Surely not a mini-PCT?

Governance and relationships for GP commissioning consortia

The NHS White Paper "Liberating the NHS" has confirmed the Government's proposal for commissioning to be devolved to GP commissioning consortia, and the follow-up consultation paper "Commissioning for Patients" has fleshed out some of the detail of the proposals and identified areas for consultation. In this note we look at the proposals and some of the implications for the development of GP commissioning consortia. 

What is proposed – so far

The proposal clearly sets out the requirement for all GP practices, including any private sector organisation holding a GP contract with a list, to form part of a consortium.  The consortium will be responsible for commissioning the majority of NHS services but not primary care contracts, maternity services or specialist services where these require to be dealt with on a national or regional basis. It is also clear that the commissioning consortia will be statutory bodies whose role and functions will be determined by primary and secondary legislation. This will carry with it a number of obligations including compliance with:

• public procurement law
• general public law requirements for decision-making
• equalities legislation
• consultation obligations
• the NHS Constitution
• duties of co-operation with other bodies both generally and specifically in relation to protection of the vulnerable and management of dangerous offenders
• and probably, freedom of Information.

Although the commissioning consortia will not have a number of functions currently carried out by PCTs, notably the health improvement and public health functions and the primary care functions, the status and requirements begin to look somewhat like those facing PCTs. 

Size and shape

The White Paper documentation is non-prescriptive around size and geographical shape of the consortia. Consortia will have to have geographical boundaries if only in order to deal with responsibilities for people where this is not tied to GP registration or the individual is not in fact registered. It is recognised that some degree of geographical coherence will be required but this is part of the consultation.  It also raises interesting questions around the relationships with local authorities, both on the basis of practice areas not necessarily corresponding to local authority boundaries and joint working possibly being prejudiced by too great a dissociation between GP consortia and local authority areas. 

Governance

At present, the only governance requirements appear to be that the consortia will be controlled by the GP practices, and will have an Accountable Officer and a Director of Finance. It appears, particularly from the proposal to abolish the Appointments Commission, that they will not have non-executive directors in the way that PCTs do. In practice it is likely that, given the clinical commitments of GPs, what will emerge is a model not dissimilar to a local authority where GPs equate to the authority members and there is a support team of officers, which may include individual GPs working whole- or part-time within the commissioning organisation. The perhaps more interesting implication of the current proposals is the reference to an NHS Commissioning Board authorising GP commissioning consortia. This may mean that the Commissioning Board will insist, both at the initial authorisation and subsequently, on the consortia being able to demonstrate adequate engagement with public and patients, and indeed with the local authority. It could require non-GP clinical input into the consortia or public representation on the Consortia Board. 

Whatever governance structure evolves, it would appear that GP consortia will need to have clear decision-making processes and for some of these, such as decisions around the margins of NHS, care will need to be addressed.

The nature of the relationship between the consortia and the Commissioning Board may be dealt with through something resembling an FT authorisation or may be more a matter of regulation, or a combination of both. It is quite likely that, given the fact that membership of a consortium is compulsory and the consortia need to cover the whole of the country, the effective sanctions for poorly performing consortia will be either financial, both in terms of individual GP contract payment variation and loss of incentive payments in the consortia, but beyond that the scope would appear to be limited to imposition of external management on a consortium in much the same way that Monitor has his powers under section 52 of the 2006 Act. 

Governance within the consortia

In addition to the normal internal procedures for any organisation the commissioning consortia will need to consider the nature of their relationship with the individual GP practices. The standard form primary care contracts will be amended, subject to negotiation, to impose obligations on the contract holders to engage with the consortia and to co-operate in achieving the aims. This is likely to be linked to payment.

The extent to which consortia or members can give notice of change or indeed on what basis or terms is at present unclear. Subject to any legislative constraints we would recommend that the consortia consider quite detailed agreements as to membership of the consortium, processes for the co-operative achievement of aims and requirements around sharing of practice information, particularly if the consortia in effect inherit the responsibility of assessing performance for the purposes of the revised Quality and Outcomes Framework. Given the scope for these arrangements to become contentious, consortia should consider dispute resolution processes as part of the exercise. It is at present unclear whether the current FHSAU dispute resolution option will be available, but that may well be cheaper and quicker than the courts in the event that disputes cannot be resolved amicably.

Relationships with the local authority

It would be a mistake to view the current round of changes as purely an NHS issue and a time for the NHS to turn inward and sort out its own future. Local authorities have an enhanced role around health planning and public health and it is anticipated that the GP commissioning consortia will inherit current PCT roles in relation to Section 75 partnership working and, in particular, around joint commissioning and pooled funds. GPs may need to understand a new range of skills and abilities and failure to engage effectively is likely to prejudice the outcomes for patients on which both consortia and the Commissioning Board will be judged. This may raise some important issues around time commitment from consortia and, while it is possible that much of the operational liaison can be carried out at officer level, there will need to be adequate delegation of authority within the consortia to enable this to be effective. 

Conclusion

The new consortia which PCTs are to support over the next 18 months as they emerge will need to consider a range of governance requirements that flow from public body status and the need to deliver challenging financial and clinical targets. The nature of consortia is likely to lead them to imitate some of the characteristics of other public bodies but the intention is clear that these should be slimmed down and will not have a complex bureaucracy. Whether they can deliver the requirements on that basis remains to be seen.