The path to GP commissioning - April 2011

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"The path to GP commissioning" is based on intelligence gathered and analysed in CommIT, MHP Health Mandate’s propriety commissioning intelligence tracker, which contains detailed information about …

"The path to GP commissioning" is based on intelligence gathered and analysed in CommIT, MHP Health Mandate’s propriety commissioning intelligence tracker, which contains detailed information about the priorities of health service commissioners in England, as well as the outcomes they achieve and the costs they incur.

For more about the report see http://www.mhpc.com/blog/path-gp-commissioning

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  • 1. T ep t t G h ah o Pc mmi inn o s o ig sA a ay i o ted v lp n a d n n ls f h e eo me t n sp ir is f Pp tfi d r o s ri r ie o G ah n e c n o t ot aA r2 1 pi 01 l
  • 2. ContentsIntroduction ............................................................................................................................................ 3Summary of key findings ......................................................................................................................... 4Summary of recommendations .............................................................................................................. 5Background ............................................................................................................................................. 6Methodology........................................................................................................................................... 9Location and size of pathfinder consortia ............................................................................................ 10Areas of focus for pathfinder consortia ................................................................................................ 12Developments in commissioning priorities .......................................................................................... 19Conclusion ............................................................................................................................................. 23References ............................................................................................................................................ 24 1
  • 3. List of figures and tablesFigure 1: Percentage of population covered by GP pathfinder consortia ............................................ 10Figure 2: Consortia population size ...................................................................................................... 11Figure 3: Average size and number of practices in pathfinder consortia ............................................. 11Figure 4: Most common areas of focus ................................................................................................ 13Figure 5: Percentage of consortia focusing on integration with social care......................................... 14Figure 6: Percentage of consortia focusing on care pathways ............................................................. 14Figure 7: Percentage of pathfinder consortia identifying governance as an area of focus .................. 15Figure 8: Proportion of pathfinder consortia in each wave focusing on governance issues ................ 16Figure 9: Commonly selected clinical issues ......................................................................................... 18Figure 10: Issues of consortia focus according to pathfinder wave ..................................................... 21Figure 11: Level of detail in consortia priorities ................................................................................... 22Table 1: Key milestones in developing GP consortia .............................................................................. 6Table 2: Key functions of GP commissioning consortia .......................................................................... 7Table 3: Comparison of PCT and GP consortia priorities ...................................................................... 19 2
  • 4. IntroductionA revolution is taking place in health and social care. Although much of the focus is on the changesproposed in the Health and Social Care Bill and the political debate around them, many of thechanges which will matter most to health and social care delivery for patients are already takingplace across the NHS.NHS organisations are not waiting for legislation to be passed, nor for a policy consensus to emerge.Already structures from the new world are working alongside those from the old. For example, largeareas of the country are now covered by pathfinder GP consortia. These emerging organisationsalready wield a great deal of power even though they do not yet have a statutory footing. FromApril 2011, when the pathfinders begin to receive funding to manage the transition, the NHS willbegin to witness the true impact of the changes to commissioning structures and processes.MHP Health Mandate is a specialist health policy and communications consultancy, advising theNHS, voluntary sector and commercial organisations on some of the highest profile issues of the day.A key part of our role is to provide organisations with strategic policy consultancy and analysis,transforming their objectives into workable policies and in turn ensuring that their priorities aretranslated into positive change in the health service.Anyone in the business of trying to deliver change or influence behaviour in the NHS needs tounderstand the interplay between policy priorities and service delivery, as well as the extent towhich the prioritisation of an issue can be expected to accelerate improvements in the quality andefficiency of care and the health outcomes delivered.Although there remains a great deal of uncertainty about the implications of reform, the issues onwhich pathfinder consortia are choosing to focus provide an early opportunity to examine the areasof health delivery which will pre-occupy the latest generation of commissioners. This reportexamines the early priorities of pathfinder consortia, looks at how the focus of pathfinders is alreadyevolving and assesses the extent to which they represent a break with the past or a continuation ofexisting trends in commissioning.MHP Health Mandate has developed two proprietary sources of intelligence:• CommIT – the commissioning intelligence tracker – contains detailed information of the priorities of health service commissioners in England, as well as the outcomes they achieve and the costs they incur• ProvIT – the provider intelligence tracker – contains information on the quality priorities of providers to the NHS, as well as the incentive systems which are in place to encourage improvementsCommIT and ProvIT enable MHP Health Mandate to support organisations in: (1) engaging withcommissioners and providers on the issues that they care about most, thereby maximising thelikelihood of receiving a positive response; (2) conducting bespoke analyses to analyse trends inhealth service commissioning and delivery; (3) identifying and spreading good practice as well ashighlighting examples of poor practice which need to be challenged; (4) encouraging scrutiny of localprioritisation and variations in the outcomes achieved by this; (5)and developing constructiverecommendations for improving the commissioning and delivery of health services. 3
  • 5. Summary of key findings1. The development of GP pathfinder consortia has been uneven across different geographical areas. The South West Strategic Health Authority (SHA) now has 100% population coverage, whereas the West Midlands only has 40% coverage and the North East 56%2. There is significant variation in population size among consortia. The smallest consortium (East Cliff Practice) covers a population size of 14,000, while the largest will commission services for 693,000 (Gloucestershire)3. GP consortia now cover 70% of the population. Based on this, it can be expected that there will be approximately 260 consortia. This is considerably lower than initial projections about the number of consortia that would be created4. Despite the commitment to increase transparency in health service commissioning, information on the priorities of 28 (15%) consortia has not been published5. The most common areas of focus identified by consortia relate largely to the integration of services, whether it be with social care, community services or improving the care pathway6. Many pathfinder consortia have opted to focus on issues which could lead to efficiency savings, although explicit recognition of the role of the Quality, Innovation, Productivity and Prevention (QIPP) programme is limited7. Some geographical areas have focused on governance issues more than others, indicating that this has either been strongly encouraged by some SHAs or discouraged by others. Governance issues were particularly common amongst commissioners from the second wave, and yet none of the third wave opted to focus on the issue8. Few of the most common areas selected relate to specific conditions or programmes. However, mental health was one of the ten most commonly selected areas of focus. Other commonly identified clinical areas included Chronic Obstructive Pulmonary Disease (COPD), dermatology, diabetes, musculoskeletal conditions and cardiology9. The style and the content of areas of focus identified by consortia are different to the priorities selected by PCTs. However, it is clear that in some cases the areas of focus identified by consortia could help to achieve improvements against the priorities previously identified by PCTs. The extent of continuity, however, varies according to commissioner10. Consortia have become progressively more specific in their areas of focus as the waves of pathfinders have progressed and there has been a step change in the level of detail made publically available in the third wave 4
  • 6. Summary of recommendations1. The Department of Health should remind pathfinder consortia of their responsibility to publicly account for their decisions and priorities. In order to promote accountability, all pathfinder consortia should publish the issues on which they intend to focus2. In order to support the longer term development of consortia, the NHS Commissioning Board should undertake an evaluation of the strengths and weaknesses of different models and population sizes. Consortia should be required to explain to local communities the reasons underpinning their configuration3. Work undertaken by pathfinder consortia on governance issues should be collated and shared, so as to avoid duplication of effort4. Given the focus on improving outcomes, all consortia should be encouraged to identify priorities which directly relate to the quality of care commissioned. Those consortia that have only identified governance or process priorities should now identify clinical priorities as well5. Commissioners should be encouraged to use prioritisation as a mechanism for controlling costs. The Department of Health should, as part of the commissioning outcomes framework, develop nationally validated outcome indicators which address efficiency issues6. As part of guidance to support GPs in delivering on future QOF indicators, NHS Employers and the BMA should provide advice on how a GP’s provider and commissioning responsibilities should align on an issue. This will also be important to help GPs avoid any perception of a conflict of interest7. Consortia should be encouraged to consider clinical areas for improvement when identifying areas of focus. This should be based on an analysis of the needs of their local population8. The Department of Health should set out in clinical outcomes strategies the measures which commissioners may wish to use in assessing their progress on improving services for different conditions9. In order to support consortia in identifying appropriate clinical issues on which to focus, the Department of Health and the NHS Commissioning Board should signpost nationally comparable data in commissioning support packs10. In developing their priorities, consortia should work with local health and wellbeing boards to ensure that progress made on the issues prioritised by PCTs is not lost11. Consortia should be encouraged to develop detailed identified priorities, enabling an assessment to be made of their success in delivering against them12. Priorities should be set out in commissioning plans, which should be published as soon as possible 5
  • 7. BackgroundGP-led commissioning is central to the Government’s reforms to health and social care, with theDepartment of Health arguing that the reform will 1:• Put patients at the heart of everything the NHS does• Focus on continuously improving those things that really matter to patients – especially the outcome of their healthcare• Empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare servicesLiberating the NHS: Legislative framework and next steps set out how the transition from PCTcommissioning to GP-led commissioning will be managed, with the intention that consortia would beresponsible for commissioning the majority of NHS services by April 2013 2.As a first step towards this goal, pathfinder consortia are being introduced across the country to testdifferent arrangements and aid the transition of commissioning responsibilities from PCTs to GPcommissioners 3. The approval process for pathfinder GP consortia has been led by SHAs 4. SimonBurns set out that SHAs will “approve any group of practices to become a pathfinder if they candemonstrate clinical leadership, local authority engagement, and an ability to contribute to thedelivery of the local quality, innovation, productivity and prevention agenda in their locality” 5. This isevident in application forms used by the SHAs, which ask for an outline of consortia vision, as well astheir plans to work closely with other groups locally and their commitment to the QIPP agenda 6.The first wave of pathfinder consortia were announced in December 2010, shortly followed by asecond wave in January 2011 and a third wave in March 2011.Table 1: Key milestones in developing GP consortiaThe path to GP commissioning: key milestones 2010White Paper publication day 12 JulyFirst wave of GP pathfinders 8 DecemberThe Operating Framework for the NHS in England 2011/12 15 DecemberLiberating the NHS: Legislative framework and next steps 15 December 2011Second wave of GP pathfinders 18 JanuaryHealth and Social Care Bill introduced to Parliament 19 JanuaryPCT cluster implementation guidance 31 JanuaryThird wave of GP pathfinders 2 MarchWorking document for GP consortia released 10 MarchEarly implementers of health and wellbeing boards announced 16 MarchGP consortia take on delegated authority 1 AprilShadow NHS Commissioning Board 1 AprilPCT clusters to be formed June 6
  • 8. 2012GP consortia can begin to be authorised to take on as much delegatedauthority as possible (overall accountability still ultimately rests with the AprilPCT)Abolition of SHAs AprilNHS Commissioning Board formally established AprilLocal HealthWatch fully established AprilHealth and Wellbeing Boards established in shadow form April 2013GP consortia take full control of budgets AprilAbolition of PCTs AprilHealth and Wellbeing Boards formally established AprilCentral to the vision for GP consortia is to “ensure that in future, NHS commissioners have a strongerfocus on improving the quality and outcomes of care for patients” 7. All NHS commissioners will beunder a duty to improve quality in the NHS and, in order to support this, the NHS CommissioningBoard will be developing a Commissioning Outcomes Framework to hold GP consortia to account ontheir success in improving outcomes for patients.MHP Health Mandate has already undertaken extensive work examining the extent to which theprioritisation of outcomes can lead to improvements in the quality of health outcomes, as well asthe containment of costs. Commissioning in the new world: an analysis of the impact ofprioritisation on quality, expenditure and outcomes in the health service found that a focus onoutcomes by commissioners can be a highly effective mechanism for driving health serviceimprovement 8. It is therefore encouraging to see the recommendations we made about placing theprioritisation and measurement of outcomes at the heart of the proposed commissioningarrangements 9. We look forward with interest to the forthcoming consultation on how theCommissioning Outcomes Framework will ensure outcomes prioritisation is central to the newperformance management and accountability system.Table 2: Key functions of GP commissioning consortiaKey functions of GP commissioning consortiaThe Functions of GP Commissioning Consortia: A Working Document sets out the proposed range ofGP consortia responsibilities and functions that will apply to consortia from April 2013 onwards,subject to the approval of the Health and Social Care Bill and subject to individual consortia beingestablished as statutory bodies 10.Consortia will be responsible for commissioning a range of healthcare services from community andmaternity services, to commissioning care for specialist conditions such as mental health andlearning disabilities. In their commissioning role, consortia have a duty to co-operate with otherNHS bodies and local authorities, and must have regard to Health and Wellbeing Boards and the NHSCommissioning Board. Consortia must also involve patients and the public in developing,considering and making decisions on any proposals that would have a significant impact on servicedelivery or the range of health services available 11. 7
  • 9. A consortium’s functions must be laid out in a commissioning plan before the start of each financialyear, detailing how it will secure improvement in the quality of services and outcomes for patients.Such plans could include:• Identifying inequalities in access to healthcare services, quality and outcomes• Identifying indicators in the Commissioning Outcomes Framework where there is scope for local improvement• Redesigning services and/or pathways to deliver improved outcomes• Identifying which services will be most effective and cost effective and planning new investmentsConsortia have a duty to monitor the services commissioned with regard to any regulations set bythe NHS Commissioning Board and any ‘standing rules’ that may be required under the Bill.Consortia are required to continually secure improvement in the quality and services for patientswhile operating within a commissioning budget. 8
  • 10. MethodologyAlthough the arrangements for pathfinder consortia are still emerging, it is possible to examine theirareas of focus. This report considers the shape of the pathfinder consortia that are emerging, andthe quality issues on which they are choosing to focus as they develop their organisational capacityand test their new powers.The MHP Health Mandate team has undertaken quantitative analysis of the size, local and focus ofpathfinder GP consortia established by March 2011, including:• Mapping the published priorities of pathfinders• Analysing these priorities for trends according to geography, population size and historical focus• Assessing common priorities and the potential explanations for theseMost pathfinder consortia have published details of their initial areas of focus. In total, this analysisincludes details of 156 out of the 184 pathfinders that have been approved (85%) 12. Given thedebate that has occurred about the accountability of consortia in the new world, it is notable that28 consortia have so far failed to provide information on their areas of focus. This calls into questionthe basis on which they were approved for pathfinder status. The process for approval has variedacross strategic health authorities, as the principles of the national pathfinder programme provideno clear criteria for approval 13.Recommendation 1: The Department of Health should remind pathfinder consortia of theirresponsibility to publicly account for their decisions and priorities. In order to promoteaccountability, all pathfinder consortia should publish the issues on which they intend to focusA great deal of autonomy has been afforded to GP consortia in defining their areas of focus and it istherefore not surprising that there is a wide range of terminology and scope in the priorities thathave been identified. In order to facilitate a meaningful analysis it has therefore been necessary tocategorise some of the areas of focus in to healthcare themes. Further details of the categorisationguidelines adopted are available on request. 9
  • 11. Location and size of pathfinder consortiaConsortia locationThere are now pathfinder consortia in each of England’s Strategic Health Authorities (SHAs) althoughsome SHA areas have seen faster coverage than others. Figure 1 shows the percentage of eachSHA’s population that is covered by pathfinder consortium. The South West has seen the fastestprogress, with pathfinders extending across 100% of the region. This compares with only 40%coverage in the West Midlands and 56% in the North East.Figure 1: Percentage of population covered by GP pathfinder consortiaThese numbers are likely to change rapidly as further pathfinder consortia are approved by theDepartment of Health. Based on current coverage of 70% of the population, we project that therewill be approximately 260 consortia when the entire population of England is covered by pathfinderconsortia 14. This number is significantly lower than some of the numbers originally suggested byhealth commentators and gives an idea of how the commissioning structures may look by April2013 15.Consortia sizeThe Department of Health and Strategic Health Authorities have mandated few criteria for the sizeand shape of GP consortia, with the express intention to pilot different sizes and structures. As such,there is considerable variation in the size and geography of pathfinders as well as much debateabout whether there is an optimal population size.Arguments in favour of larger consortia include greater purchasing power and economies of scale,whereas arguments in favour of smaller sizes include being able to secure a greater focus on thepopulation health needs of particular communities. The Department of Health has recognised the 10
  • 12. variety of views on consortia size and concluded that GP practices should therefore be givenflexibility to decide how they come together to form consortia 16.Within the 184 pathfinder consortia already established, there is significant variation in populationsize. The smallest consortium (East Cliff Practice) covers a population size of 14,000, while thelargest will commission services for 693,000 (Gloucestershire). Variation in size is 49-fold, asdemonstrated by Figure 2. 25 (14%) of the consortia are greater in size than an average PCT. Theaverage (mean) consortia size is 197,843.Figure 2: Consortia population size 700,000 600,000Consortium population 500,000 400,000 Population size of average PCT size 300,000 200,000 100,000 0The announcement of the third wave of pathfinder consortia saw a few consortia merging toincrease their coverage. Other changes are likely as consortia begin commissioning services.There are also significant variations in the size of consortia according to geographical location.Figure 3 shows the average population size and number of practices covered by consortia brokendown by SHA. The consortia in the North East tend to be the largest, with an average population ofover 280,000. At the other end of the scale, the average population covered by consortia in NHSSouth East Coast is little over 128,000.Figure 3: Average size and number of practices in pathfinder consortia 300000 45 Average consortia population Average number of practices 40 250000 35 200000 30 25 150000 20 100000 15 10 50000 5 0 0Recommendation 2: In order to support the longer term development of consortia, the NHSCommissioning Board should undertake an evaluation of the strengths and weaknesses ofdifferent models and population sizes. Consortia should be required to explain to localcommunities the reasons underpinning their configuration. 11
  • 13. Areas of focus for pathfinder consortiaCommissioning in the new world: an analysis of the impact of prioritisation on quality, expenditureand outcomes in the health service demonstrated that commissioners who prioritise an issue appearto achieve a faster rate of improvement than those that opt not to prioritise the same issue 17. Theareas of focus that pathfinder GP consortia choose will therefore have a significant impact on theirability to improve quality and outcomes in their local area.From April 2013, GP consortia will be under a duty to prepare and publish a commissioning planbefore the start of each financial year, “explaining in particular how the consortium intends toexercise its functions with a view to securing improvement in the quality of services and outcomes forpatients”. In practice, this could include “identifying indicators in the Commissioning OutcomesFramework where there is scope for local improvement” 18.Although the requirement to publish a commissioning plan will not be a statutory duty on GPconsortia until April 2013, pathfinder consortia were asked to state their vision and objectives in theapplication process 19. For most consortia, the areas of focus that they have identified have beenmade public on the Department of Health website 20.The approval process for pathfinder consortia has allowed a significant degree of flexibility forconsortia and so has not been prescriptive on the areas of focus that consortia can choose. As such,the information that has been provided by pathfinders in waves one to three has varied in level ofdetail and in areas of focus. Some consortia have chosen to focus on particular clinical pathwayswhile others will look at the care pathway more generally. Of the 184 pathfinder consortia listed onthe Department of Health website on 14 March 2011, information on their chosen areas of focus isavailable for only 156. This information contains the basis for the analysis contained in this chapter.Commonly identified areas of focusFigure 4 shows the areas of focus most commonly adopted by pathfinder consortia. It is notablethat the most common areas of focus relate largely to the integration of services, whether it be withsocial care, community services or improving the care pathway. It is worth noting that the ability ofGP commissioners to improve the continuity of care across services was a key argument in favour ofGP-led commissioning. The early focus of pathfinder consortia on the issue suggests that this is anarea which interests the GP community. 12
  • 14. Figure 4: Most common areas of focus 45 Percentage of consortia that identified 40 the most common areas of focus 35 30 25 20 15 10 5 01. Integration with social careIntegration with social care featured in the areas of focus adopted by 40% of pathfinder consortia.This is not surprising given the focus on integration in the NHS reforms.Andrew Lansley set out early on in his time as Secretary of State for Health that integration betweenhealth and social care was central to the aims of the reforms, arguing: “we must reform social carealongside healthcare – and deliver closer integration in how services are commissioned andprovided” 21. This aim has been evident in a number of reforms, including the overlapping NHS andsocial care outcomes frameworks and the planned introduction of health and wellbeing boards.Almost 90% of all local authorities have now signed up to be early implementers of new health andwellbeing boards, creating shadow boards which, subject to legislation, will be operational by April2013 22. The health and wellbeing boards are intended to guarantee joined-up commissioning at alocal level, with an obligation to prepare joint strategic needs assessments and a joint health andwellbeing strategy spanning the NHS, social care and public health 23.Figure 5 demonstrates the areas of the country where consortia have identified integration of healthand social care as an initial area of focus. 13
  • 15. Figure 5: Percentage of consortia focusing on integration with social care2. Care pathwaysCare pathways was the second most common of area of focus identified by pathfinder consortia.Again, this has been seen as central to the Government reforms in that without clearly definednational and local care pathways it is difficult to offer patients informed choice or to implement theAny Willing Provider model 24. Figure 6 shows the regional breakdown of consortia identifying carepathways as a priority.Figure 6: Percentage of consortia focusing on care pathways 14
  • 16. 3. GovernanceMany consortia opted to focus on governance issues relating to their establishment, rather thanareas of commissioning which might have a direct impact on outcomes. In total, 49 out of 156included some aspect of governance in their areas of focus. Priorities included:• “Focusing on role as an independent commissioning practice” 25• “Focusing on developing the organisation and in preparation have completed the organisational development plan” 26• “Focusing on exploring governance arrangements, identifying how to work independently as a federation” 27• “Focusing on identifying how to capitalise on the devolution of management and budget” 28This focus is perhaps to be expected given that a key task for pathfinders is to learn lessons abouthow GP-led commissioning can be most effective ahead of April 2013 as well as news that theDepartment of Health has deliberately avoided prescription in relation to the way that consortiashould govern or organise themselves 29. However, it is concerning that 12 consortia have focusedon governance arrangements alone.Some geographical areas have focused on governance issues more than others, indicating that thishas either been strongly encouraged by some SHAs or discouraged by others. Figure 7 shows that88% of pathfinder consortia in Yorkshire and Humber identified governance as an area of focus,compared to only 4% of those in London.Figure 7: Percentage of pathfinder consortia identifying governance as an area of focusHowever, the focus on governance has varied according to the wave in which pathfinder consortiawere approved. Governance issues were particularly common amongst commissioners from thesecond wave, and yet none of the third wave opted to focus on the issue, as set out in Figure 8. 15
  • 17. Figure 8: Proportion of pathfinder consortia in each wave focusing on governance issues 60 Percentage of consortia identifting 50 governance as an area of focus 40 30 20 10 0 Wave 1 Wave 2 Wave 3Recommendation 3: Work undertaken by pathfinder consortia on governance issues should becollated and shared, so as to avoid duplication of effortRecommendation 4: Given the focus on improving outcomes, all consortia should be encouragedto identify priorities which directly relate to the quality of care commissioned. Those consortiathat have only identified governance or process priorities should now identify clinical priorities aswell4. Urgent careIt is unsurprising that urgent care is a popular issue for consortia focus given the Government’sintention of transferring responsibility for urgent care provision to GPs 30. This follows a number ofcontroversies about the quality and nature of out of hours urgent care provision31,32. With theintroduction of new quality indicators for urgent care from April 2011, the quality of urgent careservices is likely to be seen as a key early test for the effectiveness of consortia.Over 15% of all consortia have opted to focus on the issue, with over 30% of the third wave choosingto do so. It should be noted that urgent care is a very broad topic and can refer to a wide range ofservices, from ensuring out of hours access to primary care to accident and emergency services. Thishas been reflected in selections by pathfinder consortia, which vary from “developing the localityleadership role for urgent care” to “focusing on further work to reduce A&E attendances” 33.5. Delivering efficiency savingsGiven the current funding environment for the NHS, it is not surprising that many pathfinderconsortia have opted to focus on issues which could lead to efficiency savings. Our previous work,published in Commissioning in the new world, demonstrated the positive impact that commissionerprioritisation could have on cost savings and therefore it is welcome that many pathfinder consortiahave chosen to focus on issues which could generate efficiencies. 16
  • 18. At a national level the efficiency drive has been led by the Quality, Innovation, Productivity andPrevention (QIPP) programme 34. Only 5% of pathfinder consortia have actually named QIPP inidentified priorities, but a number of other areas of focus set out in Figure 4 also form part of theQIPP agenda. For example, issues such as improving care pathways, focusing on referral patterns orprescribing could all contribute to savings for the NHS.Among GP consortia that identified prescribing as an issue of focus, few have provided further detailon how they intend to make improvements in this area. However, one consortium set out that it will“develop a comprehensive peer review programme for referrals and prescribing that is supportiveand educational”, while another intends to review and streamline prescribing.It is notable that a series of prescribing efficiency indicators are also being developed as part of the2011/12 agreement between NHS Employers and the British Medical Association (BMA) on theQuality and Outcomes Framework (QOF) of the GMS Contract 35. This could be a good example ofhow a GP’s provider and commissioning priorities could align.Recommendation 5: Commissioners should be encouraged to use prioritisation as a mechanismfor controlling costs. The Department of Health should, as part of the commissioning outcomesframework, develop nationally validated outcome indicators which address efficiency issuesRecommendation 6: As part of guidance to support GPs in delivering on future QOF indicators,NHS Employers and the BMA should provide advice on how a GP’s provider and commissioningresponsibilities should align on an issue. This will also be important to help GPs avoid anyperception of a conflict of interest6. Clinical prioritiesFew of the most common areas identified relate to specific conditions or programmes. However,mental health was one of the ten most commonly selected areas of focus, chosen by 8% ofpathfinder consortia.Figure 9 shows the most commonly selected clinical areas, which include chronic obstructivepulmonary disorder (COPD), dermatology, diabetes, musculoskeletal conditions and cardiology. 17
  • 19. Figure 9: Commonly selected clinical issues 9 Percentage of consortia that identified the 8 7 most common clinical issues 6 5 4 3 2 1 0 Mental health COPD Musculoskeletal Dermatology Diabetes conditionsThe identification of mental health as a priority reflects not only its population impact but also GPs’direct role in helping manage many mental health conditions. Indeed, this also holds true for COPD,musculoskeletal conditions, dermatology and diabetes, all of which are often managed primarily inprimary care settings. It is also notable that a number of these conditions feature prominently in theQOF 2009/10. For example, there are 100 QOF points for diabetes, 59 for mental health and 30 forCOPD 36. Therefore GPs are likely to have not only extensive experience of managing them, but alsoaccess to local data on prevalence and the effectiveness of care collected through the QOF.Recommendation 7: Consortia should be encouraged to consider clinical areas for improvementwhen identifying areas of focus. This should be based on an analysis of the needs of their localpopulationRecommendation 8: The Department of Health should set out in clinical outcomes strategies themeasures which commissioners may wish to use in assessing their progress on improving servicesfor different conditionsRecommendation 9: In order to support consortia in identifying appropriate clinical issues onwhich to focus, the Department of Health and the NHS Commissioning Board should signpostnationally comparable data in commissioning support packs 18
  • 20. Developments in commissioning prioritiesIt is possible to identify trends in commissioning priorities, both in comparison to those adopted bypredecessor organisations to consortia and between different waves of pathfinders. This chapterexamines how priorities have evolved over time.Continuity with PCT prioritiesPathfinder consortia will start to assume responsibility for commissioning budgets from PCTs in April2011. Although there were many weaknesses in PCT-based commissioning, the performance of PCTsas commissioners did improve 37. One criticism levelled at GP-led commissioning is that itsdevelopment could disrupt this progress or undermine efforts to ensure accountability for mediumterm performance 38.Since 2009/10 PCTs have used the World Class Commissioning assurance programme to identifypriorities for their local area 39. The priorities that could be selected by PCTs and the number ofidentified priorities they were required to have, were prescriptive, unlike areas of focus for thepathfinder consortia. It is therefore unsurprising that, overall, there is little continuity between thepriorities of PCTs and their successor consortia.Table 3 illustrates how priorities have evolved in four randomly selected areas where there are closegeographical links between PCTs and consortia. This shows that both the style and the content ofpriorities tend to be significantly different. Despite this, some consortia show continuity in areas offocus. Others, however, represent much more of a break with the past.Table 3: Comparison of PCT and GP consortia priorities PCT priorities Pathfinder consortium areas of Comment on extent of continuity focus Bassetlaw PCT Bassetlaw Commissioning Bassetlaw Commissioning • Public health Organisation Organisation gives limited detail on • Cancer • Focusing on governance and focus. However, a focus on • Stroke working in partnership with partnership working could contribute • Hospital the local authority to earlier PCT ambitions to improve admissions public health, hospital admissions and • End of life care end of life care. Norfolk PCT North Norfolk Health Consortium There are overlaps between the • Public health • Reduce health inequalities priorities selected by Norfolk PCT and • Early diagnosis • Enable people to live longer, the focus on the North Norfolk Health • Admissions healthier lives Consortium. The consortium’s focus • Healthcare • Work with partners to on working with partners to improve Associated improve health and wellbeing health and wellbeing could be seen as Infections (HCAIs) • Focus on people’s individual a continuation of the PCTs • End of life care needs prioritisation of public health and • Provide high quality, safe early diagnosis. There is also overlap healthcare services between the PCT commitment to • Provide right care, right time, reducing health care acquired 19
  • 21. right professional infections and the consortium goal to • Ensure people are treated provide high quality, safe healthcare with dignity and respect services. NHS Dorset Dorset GP Commissioning The priorities identified by Dorset GP • Hospital Consortium Commissioning Consortium are largely admissions • Identifying what the general and focus on joint working. • Immunisations consortia will do and what it This links broadly to PCT priorities on • Public health will “buy in” public health, hospital admissions and • Delayed transfers • Exploring devolution versus delayed transfers of care. The PCT of care federation prioritisation of immunisations, • Mortality rate • Spreading clinical leadership mortality rate and end of life care is • End of life care and ownership of the not reflected in the areas of focus commissioning agenda identified by the consortium. • Exploring the role, function and level of autonomy of localities within consortia NHS County Durham County Durham and Darlington County Durham and Darlington GP • Public health • The role of community consortium has identified a number of • Cancer hospital in delivering specific focus areas. Focus on the role • CVD mortality intermediate care of community hospitals and the • End of life care • QIPP priorities development of streamlined • Care pathways • The COPD respiratory unplanned care will both have an pathway impact on care pathways, a priority • Children’s commissioning identified by the PCT. There is less • Budget for planned care overlap with other PCT priorities. • Purchase of nursing home beds • Development of streamlined unplanned careRecommendation 10: In developing their priorities, consortia should work with local health andwellbeing boards to ensure that progress made on the issues prioritised by PCTs is not lostDevelopments across pathfinder wavesThe issues on which consortia have chosen to focus vary according to the pathfinder wave in whichthey were announced. As Figure 10 demonstrates, integration with social care and care pathwayswere common areas of focus across all three waves of consortia announced to date. Governance,however, was not chosen as an area of focus for any of the third wave of consortia, despite beingthe most commonly selected area of focus by consortia in the second wave. 20
  • 22. Figure 10: Issues of consortia focus according to pathfinder wave 60 50 40 Percentage 30 20 Wave 1 Wave 2 10 Wave 3 0A focus on community services, urgent care, referrals, prescribing and mental health are all morecommon amongst the third wave of pathfinder consortia. Consortia approved in the third wavewere three times more likely to focus on urgent care than those approved earlier in the process, andtwice as likely to focus on community services.The specificity and detail of focus areas selected by pathfinder consortia have also varied across thewaves. Some consortia areas of focus has been as general as: “Focusing on cross-boundary workinginvolving NHS and local authorities” whereas others have been much more specific, such as“improving access to high quality primary care services, reducing referrals and avoiding admissionsthrough a number of initiatives e.g. setting up a referral management centre, establishing nurse-ledstep-up community beds” 40.It is notable that consortia have become progressively more specific in their areas of focus as thewaves of pathfinders have progressed and there has been a step change in the level of detail madepublically available in the third wave, as set out in Figure 11. 21
  • 23. Figure 11: Level of detail in consortia priorities 100 90 Percentage of consortia identifying 80 70 detailed areas of focus 60 50 General 40 Specific 30 20 10 0 Wave 1 Wave 2 Wave 3Recommendation 11: Consortia should be encouraged to develop detailed identified priorities,enabling an assessment to be made of their success in delivering against themRecommendation 12: Priorities should be set out in commissioning plans, which should bepublished as soon as possible 22
  • 24. ConclusionThe achievements of pathfinder consortia will go a long way to determining the overall success orotherwise of the reforms to health and social care. Therefore the issues on which consortia chooseto focus provide an important perspective on the issues which matter to those tasked withimplementing the reforms.What is clear is that, despite national controversies and heated debates about the nature andpurpose of the reform agenda, local NHS services have been moving ahead with implementing thereforms. Consortia now cover 70% of the population and have already begun work on identifyingand addressing their priorities 41.Given the nature of the reforms, it should not be a surprise that there is a high degree of variation inthe issues on which consortia are focusing and the way that they choose to describe these priorities.There are also some strong areas of consensus. The GP commissioning community is expressingdesire to address issues such as links with social care, improving care pathways and addressing someof the challenges that have emerged in urgent care. All of this will be welcome news to advocates ofreform, who have argued that these issues were neglected by many PCTs.Perhaps less welcome will be the lack of specificity shown by some consortia in describing theirpriorities. Although it is early days, this will add to the concerns of critics of the reforms who arguethat the development of consortia could lead to an accountability deficit.Irrespective of an organisation’s view of the reforms, it is clear that change is already occurring inthe NHS and that much of this change could not be reversed, even if there was a change in nationalpolicy. Understanding the priorities of the new generation of commissioning organisations will becritical to delivering change in the new NHS. Any organisation whose business depends uponengaging with the NHS would do well to understand these priorities. 23
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  • 27. I h at , vd n ei e eyhn . n t en e l e ie c s v rt ig A d h he ie c f r Pi o ewh l n . vd n e o MH s v r emigIy uwo l l et fi do t r, la efo ud i o n u mo e pe s kg tnt u h e i o c.c mmi inn @mh cc m o s o ig s p .oMHP6 G e t o t n S re 0 ra P rl d te t aLno odnW1 7 T W RT 4 ( ) 032 80 : 4 0 2 18 1 0F 4 ( ) 032 87 : 4 0 2 18 11www. p .ou mh cc .kMH i p r o E gn P s at f n ie ©MH A r 2 1 P pi 01 l