Paul Zollinger-Read, NHS Cambridgeshire Chief Executive, looks at whether GPs will be able to 'make' as well as 'buy' services from a Primary Care Trust perspective.

1. Make or Buy ? A particularly wicked issue Dr Paul Zollinger-Read

2. What’s at stake? We have a golden opportunity to put in place a more effective system clinically led model of commissioning GP commissioning aligns clinical and financial responsibility and empowers GPs to be innovative Patients will have more power to make informed choices about their healthcare − this will drive up quality and cost effectiveness

3. Innovation GP commissioning encourages organisation around interests – eg: the federation model GPs want to be innovative and shift services into the community PBC innovation was partly through local provision

4. Why become a federation? Strengthening the capacity of practices to develop new services out of hospital To form an entity that can tender for services offered by a future GP commissioning consortium To improve local service integration across practices and other providers To enhance the capacity of practices to compete with external private sector companies

6. Anglia Community Eye Service (ACES) Community-based ophthalmic service (including cataract surgery) Clinically led (local GPs and Ophthalmic Surgeons) First patient seen September 2007 Patient at heart of service – from design of service to care received Mr B, Nr Spalding: ‘Your care and concern during a stressful time is much appreciated…and the results are amazing! The relaxed atmosphere that I felt, on all three occasions of attendance at your clinic, made the whole ordeal seem positive and bearable.’

7. Harlow Improving Health and Well Being Service Nurse-led clinics in sheltered housing complexes, residential homes and other community settings Nurse-led memory service to identify and support those with mild to moderate dementia and their carers/families Develop an enhanced primary care service that acts as a bridge between primary care and community services

8. Colchester Community 24hr/7 day ECG commissioned as a LES from local practices Five additional community matrons commissioned as a contract extension from provider services AF screening at flu vaccination commissioned as a LES contract variation from primary care

9. AWP Community physiotherapy 15 providers Poor demand management Over-spent £200K

10. What’s the mechanisms? Local enhanced service AWP Tender NHS contracts

11. Options Equal footing: transparency − all details of investments in your own services open and transparent A primary care AWP model, with significantly lower barriers than the hospital model (ie: not gummed-up with onerous contracts / separate CQC and Monitor registration) A fund-holding type menu of things you are allowed to do Some national reference costs for primary care/community services

12. Five factors that influence if competition is healthy What is relevant market share? What is minimum economic scale? What is minimum clinical scale? Are there significant barriers to market entry exit? Are there significant barriers to switching?

13. Competition Uncontested Monopoly Contested Monopoly Oligopoly Active Competition Tertiary Non elective and complex care Less complex hospital Out of Hospital

14. Procurement rules ‘Make or buy’ decision is taken in the context of competition regulation and procurement law will ‘making’ the service create conflicts of interest or potential competition/choice issues? No legal reason not to commission and procure from one place – historic PBC arrangements GPs need transparent and robust separation between roles GPs cannot direct choice Any willing provider will allow greater choice and competition

15. Questions for consortia Need to understand the relevant market is it: developed, immature, non-existent? Can you take cost out by working with providers rather than taking it to market, which incurs cost and takes time? Commissioner should, as good practice, consult with the system or market in the design of service specifications Commissioner wants, in most areas, plurality of provision within the market to maximise choice for patients.

16. Questions for consortia 2 The decision to ‘make’ could be because there is not a developed market or the ability to innovate and develop an alternative solution In some areas demand will not support significant plurality of provision From either commissioner or provider perspective you will need to know that the market can sustain the number of providers and that there are effective systems in place to manage demand

17. Procurement pitfalls Potential to stifle innovation and change, particularly the shift to primary care White Paper promised less bureaucracy This is about improving patient care – therefore we need to find a fair but flexible system However let’s use Pathfinders and Learning Network to test out

18. What’s the question we seek to answer Value Value = Quality/Cost effectiveness GPs seek to manage the pathway Cambridge: Nine strategic work streams with joint clinical chairs

19. Managing conflict of interest Probity in decision making Openness and transparency Real choice for patients Patient and public confidence in decision making Consistency with standards of professional practice required of GPs Any breach needs to be dealt with rigorously

20. Secretary of State, 3 Nov ‘We’re intending to have extended tariff arrangements out into the community by 2013. ‘So general practice won’t be able to take an excess profit , there will be transparently and also have to demonstrate they have met quality standards and the price available from other providers. ‘When GPs do that referral, part of the contractual obligation will be to provide patients with choice. So they have to offer the choice and demonstrate they’ve offered choice,.

21. Do we need to worry? Outcomes and satisfaction levels will make the decisions