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BMA White Paper Meeting


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2010 UK NHS reforms, critical commentary

2010 UK NHS reforms, critical commentary

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  • 1. The White Paper- Equity and excellence- implications for GPs Dr Chaand Nagpaul, GP, North London Negotiator, BMA GPs committee
  • 2. Overview
    • White Paper published 12 th July 2010
      • “ Equity and Excellence: Liberating the NHS”
    • Further consultation documents in July
      • Commissioning for Patients
      • Transparency in outcomes
      • Regulating healthcare providers
      • Local democratic legitimacy
      • Review of Arms Length Bodies
    • “ Choice” consultation November
  • 3. White Paper: Equity and excellence: Liberating the NHS
    • We’re awaiting the government’s response to WP consultation; the final product may be different
    • Much more than GP commissioning
    • Wholesale change to entire NHS landscape
    • Changing the top of the NHS
    • Passing control for NHS decisions away from Ministers
      • towards patients and professionals
    • NHS Commissioning Board “free from day to day political interference”
    • GP-led commissioning consortia-accountable to NCB
      • with abolition of SHAs & PCTs by 2013
  • 4. White Paper: Equity and excellence: Liberating the NHS
    • Explicit competition agenda with private sector parity
    • “ any willing provider”
    • All NHS Trusts to be FTs-greater flexibilities
    • Monitor - economic and competition regulator
    • New, expanded role of Local Authorities - Public health, Health and Wellbeing boards
    • Patient Voice- HealthWatch
    • Patient choice and “Information revolution”
    • NHS Outcomes framework
    • £20b efficiency savings by 2014, 45% management cuts
    • Workload shift from secondary to primary care
  • 5. NHS Outcomes Framework
    • Domains of quality measured by clinical outcomes and patient reported outcome measures (PROMS)
    • National Commissioning Board to implement
    • Quality standards developed by NICE
      • available 2011 with implementation in 2012
    • 150 standards with up to 10 quality measures each - possible 1,500 targets – potentially time consuming and bureaucratic
    • Create incentives for GP consortia to deliver
    • BMA position that process is also vital
  • 6. Putting patients first
    • Shared decision making
      • “ Nothing about me without me”
    • “ NHS information revolution”- supporting patients to make choices and look after their own health
    • New online services in addition to NHS Choices
    • PROMS, patient experience surveys and real time feedback to rate services and departments
    • Comparative provider performance data (Quality accounts)
    • Comparative GP commissioner performance data
    • Patient access to health records- GP and other providers
    • Patient voice-Healthwatch
  • 7. Patient Choice - promoting competition
    • Current consultation: “Greater choice and control”
    • Choice of “any willing provider”
    • Choice of consultant-led team (elective care 2011)
    • Choice of some mental health services by 2011
    • Maximise use of Choose and Book
    • Extended maternity choice
    • Choice of diagnostic testing, and post diagnosis by 2011
    • Choice of treatment, care in long term conditions and end-of-life care
    • Choice of registration with any GP practice – not limited by where a patient lives or practice boundary
  • 8. GP commissioning consortia
    • Not GP fundholding revisited
    • Not PBC consortia revamped with budgets
    • Unchartered waters
    • Statutory bodies –accountable to NCB
    • Accountable officer and Chief Finance Officer
    • Hard budgets; “No bail out”
    • Will commission community and secondary care, emergency services inc OOH
    • QIPP- £20b efficiency savings, 45% reduced management costs
    • Local prioritisation/rationing – diminished role of NICE
    • Being asked to do what PCTs were unable to –cannot be “more of the same”
  • 9. Much more than “commissioning”
    • Duty to determine local health needs
    • Duty to promote equalities
    • Duty to work with local authority (public health, social care, safeguarding)
    • Duty of public and patient involvement
    • Other current PCT functions?
  • 10. Consortium size and configuration
    • Likely between 100-750k
    • Need GP engagement and ownership, AND managing financial risk, low management costs, commissioning effectiveness
    • Financial constraints- “no bail out”
    • “ Small” – GP engagement +, higher management costs -
    • “ Large” – economies of scale +, acute hospital commissioning +
    • “ Large” with locality commissioning substructures
    • Federated with lead consortia
    • Risk pooling arrangements
    • Lead consortium on behalf of others
    • Acute hospital commissioning
  • 11. Consortium commissioning management functions
    • Financial management
    • Financial planning, Budget management, Transaction processing
    • Information and knowledge management
    • Predictive demand, risk modelling and pathway design, Data returns management, Data validation , IT systems management
    • Provider management
    • Contract negotiations and procurement, Contract performance management, Provider payment systems,
    • Stakeholder engagement : patients and the public, local authorities, secondary care and public health specialists
    • Consortium management
    • Human resources systems for employed staff, Estates management, corporate governance, Legal services, complaints, External auditing
  • 12. Management support
    • Directly employed staff by consortium:
    • -local PCT staff with local knowledge; TUPE considerations, management cost constraints
    • Service agency supporting consortia
    • External independent sector commissioning support/consultancy
    • Need management infrastructure discussions NOW to retain skilled local managers and staff
  • 13. GP involvement
    • Will affect ALL GPs
    • 3 tiers of GP involvement:
    • Consortium GP leads (top table)
    • GPs with defined commissioning roles
    • Grassroots constituent GPs: partners, salaried, peripatetic locums
    • Commissioning budgetary spend will be affected by grassroots GPs’ clinical decisions in the consulting room
    • Success of consortia will depend upon sign up, engagement and changing behaviour of grassroots GPs
  • 14. Developing consortia
    • Timescale is short
    • Detail not yet known- Andrew Lansley letter to GPs 24 September
    • Pathfinder sites
    • Don’t rush –important to get it right
    • Legal implications
    • Should await details before any formal local proposals
    • Start early discussion- should involve all GPs –not just “PBC leads”
    • Need democratic equity of opportunity and legitimacy
    • Resist PCT/SHA interference in consortium formation
    • LMC- only statutory body representing all GPs; “honest broker”
  • 15. Shadow consortium GP leadership
    • Need the RIGHT people for the job
    • Need skills, knowledge and appropriate ethos AND
    • Need support amongst constituent GPs and practices
    • Opportunities for commissioning leadership skills
    • Election per se could result in popularity contest vs competence
    • Selection followed by election?
    • Selection with “board of appointment” with democratic legitimacy?
    • Conflicts of interest?
  • 16. Peer review and performance management
    • GPs leading GPs: key to WP ethos and financial management
    • Consortia to “hold constituent practices to account” ; “drive up quality and improve use of NHS resources”
    • “ Proportion of GP practice income linked to the outcomes that practices achieve collaboratively in consortia and the effectiveness with which they manage NHS resources ”
    • Benchmarking practices -must make fair comparisons:
    • differences in practice casemix
    • Differences in practice funding and infrastructure
    • limitations in accuracy of practice commissioning budgets
  • 17. What will be different for practices?
    • Working corporately: part of a greater whole
    • Being compared-peer review and pressure
    • Scrutiny of budgetary spend-referral/prescribing management
    • Reducing Hospital utilisation (vs AWP choice):
    • Referral management, pathway adherence
    • Emergency admission reductions
    • Expanding GP practice and community provider capacity
    • Intra-practice peer review
    • Need to understand variation and reasons
    • Facilitation for outliers to improve; carrots not sticks
  • 18. What will be different for practices?
    • Great potential for disharmony: -
    • -within practices
    • -between practices
    • -between consortium board and member GPs (real budgets, “no bail out”)
    • Could expel practice from consortium ?
    • Need for mature sensitive consortium leadership
    • Must maintain professionalism and patient interest
    • Role of LMC as honest broker
  • 19. Equity and excellence: Liberating the NHS - BMA Response
    • “ Critical engagement”
    • Remain opposed to commercialisation agenda
    • Oppose Monitor’s role in promoting competition
    • ‘ GP- led commissioning groups’ –must include other Drs
    • Welcome reduction in top-down targets, but concern that being replaced by quality indicators
    • Support outcomes. ?PROMS, should retain process targets
    • Sceptical about foundations trusts and social enterprise
    • Oppose local pay determination
    • Oppose localised education and training
    • Proposals expensive at ‘time of austerity’
  • 20. White Paper proposals Risks…
    • Local rationing by GP consortia
    • GPs blamed for cuts
    • Damage to doctor/patient relationship
    • Privatisation by the front-door
    • Funding formula not accurate
    • Enough local leaders with the right skills?
    • Enthusiasts without a mandate setting an inappropriate agenda
  • 21. … more Risks…
    • Some GP Consortia will fail – what then?
    • How to handle inherited or new debt
    • PCT implosion, loss of key staff and skills
    • Competition v collaboration
    • Choice v rationing
    • Conflict between practices
    • Conflict between practices and consortium board
    • Learn the lessons of PCG/PCT mergers
    • Learn lessons of Fundholding, commissioning, PBC
  • 22. … and opportunities?
    • Clinical leadership; absence of SHA/PCT hindrance
    • Real involvement in re-designing services and improving services for patients
    • Opportunity to manage and resource secondary to primary shift
    • New OOH services, 111 and life after NHS Direct
    • Developing practices
    • Developing meaningful partnerships between consortia, LA, hospital trusts and consultants
    • Can we avoid the re-creation of PCTs?
  • 23. GPC guidance on the White Paper
    • The GPC is producing a series of guidance – 6 published so far:
    • “ The Principles of Commissioning – A GPC statement in the context of Liberating the NHS”
    • “ Legal overview view and guidance on the commissioning proposals”
    • “ The Role of Local Medical Committees in supporting the development of GP Consortia”
    • “ GP consortia commissioning – initial observations”
    • “ The form and structure of GP-led commissioning consortia”
    • “ Shadow consortia, developing and electing a transitional leadership”
    • -
  • 24. In summary
    • Unprecedented threats
    • Unprecedented opportunities
    • “ Eyes wide open” approach
    • Await emerging policy
    • Mitigate risks and threats
    • Influence health bill
    • BMA “Look after Our NHS” campaign