BMA White Paper Meeting


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2010 UK NHS reforms, critical commentary

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BMA White Paper Meeting

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