CCGs are the core of the new NHS – but are they running the game?

The emerging clinical commissioning groups (CCGs) embody a core principle of the new NHS: that commissioning decisions should be made locally, by clinicians, and be focused on community-based care. According to Andrew Lansley, the defining feature of the NHS reform is a “shift of power” from national and regional organisations to local ones, of which the CCGs are the most important.

The role of CCGs in the new NHS is both structural and dynamic. They will commission healthcare at a local level, spending £60 billion of the £80 billion NHS commissioning budget, and will hold together the relationship between patients and providers. They will also work with providers and business partners to redesign local services, and those new solutions will spread through the NHS. The CCGs will thus be the drivers of healthcare innovation.

However, given that GPs are meant to lead the CCGs, the concerns raised by many GPs about the new system are significant. Will CCGs really have the opportunity to improve care, or will they simply have to drive through spending cuts? Will they really be run by clinicians or by the private sector? Is the heart of the new NHS dynamic and responsive, or divided and unstable?

Development of CCGs

In July 2010, the white paper Equity and Excellence: Liberating the NHS spoke of “putting GP commissioning on a statutory basis” through the development of ‘GP consortia’. These new organisations, to which every GP practice would belong, would run each local health economy: they would contract providers, partner with local authorities, and be accountable to patients and the public for outcomes. They would be authorised by a new national body, the NHS Commissioning Board, which would also commission GP services.

The initial reaction of the GP community was positive. Being in the driving seat of a fast-evolving NHS, able to redesign local services for their patients, appealed strongly. However, the codification of the reforms in the Health and Social Care Bill led to growing opposition among GPs. Issues raised included the power of the Board to direct GP consortia and the requirement that consortia embrace provider competition. Above all, the deepening economic crisis made GPs fear their role would be one of rationing services, not finding solutions.

The Government’s ‘listening exercise’ did not resolve the concerns about competition and rationing, but it led to a stronger assertion of the autonomy of the consortia. An important change concerned the scope of clinical representation: the new ‘clinical commissioning groups’ were defined as including specialist consultants and nurses as well as GPs. That was a step towards the ‘integrated care’ that the BMA had highlighted as a priority.

Breaking the waves

The NHS Commissioning Board Authority, set up in October 2011, has the primary responsibility of putting in place a nationwide system of CCGs to replace the PCTs by April 2013. A total of 212 CCGs have been approved to go through the authorisation process in four waves: 35 in wave 1 (commencing in June 2012), 70 in wave 2 (July), 67 in wave 3 (September) and 40 in wave 4 (October).

The authorisation process is designed, according to the Board, to ensure that CCGs have a “strong clinical and multi-professional focus”; have meaningful patient engagement; have credible plans to “deliver the QIPP challenge”; have proper governance arrangements; are set up to collaborate with other CCGs, local authorities and the Board; and have strong leadership.

It has not always been a smooth road, however. The Board, concerned at the prospect of CCGs competing for providers of commissioning support, announced it would take over the appointment of leaders to Commissioning Support Services. One CCG has already protested that its authorisation has been delayed by this.

Another issue is lack of GP leadership. Clare Gerada, chair of the Royal College of GPs, said that only “about 25 GPs” in England were actively interested in leading local commissioning. The reason, she said, was that the “transactional” aspects of commissioning as a business did not appeal to them. 

GP-led commissioning

CCGs will be responsible for commissioning community health services (including mental health care and services for children and elderly people) and hospital care (both A&E and elective care). The NHSCB will be responsible for commissioning primary care as well as pharmaceutical and dental services. Local authorities will be responsible for public health, with the NHSCB covering certain aspects.

Collaborative working between CCGs and the other statutory organisations involved in healthcare is anticipated, but the model is not one of top-down control – rather, it is one of business partnership. The NHSCB can provide assistance or support to CCG commissioning; this may take the form of extra funding or access to staff and other resources. CCGs have a duty to co-operate with local authorities in supporting aspects of public health, including child health and mental health.

CCGs are able to buy in support from external organisations, including the CSUs whose development is currently being governed by the NHSCB. For more details on the CSU landscape. CCGs can also buy in support from the private and voluntary sectors, but will retain control of commissioning decisions. These relationships will differentiate CCGs, as some are keener than others to engage in private sector partnerships.

Commissioning of hospital services is also likely to differentiate CCGs, especially as many hospital trusts are facing financial challenges as they shift to foundation trust status. CCGs will influence the development of FTs through their commissioning strategies – for example, they may promote private providers both within and beyond FT-provided services. The acute sector will have a voice in CCGs, though its representatives on a CCG board cannot come from the local area.

The GP-led nature of CCGs is variable. Fewer than 50% of current CCG board members are GPs, and there is potential for the management of local commissioning to be outsourced. CCG boards should include a non-practice nurse and a specialist consultant, but local government are excluded.

Life after April 2013

Securing GP ‘buy-in’ remains an issue for the NHS reforms, but those GPs who support the reforms have been most active in developing CCGs. The CCG boards thus represent a more pro-market segment of the GP profession. Pharma companies may find that their CCG customers and GP customers require a nuanced and varied approach.

Each CCG will have a different mix of GPs, hospital clinicians and financial or management specialists. It will also be dealing with local health issues, which are also impacting on local government and the local Healthwatch body. Every CCG will have to find its own balance between clinical outcomes and economic success.

CCGs will also face a tension between the ‘autonomy’ stressed by the NHSCB and the need for partnership with other stakeholders, within and outside the NHS. Will this tension lead to fragmentation and paralysis, or to dynamic innovation driven by the local synergy of clinical and commercial talent? Whatever the answer, the CCGs hold the key to the success or failure of the new NHS.

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.

In Part III of his diary, Omar Ali discusses the significance of process mapping and the wide reaching influence of health technology assessments and regulatory bodies.

1.10pm: GP CONSORTIA/CCG – RESPIRATORY ASTHMA PROCESS MAPPING & FORMULARY

I’m trying to step into the main meeting room but one of the CCG/GPs pulls me aside. It’s a mixture of a low-key signal and a discreet ‘thumbing’ to pull away from the group. He wants a quiet word and it’s clear that there are some key issues, agendas and directions that are on the table for this asthma meeting.

The process mapping event takes some four hours – evaluating everything and anything that ‘leads to an asthma admission’, followed by everything and anything that occurs after the admission and leads to discharge – which is then followed by QIPP ‘bottlenecks’, where re-admissions and inefficiencies occur.

It’s always a challenge having so many viewpoints – nurses, physicians, pharmacists, budget holders, and of course patients and carers who often change the whole paradigm when we hear about their experience, expectations and concerns around ‘choice’.

Thoughts for pharma

Respiratory is big. Whether on prescribing budgets, healthcare priorities, implementation of national guidance or QIPP streamlines. Companies haven’t yet got their act together on process mapping of care pathways, but it’s the only way to invest in prescribing up-front drugs for potential ‘return to the QIPP baseline’ over the next three to five years. Needless to say, whilst the NHS talks QIPP, pharma is getting used to it and patients are still puzzled by it.

Asthma

With so much behind National Guidance/BTS, QoF and commissioning cycles, some companies are indeed getting into the mix with Clinical Commissioning Groups and supporting process mapping. That support is vital, as not only does it bring pharma in as key stakeholders, but more importantly there is a level playing field here in the same room bringing the cause back on track.

So often in the NHS we have silo budgets chasing after silo savings. Process mapping brings us out of our silos into the bigger picture and into the ‘process map’. Seeing it happen is a wonderful thing.

COPD

Given we make such a fuss around the cost of drugs, in truth we know two things: the most expensive drug is the one that is not being taken, and the tariff for an admission for COPD at £3,400 is more expensive than the annual price of the most expensive inhaler!

So where’s the issue? It goes like this. Pharmaceutical companies come to us quoting the costs of admissions in COPD then tell us how amazing it would be to reduce these hospitalisations.

They then tell us how amazing their COPD product is and tell us that we would be crazy to not buy their inhaler, which is a fraction of the cost of COPD burden/admissions. The GPs, nurses and patients love it and want it and state they ‘need it’. Medicines Management then look like the bad guys for not funding the said branded inhaler.

4.15pm: DRIVING BACK TO NHS BASE CAMP – CHECKING VOICEMAILS

One of the big five companies has asked me to come and present to their European heads-of-country on ‘payer issues’ in the UK and the influence of HTAs.

It’s a bit short notice and I gather the VP for Europe, Middle-East and Asia will be there. Times are tough and I see this as an example of how the EU can join forces on some of the key payer issues beginning to filter through.

I have one question back to these pharma companies. What is your data on reducing these expensive hospitalisations in COPD? Because in truth, with the data, I buy the story.

In most cases pharma will then spin another story around how compliance is great, or a patient support programme is excellent. But given all the spin that has come on how much COPD costs me in hospitalisations, it’s a shame many of the companies don’t have the evidence to help me.

They have marketing but not the evidence. Show me the money. And the formulary will be yours.

Thoughts for pharma

There is no doubt that the UK is ‘different’, but I don’t imagine global HQ for any of the pharmaceutical companies readily accepting that – especially when the targets are high and sales may not be so. It sometimes takes global agencies to hear about payer issues ‘from the horse’s mouth’.

This was the quote stated to me regarding this piece of work/event. From my work abroad – at NICE I informally interact with a number of contacts in other countries who belong to their residing equivalents – I can’t stress enough the importance of NICE, the SMC and similar bodies.

The last SMC decision on pain management was quoted verbatim within two weeks by three different countries within the EU. I’m also aware from my US/value-based pricing work that when NICE rules on a drug the impact on the US healthcare system is far reaching.

Insurance companies download the information – they can’t believe NICE do all this work transparently and then leave it freely available for anyone to download – and the US agencies then use this information on deciding what percentage they will ask patients to pay.

So, if NICE say no and SMC say no, somewhere a butterfly flaps its wings and then a patient in the US, who has paid extra funds into a private insurance policy, will be told that this particular brand is not covered and that the patient will have to make an additional payment if they want the drug.

To be continued...

Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust and sits on the External Reference Group for Cost Impact Modelling for NICE. He may be reached on omar.ali@sash.nhs.uk.

The Government has made revisions to its Health & Social Care Bill following recommendations from the NHS Future Forum.

Andrew Lansley said the proposals, which include modifications to the timetable for change and an expansion of GP Commissioning, will ensure the NHS is more efficient and more accountable.

But former Health Secretary Alan Milburn described the watered-down proposals as “the biggest car crash in NHS history”, saying the Bill was not radical enough in opening up the NHS to more competition.

Under the new plans, GP Consortia will be renamed as Clinical Commissioning Groups, and will have governing bodies that include at least one nurse and one specialist doctor. Commissioning Groups will all be established by April 2013 but will not be authorised to take on any part of the commissioning budget in their local area “until they are ready and willing to do so”. Where groups are not ready, the NHS Commissioning Board will commission on its behalf.

Commissioners are to be supported by clinical networks, to advise on single areas of care such as cancer, and new ‘clinical senates’, who will provide multidisciplinary advice on local commissioning plans.

The role – and indeed the name – of NICE has also been modified. The Health Bill will rename NICE as the National Institute of Health and Care Excellence, to reflect its extended remit over social care. In a u-turn of sorts, NICE is to retain responsibility for recommending drugs and treatments on the NHS. Original proposals had suggested the agency would only appraise new products. NICE Chairman, Professor Sir Michael Rawlins, said the change would be welcomed by GPs who, he said, wanted a “blame quango” to be responsible for making decisions on whether or not drugs were cost-effective.

On the contentious issue of competition, the Government has said it will keep the existing rules on co-operation and competition in the NHS, and provide additional safeguards against ‘cherry-picking’ and price competition. Monitor’s core duty will be to protect and promote the interests of patients – not to promote competition “as though it were an end in itself.”

But Alan Milburn, now the Government’s social mobility tsar, accused ministers of backtracking. Milburn, who as Health Secretary began many of the market reforms, told the Daily Telegraph: “The promise of the coalition was that it would go where New Labour feared to tread when it came to public service reform. In fact, David Cameron’s retreat has taken his party to a far less reformist and more protectionist position than that adopted by Tony Blair and even Gordon Brown.”

Milburn said the new policy was the ‘biggest nationalisation since Nye Bevan created the NHS in 1948’ as it handed over control to ‘the daddy of all quangos’, the NHS Commissioning Board.

David Cameron has outlined a number of amendments to the Health and Social Care Bill following the Government’s ‘listening exercise’.

Hospital doctors and nurses will now be involved in commissioning services, health regulator Monitor will have a duty to promote integration of care, and the creation of ‘clinical senates’ are amongst the changes.

The BMA welcomed the changes to the Bill and says it is a “significant step in the right direction”.

The announced changes come after the Prime Minister pledged five ‘guarantees’ for the NHS to ease any worries over the controversial reforms.

In a speech to NHS staff in London, Mr Cameron said that the Government had listened and acted on the concerns from critics and introduced a number of important changes to the Bill.

Consortia – now to be made up of GPs alongside doctors and nurses – will only take over commissioning responsibilities when they are in a position to do so, and not by April 2013 as was first proposed.

The new ‘clinical senates’, which will consist of experienced medical professionals, will oversee the integration of NHS services across local areas. Monitor, the NHS economic regulator, will also have a duty to promote the integration of care across local areas. Also, greater competition of services will only be introduced when it benefits patient care and choice.

“We have listened and engaged and not just heard what people have said but we are going to reflect it in what we are going to do,” the Prime Minister said. “There are real changes being made to these health reforms to reflect the concerns of patients, doctors and nurses so we get that right.”

Hamish Meldrum, BMA Council Chairman, says it is encouraging the worries over the proposed reforms are been addressed by the Government.

“The Prime Minister’s speech suggests he is committed to integrated NHS services, and the involvement of a wider range of staff in their design,” he said. “However, he also spoke in glowing terms about the benefits of competition, and we would point to the many damaging effects its application in the NHS has had so far.”

“As always, it will be the reality of the changes that is important.”

As widespread changes from the NHS implementation begin to take shape, all eyes are turning towards the new plans for GP commissioning and GP consortia prescribing formularies. Omar Ali evaluates the changes and reviews the impact for both the NHS and pharma.

Access to medicines has wide reaching implications to every aspect of healthcare ranging from individual doctor-patient interventions, through to strategic shared care formularies across healthcare economies. However, as medicine access has far reaching tentacles entwining government policies, patient support groups and the pharmaceutical industry, any process to bring a change to the current status quo will be a challenging task. Bring forth The Coalition: our programme for government, an NHS document from the Secretary of State for Health whereby the introduction of GP Commissioning on outcomes and the creation of new GPC prescribing formularies is already underway.

The deficit and transitional mindset

The NHS already has its past – and the vision for the future is taking shape. But as with most things in life, it’s the transitional state of flux which is most painful. And this painful process will take some time. In years gone by, the NHS has seen budgets increase from £40billion to over £112 billion last year. The coalition has stated clearly, growth stops now. Growth this year was a miniscule 0.1%. It’s a flat line.

It is this flat line that is causing all the consternation around the £20 billion deficiency to come in the next seven years – this does not take into account the current deficit, which all PCTs need to settle prior to being extinguished. Whilst we can plan for future deficits and can do nothing about the past history, what the NHS is doing right here, right now, is having a direct impact on healthcare, associated providers, commissioning organisations, and of course the pharmaceutical industry.

When you next see someone from the PCT about why a drug isn’t funded – please don’t fall for the QIPP line, much abused terminology – remember this mindset. The PCTs have been combined into large regional clusters now – another process by which many jobs are ‘released/lost/liberated’, depending on your viewpoint. But what of the PCTs’ functionality when its days are numbered? Well, it goes like this: switch off the electricity, disconnect the gas, turn out the lights and vacate the premises – and don’t forget to settle the bills before you leave…

It’s a tough ask, but not an alien mindset. Settle all bills, leave everything as you found it, vacate the premises. I want to concentrate on this mindset. Firstly, it’s going to be difficult to think ahead about commissioning plans, medium term intentions and future funding when you’re not planning to be in the neighbourhood as such – or if you are, under a different role/guise/business solution. It’s probably quite easy and functional to get into ‘bailiff’ mode – sell assets, throw out excess junk, and remember, don’t forget to settle the bills. It is exactly this ‘interim’ phase of NHS reform that pharma is struggling with – no wonder your drug is not funded! No wonder medium term investment is often missing. No wonder QIPP is misaligned for simple ‘saving money’ as opposed to ‘self-funding innovative interventions’.

GP consortia will not inherit the current deficit of the PCTs/SHAs before they disappear – remember they will have their own £20 billion deficit to handle in less than seven years due to flat-line funding. Growth of NHS costs is, and will, continue to grow as it has done. Just because the coalition has stated flat-line funding it doesn’t mean patients/clinicians/interventions/pace-of-technology will change. It will continue, it’s just not matched by funding.

PCTs are desperately trying to ‘settle their bills’ before they vacate the premises. This will of course lead to some rash decisions, serious financial cuts and restricted investments. It must also be hard to keep delivering savings when you know that the gratitude at the end of it is probably ‘your job no longer exists, in fact, neither the does the PCT’. That probably explains why so many have left or are planning on leaving. It’s a thankless job with a thankless future. In fact, at least a quarter of my good NHS medicines management contacts have left their roles – which makes decision making on current PCT formularies even slower. But where have they all gone?

The new tenants

Current PCT medicines management (MM) teams can see what’s coming and, although some individuals do have their heads firmly in the sand, many are defining future roles and interpreting new models of medicines management and how GP consortia formularies will work. There’s basically four models of what medicines management will look like; but it’s crucial to understand how current medicines management model is funded.

The current model

We have more than 20 members within the medicines management team at our PCT. The funding required for this team’s salaries, wages, pensions, holidays and sick leave is more than £1 million per annum. The money is top-sliced further back at a SHA level – so it’s never really viewed as a cost at any level below this. The team are ‘just there’ – and they carry out the functions – as those in the industry have come to learn and love so well! Now, with SHAs & PCTs dissolving, this top-sliced money gets redirected back to the GPs.

Now they have the funds and decide what to do with it they will essentially become MM teams of the future. The issue is really on a day-to-day basis. The GPs would see various elements of what the MM team would do and they could take it or leave it to a certain extent. When you are not directly paying for something it’s easy to be keen, indifferent or against. So teams were often invited, and often unwelcomed, into GP premises to give prescribing advice which was either followed, obeyed or ignored. We were viewed as ‘reps for the government’ in a way. With prescribing plans and ideas that were ‘dislocated from the work that GPs do on a day-to-day basis’. Well, all that is about to change. Why? Because GPs will now pay for medicines management advice – and how they commission it will have a dramatic effect on how pharma interacts with the new GP consortia and the formularies they create.

The future model

There are four separate models of medicines management provider solutions that have emerged and are in play. It is critical for you to know about how these shape up in your territories – they will form the basis of the future relationships and in-roads to the new GPC prescribing formularies.

Why not just continue and not change? It’s not an option. Remember the £1 million that has been top-sliced by the SHA to pay for the MM team? Well the SHA/PCT are disappearing – and so with it does the £1million budget. So all around the country, MM teams need to devise a future model action plan for survival and they need it fast.

Model a: pharmacist/GP and the NHS ‘speed date’

Pharmacist(s) who are in well serving relationships and project interactions split away from the PCT/MM team and secure salary/funding with a GPC/or set of practices within the GPC. Trust me, GPCs don’t really understand what we do, so their idea of what we are worth, and my idea of what I am worth is fairly polarised. But they have the money and so proving this is firmly in my court. As an interim phase, some PCTs have ‘hived off’ their MM teams in an effort to assist the ‘speed date’ process. It’s kind of ‘here, check out these guys, fancy some of this?’ type discussion. To which the answer could be yes, no, or I will consider some other options.

Model b: pharmacy MM team forms a social enterprise

It rings of NHS and feels like NHS. All transactional profits are invested back into the system to pay for the services and projects carried out by MM teams. It’s an interesting notion and could be less appealing for those keen on starting enterprising ventures. But funds can come from a variety of sources including sponsors and the government when you are a social enterprise. Furthermore, it may be that GPCs are more willing to commission from a MM team that is set up not take profits out of the system.

Model c: pharmacy MM team forms a profit making company

You will see a fair amount of this. In fact, in our region, GPCs were encouraging a profit making company model. I guess it was kind of ‘why not join us in this new adventure’. Whereas actually it was more like, ‘we’ve all set up GP provider companies which make a profit, so what are you waiting for?’

What’s interesting about this model is that it takes away the responsibility from the GPCs that ‘they need to keep the team in existence’ or similar. Very often, I have encountered within England a GPC view that goes along the line of ‘we like what the team do, we think they should stay in some form, but we certainly won’t be coughing up £1million to keep them there’. That translates to: set yourselves up as a company, show us what’s on offer, and if it’s good, we may commission it. If it’s not then tough! That’s what being a company is all about.

Model d: GPCs opt for corporate management teams

This may not be good news. It’s the focus of a lot of critics of the White Paper. Remember when I said many of my colleagues had left the NHS? Well in keeping contact I have they are being sourced into companies such as Ernst & Young, Virgin Healthcare, AXA Medical, Boots, Lloyds and KPMG to name a few. Given many of these, if not all, have little or no medicines management commercial history, I decided to call them up and ask them what on earth they were doing there? This is the reply I keep getting: “They are building an army.” An army of high grade ex-NHS medicines management and hospital chief pharmacists. Why? To descend onto GP consortia and bring the world of the US-styled Managed Care Formularies to their doorstep. Most are starting on salaries of £85-£125k before bonus.

The offerings to GPCs will be tempting but with serious kickbacks. I can assure you if KPMG are running your territory GPC formulary, not only will they earn a fortune in return for prescribing costs that make the NHS QIPP program look like an F1 annual budget, but pharma will be very low down in the pecking order of accessing and influencing formularies. In fact, by the time you get there the prescribing guidance will have been truly done and dusted.

Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust.

GP consortia should continue their pace of development, despite the second consultation period for the Health and Social Care Bill, says the NHS Alliance.

The group believes that there will be no u-turn on clinical commissioning and is set to open a listening exercise to give GP consortia the support they require.

Dr Michael Dixon, Chairman of the NHS Alliance (pictured), says there is “no going back” on the plans outlined in the Bill and that political discussions will not result in “significant changes”.

The Alliance will now launch its own listening exercise to ensure consortia have a prominent voice at a time where it says there’s a “lack of real representation and a lot of confusion”.

“We are encouraging all GP consortia, especially pathfinders, to continue their pace of development and to not be distracted by the current hiatus in the passage of the Bill,” said the Alliance’s Chairman.

“It is undeniable that we need to listen to all professionals involved in making clinically-led commissioning happen, including nurses, allied professionals and consultants.

“But, to be meaningful, this listening exercise needs to be led by frontline commissioners. It is about time that commissioners' voices are truly heard. That is what the NHS Alliance listening exercise will do.”

MPs have recommended significant changes to the Health and Social Care Bill in a new report.

The cross-party Commons Health Committee propose that a number of representatives should be involved alongside GPs on commissioning decisions if the NHS is to meet its 4% annual savings target.

Former health secretary and Committee Chairman Stephen Dorrell says it’s “crucial” to get commissioning reforms right if the NHS is to meet the “massive financial challenge” it faces.

The report, Commissioning: further issues, includes a number of other recommendations such as renaming GP Consortia as NHS Commissioning Authorities and making NHS Commissioners accountable to the new NHS National Commissioning Board.

Under the proposals, representatives of nurses, hospital doctors, public health experts and local communities would sit alongside GPs on local NHS Commissioning Boards.

The boards should also be required to comply with the highest standards of governance and accountability, the report advises.

Other significant proposals in the report include that local authorities should continue their scrutiny of health services and that NHS commissioners should have a Chief Executive and a Finance Director. The Committee recommends that all NHS Commissioners should have an independent chair who is appointed by the NHS National Commissioning Board.

Committee Chairman Stephen Dorrell says the report contains a “set of practical proposals to strengthen the Health and Social Care Bill” and help the Government meet its objectives.

“Our proposals are designed to ensure that NHS Commissioning involves all stakeholders – GPs, certainly, but also nurses, hospital doctors, and representatives of social care and local communities,” he said.

“We believe this broadening of the base for commissioning is vital if we are to achieve the changes that are necessary to allow the NHS deliver properly coordinated healthcare”.

The Committee also believes its recommendations would end proposals in the Bill to separate the commissioning of primary and secondary care. It also proposes that Commissioning Authorities should be responsible for commissioning primary, secondary and community healthcare, as well as creating strong links with social care.

“Ever since 1948 the NHS has suffered from an artificial distinction between primary and secondary care,” Mr Dorrell added.

“Instead of entrenching this distinction further, this is an opportunity to abolish it for good – and create a single, integrated health service which is able to provide properly coordinated health and social care to all patients.

“It is an opportunity to deliver greater efficiency and high quality at the same time. It is a “win-win”; what is the argument against?”

By Chris Ross, Pf Editor

Debate around the virtues and implementation of the Health and Social Care Bill continues to dominate the news. Sir David Nicholson’s frank and informative contribution to the recent Public Health Committee’s discussion of the Bill offered some fascinating insights into what is uniformly agreed to be vast change for the NHS. Indeed, its own Chief Executive says the reforms, alongside the quality and efficiency challenges facing the health service, are “so large you can see them from space”.

The recent Government announcements of 141 Pathfinder groups is already courting controversy. Analysis of the groups has revealed that NHS South West has allowed different consortia to cover the same geographical area. The Government’s draft legislation states consortia must not coincide or overlap when they are formally established in 2013. NHS South West has said the current overlap is temporary and designed to assess the suitability of different models for GP commissioning.

This appears a fair response, given the gravity of ensuring that the new system works. Nicholson says that GPs need to engage with the changes that are happening now and provide leadership and input to make them happen. One of the criteria for becoming a Pathfinder, he says, is that they engage in the QIPP process. He has warned that if they do not work through the important issues now, they will not have budgets in 2013 because all the money will have been spent.

In an economic environment pointing ever more towards demonstrating value, the industry has a great opportunity to show how investment in its products can help GP commissioners to improve services, benefit patient health and meet challenges that are so big, they can be seen from space.

 

Contact the author: chris.ross@healthpublishing.co.uk

The role of NICE will not really change under the latest health reforms, the Chief Executive has said in an interview.

Speaking to GP, Sir Andrew Dillon explained that NICE will continue to have an important role in assessing the clinical and cost-effectiveness of new drugs.

He also said that the Institute hopes to be the “go-to place” for GPs for advice and support in their new role as commissioners.

Under the changes detailed in the Government’s White Paper, NICE’s role will become more ‘advisory’ and it will be up to GP consortia to decide which treatments they will fund. However, the Chief Executive does not see this as any great change.

“NICE's guidance on new drugs has been, and remains, guidance,” he told GP. ”It doesn't override the responsibility that health professionals have in individual cases to make a judgment that is in the best interests of individual patients.”

NICE will also have a role in producing clinical guidelines and quality standards, and in developing the commissioning outcomes framework, which will judge the success of GP commissioners.

“What we want to do is to make it as easy as possible for people to make the right decision for individual patients about new drugs,” Dillon explained. “To do that, we need to very clearly set out the optimal position of new treatments in clinical practice and we hope to carry on doing that.”

He added that he is looking forward to working more closely with GPs: “There’s a real opportunity for NICE to become a really important, helpful, supportive resource for GPs. That's our intention.

“We'd love to be the go-to place for GPs both in their work as health professionals and the job they have to do as commissioners.”