More than 300 GPs have withdrawn from partnerships with Virgin Care due to a potential conflict of interest between their provider and commissioner roles.

The 25 local provider companies, known as GPCos, set up since 2006 to provide NHS community services, will now be run by Richard Branson’s Virgin Care alone.

The GPCos were half-owned by GPs and half by Virgin Care (under its original name, Assura), and provided services including rheumatology, ophthalmology and dermatology.

A spokesperson for Virgin Care said: “Many of our GPs have become increasingly worried about the perception of potential conflicts of interest. Moving away from our partnership model removes this concern.”

According to Ian MacDonald, former Chair of the Assura Coventry GPCo, “The world has changed since we began working with Virgin Care, particularly in light of recent developments such as the Health and Social Care Act, and as GPs we want to ensure that there is a clear division between provision and commissioning.”

All of the former GPCos will be GP-free by April 2013, when the CCGs formally begin their commissioning role.

After April 2013, who will commission which health services?

The new NHS structure is designed to promote integrated care by making the roles of a number of different commissioners interlock. The GP-led clinical commissioning groups (CCGs) are the core of the system, responsible for dealing with most areas of patient need in the local community. Around that, however, three other commissioning bodies are engaged with supporting patient health and wellbeing:

• the NHS Commissioning Board (NHSCB) is responsible for primary care and specialised services
• local authorities are responsible for improving public health
• Public Health England (PHE) is responsible for protecting and promoting health though intervention in health and social care services and public awareness.

A map of services

The Commissioning Board Authority’s Commissioning fact sheet for clinical commissioning groups maps the new health landscape by comparing the responsibilities of the four organisations. For each new commissioner, it lists the main functions and the similarities to other commissioners – thereby making the point that service integration is vital for effective care.

The fact sheet states that CCGs will need to work collaboratively with local authorities and the NHSCB – and that to do so, they may pool budgets or have joint commissioning arrangements. For example, it is suggested that responsibility for sexual health and for addiction-related services will need to be divided between the CCG and the local authority to avoid duplications or gaps in provision.

Clearly, the matrix of healthcare is a dynamic one that can be interpreted by local commissioners in a range of ways. The map is not a final one in any case: some details, including the specialised services covered by the NHSCB, are still to be confirmed by Parliament in the autumn.

Community healthcare

The fact sheet compares the responsibilities of CCGs and the NHSCB for commissioning patient care. It notes that local authorities will provide “public health advice” to CCGs, but will not commission at that level. The role of local authorities in commissioning social care is not covered, but is a further dynamic that CCGs will need to be aware of.

The core elements of CCG commissioning relate to: emergency care; out-of-hours primary medical care (where not covered by the GP contract); elective hospital care; community health (such as physiotherapy and continence services, but not health visiting or family nursing); rehabilitation; maternity and newborn care (except where intensive); paediatric care; mental health and learning disability care; and infertility treatment.

The core elements of NHSCB commissioning relate to: primary care through the GP contract; community pharmacy; primary ophthalmic care; all dental care; health services for people in prisons and other custodial institutions; health services for members of the armed forces; and specialised services.

The fact sheet draws out some detailed differences between the two lists in order to avoid confusion – for example, noting that health services for offenders in the community are covered by CCGs. Sometimes, as where the GP contract varies, certain services may be commissioned by the CCG in some localities and by the NHSCB in others. None the less, overall there is a clear division of responsibilities.

Public health services

With the commissioning of public health services, the picture is significantly more complex. Responsibility is divided between the NHSCB, the local authority and Public Health England. In some cases – notably immunisation programmes – these services can relate to provision of medication. In other cases – notably epidemic preparedness – they can relate significantly to medicines management and other aspects of primary and secondary NHS care.

Public health services to be commissioned by the NHSCB include services for children from pregnancy to age 5. This responsibility will transfer to local authorities in 2015. It covers health visiting, family nurse partnership and responsibility for child health data. The NHSCB will also be responsible for immunisation and national screening programmes – both being areas of increasing NHS spend, as evidenced by recent investment in cervical cancer and prostate cancer screening and in vaccines against HPV and influenza. With hepatitis C vaccines on the market and HIV vaccines a real prospect, this area of medication will become increasingly crucial for the NHS.

Local authorities will be responsible for providing or commissioning a wide range of public health services that relate mostly to preventative measures and raising awareness, including: children’s public health for ages 5 to 19; sexual health; public mental health; obesity management; drugs, alcohol and smoking services; dental public health; and seasonal mortality. Active medical intervention, including medication, features strongly in the sexual health and drug, alcohol and smoking services to be provided; the transfer of sexual health services from NHS to local authority control is a major change in the provision of UK healthcare. Notably, however, HIV treatment will be commissioned by the NHSCB.

PHE is taking over the functions of the Health Protection Agency and will impact significantly on the health protection activities of CCGs, the NHSCB and local authorities. Sometimes all relevant health stakeholders will work together – for example, PHE has a strategic role in influenza and other epidemic preparedness, to which local authorities, CCGs and the NHSCB will contribute. PHE’s role also covers behaviour change campaigns around early diagnosis and other issues; public oversight of infection prevention and control; and general intelligence on health protection and improvement, including the current functions of the Cancer Registries. These initiatives will also impact on GP services.

Joined-up care

CCGs will be the glue in the new healthcare commissioning system: the first port of call when gaps or inequalities in service provision arise. While they cannot commission GP care, their close professional connection to it should ensure that what impacts on CCGs will be taken to heart by GPs. But given that austerity measures will dominate the NHS for the “foreseeable future” (in David Nicholson’s words), it is inevitable that funding and staffing shortages will create holes in the patchwork of the new health system. The pharmaceutical industry will thus need to be alert to partnership opportunities opening up at local and national levels.

Doctors have indicated a wish to be consulted during the essential development stages of clinical commissioning groups, a new survey has found.

The Family Doctor Association survey revealed how GPs wish for further interaction during the development of commissioning groups and called for dialogue with these emerging groups.

Dr Peter Swinyard, Chairman of the Association, said the message was clear to CCGs that they must talk with member practices and “listen to them”.

The survey questioned 100 doctors. It found that more than half felt they were able to influence decision making at their nearest CCG. However, 13% of respondents said they were unable to do so and felt disempowered by the reforms.

The survey also found that doctors had a wish to avoid the reinvention of PCTs with the “same faces and policies” following the reforms in the Health and Social Care Act. 

GPs will not be allowed to vote on commissioning locally enhanced services (LES) from their own practices under new guidelines outlined by the NHS Commissioning Board (NHS CB).

An official code of conduct has been published by the Board to avoid conflicts of interest in the health service from 2013 and urges CCGs to use AQP or full tendering for LES to avoid transparency issues.

The NHS CB said the code of conduct will “enable CCGs and member practices to demonstrate that they are acting fairly and transparently”.

The code outlines how LES will form part of CCGs’ baseline allocations from next April – with the exception of public health services.

CCGs will have to commission services using the NHS standard as opposed to the GP contract, the code said, and must provide evidence that proposed services go “beyond the scope” of services provided at practices and that they have fully adhered to new procurement rules.

The code opens up services to private competition. CCGs must decide, it advises – subject to DH proposals – where to “commission community-based services through competitive tender or an AQP approach and where through single tender.”

The document also says that members of Health and Wellbeing Boards or other CCGs could be asked to sit in on primary care commissioning decisions to provide “additional scrutiny”.

Clinical commissioning groups will have to take full responsibility for the actions of commissioning support services, a legal expert has warned.

Bob Senior, Director of Medical Services at legal firm RSM Tenon, told delegates at the Commissioning Show how the Government wants CCGs to be fully accountable for all commissioning decisions.

He said CCGs cannot delegate responsibility and the “buck stops with you” if anything wrong were to happen during the commissioning of services.

CCGs were told how they would need to “do everything better for less money” when they take full control of health budgets next year and were warned to “look carefully at contract negotiations” to avoid any legal issues.

“You will have limited resources,” said Mr Senior. “Make sure you get something out of it that you want, not what they try to impose. This is your responsibility, your funding, your contract.”

Mr Senior also revealed how smaller CCGs are already struggling to deal with patient management costs and were cutting GP involvement as a result.

He told delegates how one commissioning group in the Midlands had reduced the number of doctors on its board from six to two to trim costs.

Developing commissioning groups, he said, are struggling to cope with the money allocated for patient management. “You can’t do everything you want in a small local CCG so as a result CCGs are generally becoming bigger than they originally hoped for,” he said. “The smaller CCGs are finding that £25 per head is too tight to do anything like the GP involvement they hoped for.”

GP commissioners will start their new roles free of “legacy debts” and positioned to develop innovative care solutions, Andrew Lansley has said.

The Health Secretary reassured an audience of GPs at the Commissioning Show that CCGs would not need to “provide for deficits in the local health economy”: that would be the task of Monitor, he said.

Lansley’s speech placed strong emphasis on the need for NHS service innovation to deal with the coming “demographic tsunami”.

The NHS Outcomes Framework will “focus our minds” and “enable clinicians to lead, not be micro-managed from on high,” he said.

Addressing the fears of many GPs, he said the NHS Commissioning Board would not “top-slice” CCGs’ budgets or require them to be re-authorised once in action.

He intended to ensure that CCGs started with “no legacy debts”, though that would not be true of providers.

Echoing Malcolm Grant’s speech to the NHS Confederation last week, he said that “we do not want to tell you how to achieve” – though he did not mention the recently announced NHS CB guidelines on commissioning processes.

Lansley also cited the fall in GP referral rates as a positive achievement, without mentioning the National Audit Office’s recent statement that falling referral rates were harming diabetes care.

He highlighted the potential of GP-led commissioning to develop innovative care solutions such as telehealth, and to improve dialogue between GPs and local government.

THE NHS Commissioning Board’s role in NHS reform is still widely debated. Pf looks at how it will direct the NHS of the future.

The new NHS Commissioning Board (CB) is unique in three respects. Firstly, it stands to take on more power than any arm’s length body in NHS history. For up to three years at a time, it will be entrusted by the Government to run the NHS and allocate its entire commissioning budget, without regular scrutiny by Parliament.

Secondly, it stands to hand over more power than any arm’s length body in NHS history. Of its annual £80bn
commissioning budget, £60bn will be delegated to the 212 Clinical Commissioning Groups responsible for commissioning local services. While the CB will commission primary care from the CCGs and ensure that they deliver on the NHS Outcomes Framework objectives, it will allow them to devise their own solutions and choose their own partners.

The powers of the SHAs are being delegated ‘upward’ to the CB, while the powers of the PCTs are being delegated ‘downward’ to the CCGs. The widespread concern about a potential gap in responsibility led Sir David Nicholson to say: “The NHS Commissioning Board could turn into the greatest quango in the sky. So it needs to have clinicians at its heart and the powerhouse for change in the system must be the
clinical commissioning groups.”

Andrew Lansley’s letter to the CB’s Chair, Malcolm Grant, in April about the Board’s strategic objectives stresses that its first responsibility is to make a “shift of power from national and regional organisations to CCGs, Health and Wellbeing Boards, local providers and patients.” The CB will not be a monolith within a static system: it will be a facilitator of future NHS transformation. That dynamic role is the third unique
feature of the CB, and the most important.

TAKING THE REINS

The DH plan Developing the NHS Commissioning Board (July 2011) outlines the intended structure and functions of the Board. It will have two broad national roles: to commission primary care and specialised services, and to ensure that the entire commissioning system is “cohesive, co-ordinated and efficient”.

Using £20bn of its annual budget, the CB will commission GP services and specialist health areas, including dentistry, maternity, community pharmacy and ophthalmic services. The Board will not govern the CCGs in a traditional way: it will “support” them and “hold them to account” while allowing them “freedom to innovate.” This support includes authorisation, an outcomes framework, guidance tools such as model pathways, and a means of intervening when CCGs are in difficulty.

The CB will host clinical networks to advise on specific areas of care and multi-disciplinary clinical senates to support CCG decision-making. Another key role of the CB is to lead the NHS Outcomes Framework by supporting local clinical improvement, providing “more services outside hospital settings”, improving acute care and the management of long-term conditions, and ensuring that CCGs implement NICE and other national standards.

In addition, the Board will lead patient-centred care by overseeing “the extension of patient choice and the expansion of information available to patients” and promoting both integrated care and innovative self-care.

Finally, it will develop a “medium-term strategy for the NHS” that will combine with the local priorities identified by the Health and Wellbeing Boards to provide a basis for local commissioning plans.

LEADER OF THE PACK

According to the 2011 outline, the CB will work in “partnership” with many other organisations: patient groups, healthcare professionals, healthcare providers, local government, industry and national organisations such as NICE.

The Board’s relationship with suppliers will “support its strategic approach to innovation and development” – in other words, it will play a part in the dynamic evolution of services and provider relationships.

The CB will be organised nationally around the five domains of the NHS Outcomes Framework, with a national lead for each domain. It will also divide its local teams into four ‘commissioning sectors’ reflecting the four existing SHA clusters, each with a sector lead.

The Board will take over functions performed by 8,000 people. It plans to reduce that number to 4,000 – a reflection of its ‘light touch’ approach.

RIDING THE WHIRLWIND

According to Lansley’s letter to Grant, the CB has a responsibility to “contribute to” improved health for “the whole population”, improved care and outcomes “for all patients”, and improved efficiency. Within this context, the Board Authority’s strategic objectives include “transferring power to local organisations” and “establishing the commissioning landscape”. The new NHS will then develop under its own steam, with the clinical networks and senates providing “leadership and insight rather than oversight and compliance”. The authorised CCGs will have the “assumed liberty” to design local services independently.

In addition, Lansley says, the CB will have a “vital leadership role” in enabling the personalisation of care by improving patient choice. This includes the use of personal health budgets. At the provider level, the CB will play a “crucial part” in developing a “level playing field” for competition.

In short, the role of the NHS Commissioning Board is to facilitate the evolution of a rapidly changing healthcare system. These changes will come not from the Board or the DH, but from the decisions of CCGs and their commercial partners.

The emerging CCGs are suffering from a lack of willing GP leaders, according to the Royal College of General Practitioners.

Clare Gerada, chair of the RCGP, said that only “about 25 GPs” in England were actively interested in leading local commissioning.

Most GPs were keen to support provider reform in clinical terms, she said, but the “transactional” aspects of commissioning as a business did not appeal to them.

Gerada quoted an NHS director of business development as saying: “The level of GP interest in being a lead for a given condition or pathway in some areas is disappointingly low, and in some areas there has been no interest at all.”

The same source added that CCGs “hold a limited attraction for the vast majority” of GPs.

According to Gerada, GPs are “interested in the transformational stuff, but not in the transactional stuff” – which might have to be outsourced.

“No one asked GPs if they wanted to commission,” she added. “I think there are about 25 GPs in the country who want to do it.”

This speech came just before the BMA’s membership voted to campaign for the repeal of the Health and Social Care Bill – a motion not supported by its leadership.

GPs are considering withdrawing their involvement from the NHS commissioning process in protest over their own pension reforms.

BMA members will vote at this month’s annual representatives meeting (ARM) in Bournemouth on whether to withdraw from the commissioning redesign until an agreement is reached on changes to the NHS pension scheme.

Dr Chaand Nagpaul (pictured), GPC negotiator, said industrial action was not part of the BMA’s plans “at the moment” but doctors were considering withdrawing their “goodwill”.

If doctors did withdraw their activities in clinical commissioning groups (CCG) they would not participate in any work relating to the development of CCGs and other commitments.

“The NHS reforms in England are entirely dependent on the goodwill of GPs,” said Dr Nagpaul.

“One consequence of the Government’s enforcement of pension changes will inevitably result in the loss of goodwill.

“It’s very likely this will impact on the level of engagement of GPs in CCGs.”

A similar motion was passed by a narrow margin at last month’s UK conference of the Local Medical Committee.Other motions set to be debated at the AMR include the call for Andrew Lansley to resign as Health Secretary.

The Department of Health’s risk register on the NHS reforms has been leaked online on the day the Health Bill reached Royal Assent.

The Transition Risk Register raised a host of concerns about the introduction of the Health and Social Care Bill including the NHS losing control of finance and performance, the morale of staff and dispute with unions.

Health Secretary Andrew Lansley had previously claimed the register was a “worst case scenario”.

Labour MP John Healey had requested the DH release the register whilst he was shadow health secretary in November 2010 under the freedom of information law.

A tribunal ruled earlier this month that the risk register should be published before the Bill had passed through Parliament. However, the DH indicated it would appeal the decision and the publishing of the register was again delayed.

The version which was leaked online is one of the first iterations of the register. Dated 28 September 2010, it was created three months after the Government’s initial white paper was published.

The most significant and likely risks, the document reveals, surround the loss of control of finances and performance. It states: “By dismantling the current management structures and controls, [there could be] more failures, including financial, e.g. GP consortia go bust or have to cut services, and credibility of the system declines as a result.”

Worries were also raised that the NHS Commissioning Board “is not sufficiently developed” and that consortia or GP leaders who are not sufficiently developed “may be drawn into managerial processes which drive clinical behaviour (rather than the other way around)”.

The document also warns that the “new system” will be designed from an internal perspective without considering the views of the general public and patients and lead it to being “difficult for the public to navigate or hold to account”.

Risks referring to the Treasury include: an inability to reduce running costs due to the number of consortia; a reduction in the amount of time GP spend with patients due to management responsibilities; ‘postcode’ commissioning; an increase in “catastrophic failure” with no system management; and GPs creating an increase in their remuneration by “playing the system”.

The register also indicated the Government was considering splitting the Health Bill into two parts as it faced a host of opposition against the controversial reforms in the autumn of 2010. However, there were worries over whether parliamentary time could be found for two separate pieces of legislation.