis on learning from pathfinder
consortia will not be operating in a fully developed marketplace,
as the envisaged range of providers and the consequences of their
competition have not yet emerged.
27. Our members have highlighted the clear ethical
conflict between the need for managing population health needs
on a limited budget, and meeting individual patient expectations
as they present to their GP. As commissioners, GPs will need to
balance doing what is best for their patients and what makes budgetary
sense for the wider population within their consortium of practices.
This risks misunderstanding and loss of trust by patients who
see GP decisions as financially rather than evidence based. Patients
may play the system and "shop around" (which they will
be encouraged to do by the proposed abolition of practice boundaries)
until they find a more pliant GP. This will result in duplication
of consultation costs at the very least and slowly see a drift
to market fragmentation. This is reason enough for piloting the
reforms so that these fears can be substantiated or confounded
and addressed accordingly, and we would also advocate a site of
primary registration within a geographical boundary near a patient's
home.
28. The policy of "any willing provider"
model appears contradictory to the rationale for commissioning
for whole populations and communities. Some members noted a contradiction
between the emphasis on unlimited individual choice and the policies
on localism, when set against the constraints being put on commissioners.
More than 70% of GPs who responded to our recent survey said they
disagreed or strongly-disagreed that the concept of "any
willing provider" would either achieve a patient-led NHS,
or improve healthcare outcomes. We would prefer "enough excellent
providers" to "any willing", and to be able to
make the decisions about what is needed for our local communities.
29. A further significant concern is the effective
abolition of practice boundaries implied within the White Paper
by the assertion that patients will be able to choose any GP that
they wish to see. As previously argued by the College[69],
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. The geographically defined GP practice area is
relevant in relation to working with other specialised health
services (such as for mental health, midwifery/health visitor/district
nurse) and local authorities (social care and public health) so
abolition will undermine interaction with these other services.
The Committee does not find the current stance
on patient and public engagement in commissioning persuasive.
The National Health Service uses taxpayers' resources to deliver
a service in which a high proportion of citizens take a close
interest both as taxpayers and actual or potential patients. While
the Department may be right to point out that there is no special
virtue in uniformity of structure, the Committee regards the principle
that there should be greater accountability by commissioners for
their commissioning decisions as important. We therefore intend
to review the arrangements for local accountability proposed
in the Bill. (Paragraph 118)
30. We accept the principle that patients and
the public are involved from the outset in every aspect of evaluating
needs, planning services and delivering care. Through sharing
information, decisions, power and responsibility with our communities,
we believe patients will see real improvements.
31. As discussed above, there is huge potential
to meet people's needs more effectively and promote the best use
of public resources through close working relationships between
local authorities and the NHS, to further integrate health with
social care, and wider services.
32. 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.
33. We 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.
The Government must support consortia and existing
commissioning organisations to form clear and credible plans for
debt eradication and for tackling structural deficits
within their local health economy. The Committee intends to further
review this issue in its further work. (Paragraph 123)
34. We are aware that GPs have been asked to
take on an enormous new set of responsibilities and challenges.
In addition to holding concerns about the damaging effect of dismantling
much of what is good about the present system, we believe it is
vital to ensure GPs are supported in their new role and protected
from unfair criticism arising from financial constraints. GPs
will need to set aside time from patient care in order to take
up new responsibilities in commissioning consortia. The government
must ensure that proper resources are provided for the running
of consortia.
35. We welcome that the Health and Social Care
Bill proposes a statutory failure regime for commissioners, which
will include powers for the NHS Commissioning Board to establish
and maintain a risk pool with consortia, to issue guidance to
consortia on financial risk management and to intervene where
there is a significant risk of financial failure.
36. Anything that detracts from GPs being able
to deliver excellent holistic care to patients is of concern to
the RCGP. The Government must therefore ensure mechanisms are
in place so that consortia do not start off with inherited debit.
CONCLUDING COMMENTS
37. The RCGP supports stronger clinical leadership
for commissioning services for patients and for those patients
and their communities to enjoy health care which meets the local
needs. However, we have concerns about the pace and extent of
the reforms against the context of efficiency cuts and the lack
of evidence to support many of the reforms and little commitment
to pilot or trial the changes.
38. Effective Consortia will be built on deep
engagement with clinicians, patients and the public, in which
information is shared openly, values and priorities are developed
in collaboration, and services are delivered in a context in which
patient empowerment and community organising are key drivers for
change.
Professor Amanda Howe MA MD MEd FRCGP
Honorary Secretary of Council
February 2011
67 The Future Direction of General Practice: a roadmap.
London: RCGP, 2007. http://www.rcgp.org.uk/PDF/Roadmap_embargoed%2011am%2013%20Sept.pdf;
Primary Care Federations - Putting patients first. London: RCGP,
2008. http://www.rcgp.org.uk/PDF/Primary%20Care%20Federations%20document.pdf Back
68
RCGP Response to Liberating the NHS: An Information Revolution.
January 2011. http://www.rcgp.org.uk/pdf/RCGP_response_to_An_Information_Revolution.pdf Back
69
RCGP response to Department of Health consultation "Your
Choice of GP Practice". 2010. Back
| 
