It is difficult to be sure what exactly is happening with GP commissioning across England.
Progress seems to vary across issues such as the size of patient population within GP commissioning consortia, whether control over commissioning budgets has been delegated to GPs and how being classed as a 'pathfinder' is interpreted.
Some GP consortia are hungry for responsibility; some PCTs are risk averse and reluctant to delegate budgets and powers. Some consortia have clinical leaders and management in place; others have yet to make substantive appointments.
And there is a range of practice engagement - from universal sign-up of enthusiastic practices in some localities to a mix of apathy and hostility elsewhere.
Consortia are in shadow form until April 2013 when, if authorised as a statutory body, they will have legal responsibility for their commissioning budgets. Until then PCT boards are able to delegate this responsibility to them.
With financial control being the main emphasis in the DoH operating framework for 2011/12, the new PCT clusters will be relying on their shadow consortia to make financial savings through the agreed local Quality, Innovation, Productivity and Prevention (QIPP) programme. Consortia will also be expected to come up with other approaches for redesigning local services.
So what is happening?
Take the example of Stoke-on-Trent where I practise:
- The city is ranked as the eighth worst nationally for health deprivation.
- Seventy per cent of the population live in areas classified as the 20th most health-deprived in England.
- Practice-based commissioning (PBC) was becoming well established in 2010/11.
- Each of three NHS Stoke localities were giving strong clinical leadership to different commissioning areas - to planned care and children's and maternity services or to emergency and urgent care or to mental health services.
- The PBC localities had shadow budgets with a lot of peer pressure on reducing practices' use of secondary care and incentives to contain prescribing budgets.
- Shadow consortium now covers 280,000 patients - the same population as the PCT. There are three localities, with the same practices per locality as in PBC days.
The neighbouring North Staffordshire consortium has a patient population of around 220,000.
Initially we discussed with the LMC the possibility of combining to become a 500,000 patients consortium.
This seemed worth exploring as locally there is one acute hospital trust - currently being rebuilt with 300 less inpatient beds - and one mental health trust. Both consortia commission most secondary and mental healthcare and mental health services from these two trusts.
But we decided to re-assess whether such a merger would be advantageous in 2013. While Stoke-on-Trent has a disproportionately bigger commissioning budget because of its higher levels of deprivation, it needs more time to plan how to combining the two consortia without disadvantaging the city's population.
While awaiting the SHA's response to our application for pathfinder status we set up our consortium and associated locality infrastructure with 65 per cent of the management costs previously allocated to PCT commissioning.
PBC clinical leads agreed with the PCT how the consortium would be established.
The GP chair and six GP leads were appointed in January 2011 after an application process open to any GP working for at least one day a week in a Stoke-on-Trent general practice in the previous year. GP partners, salaried doctors and regular locums could apply.
The appointment process was agreed with the LMC. The competence of any GP applicants for the position of consortium chair was matched against the job description/person specification by a GP/manager panel that included an LMC representative.
In the event there was only one applicant who was interviewed and we did not need to proceed to the planned local election process. There were competitive interviews for the six GP leads.
Our new consortium worked with the outgoing senior management team of the PCT to set up the management infrastructure before the PCT directors migrated to the new Staffordshire cluster of three PCTs last month.
The Stoke-on-Trent consortium is a subcommittee of the PCT board, with membership comprising the six GP leads, a general manager, two lay members, a PCT non-executive director, the director of public health and the GP chair.
We have a commissioning budget of around £364 million (with £45 million blocked back) for 2011/12, around 80 per cent of the overall PCT budget with expectations of making between £10 million to £15 million QIPP savings.
The consortium is responsible for some specific local enhanced service (LES) initiatives, for instance, Stoke's recently established quality improvement framework with around £1.5 million incentive and development funds being realigned to support effective GP commissioning.
The LES that underpins the inter-practice agreement with the consortium (£1.15 per patient) rewards practice engagement in the consortium's priorities, and locality development funds (£2 per patient) will aid service redesign.
The QOF's new emphasis on effective referral to secondary care should aid practice engagement in minimising avoidable outpatient referrals and hospital admissions.
So that is our structure, and we now need to further develop our processes to achieve the pledged outcomes in services redesign and service improvement within our set budgets.
- Professor Chambers is a GP in Stoke-on-Trent and honorary professor at University of Staffordshire