The White Paper requires all healthcare providers with a registered list to be part of a consortium responsible for commissioning the majority of NHS services.
The government apparently believes that for GP practices this will make for happier working relationships than many have experienced in trying to work with their PCTs to make practice-based commissioning succeed.
Currently, many GPs are thinking about which practices they would like to join forces with to commission healthcare and, no doubt, some will be thinking about a practice or two they would prefer to see joining someone else's consortium.
The White Paper states that 'practices will have flexibility within the new legislative framework to form consortia in ways they think will secure the best healthcare and health outcomes for their patients'.
Achieving huge savings for the NHS while providing improving patient care mean that consortia will need to develop strong working relationships between their member practices. While their role and functions will be determined by legislation, how to do this needs careful consideration.
There are reports of early adopters courting top performing practices. This may leave the less attractive practices on the shelf - for example, those with high referral or prescribing rates or poor patient satisfaction levels.
Irrespective of this, all practices should plan ahead and start talking to each other about what future consortia and models of provision may look like locally.
However, it may be unwise to commit to any particular consortium too soon.
Stewardship of resources
We are told that the NHS Commissioning Board will be responsible for holding consortia to account on 'stewardship of NHS resources' and outcomes for their population, and that sanctions on underperforming consortia will be financial.
In turn, it seems that consortia will be expected to hold their constituent practices to account.The consultation paper Liberating the NHS: Commissioning for patients states consortia may be required to undertake 'promoting quality improvement, reviewing and benchmarking practice performance and ensuring clinical governance requirements are met'.
Given this, each consortium will need to start preparing the ground rules on how they will interact with practices to ensure that:
- Member practices' contributions of time and other resources are recognised and reimbursed appropriately.
- What is expected from members is clearly set out, including the powers the consortium's board will have for requiring data and taking action against underperforming members.
Once member practices have signed up to these ground rules, the consortium will need to appoint the key individuals who will lead the transition to becoming operational and ensure they have the sufficient time and resources to perform this role appropriately.
Examples of clinician-led organisations in California (a similar model to our proposed GP commissioning groups) suggest that commissioning consortia can work successfully and significantly reduce admission and re-admission rates.
They have shown that cost savings can be a powerful incentive: it is financially beneficial to see that patients are kept well and not admitted to hospital unnecessarily.
They also demonstrate that the financial rewards go to those able to support and enable doctors to practise high quality and appropriate medicine and to effectively co-ordinate care with other parts of the health and social care sector.
Reward or exclusion
In the Californian model high performing practices are rewarded with bonuses. Poor performers are initially offered support to improve but, ultimately, can be excluded from the group and lose access to the group's commissioned services.
The same is likely to be true here, with the consultation paper stating consortia would be able to apply 'peer review and challenge in the first instance to areas where there appear to be unwarranted variations in practice or outcomes'.
Independent contractors are now forced to co-operate with each other, so peer review and challenge on this level will be a highly uncomfortable function for many GP practices.
Early attention to the warning signs is essential to turning around struggling practices and essential to maintaining effective working relationships. This does, however, require systematic audit and careful monitoring against benchmarks of a wide range of activity: referral, prescribing and financial data.
For every consortium this is likely to mean sharing data with member practices. This might also lead to difficult discussions aimed at ensuring an under-achieving practice brings its performance in line with the other practices.
So what happens if things go wrong and relationships are stressed, particularly where the many are let down by the few?
This is where the aforementioned ground rules will need to come into play as maintaining effective relationships within a consortium will be essential to ongoing effectiveness and performance.
If these relationships begin to break down, it may be time to bring in some external support from external colleagues, accountants, or consultants. This will provide objectivity, and help to address variations in performance.
The bottom line, if a consortium is broken up or member practices are expelled, is that outside a consortium GPs will be unable to hold a registered list.
Given this sanction and how it would impact on patient care, perhaps the threat of losing their patients will ultimately be sufficient to persuade member practices to see past the discomfort of peer review and being challenged about their performance to achieving effective teamwork and healthcare quality improvements.
Former PCT performance manager Joanne Bartlett is a consultant at Acton Shapiro Consultancy and Research, www.actonshapiro.co.uk