The Role of GPs in Commissioning in the

New NHSDr David JennerGP Cullompton

Chair Eastern Locality NEW Devon CCG

Probity Statement

These are the views of Dr David Jenner in his GP provider role and although informed by his CCG role should not be attributed in any way

to NEW Devon CCG

What Is Commissioning?

•“Is the process of specifying,securing and monitoring services to meet peoples needs at a strategic level” (Audit Commission)

•General Practice a call to action

Commissioning In Health

• In health it involves four key steps

• Health Needs Assessment

• Planning of services to meet identified need

• Procurement of services to effect health improvement and reduce inequalities

• Ongoing audit and evaluation of the effectiveness of services

A Brief History of Health Service Commissioning

1990 purchaser provider split in NHS 1991 GP fundholding started 1997 GP fundholding abolished 1999 PCGs 2002 PCTs (c300) 2003 Health Authorities go 2003 Strategic Health Authorities begin (30) 2003 New GMS contract

A Brief History of Health Service Commissioning

2004 Foundation Trusts 2005 Payment by results 2005 Practice Based Commissioning 2011 PCTs reduced in number and clustered 2012 Health and Social Care Act passed 2013 Clinical Commissioning Groups begin 2013 NHS England established

Who Commissions What Currently?

• Department of Health

• NHS England

• Local Authorities

• Clinical Commissioning Groups

• Public Health England

• Health Education England

Department of Health

• Secretary of State for Health sets annual mandate with national commissioning bodies (NHSE,HEE,PHE)

• Is meant not to intervene in day to day running of NHS but this does still happen!

NHS England• Commissions Primary Care Services

• (Core GP services,dentistry,pharmacy,optometry)

• Commissions Specialised services

• (e.g.renal dialysis,heart transplants most cancer services,specialised psychiatry)

• Regulates CCGs (has total reserved powers)

CCGs

• Commission majority of hospital based services (excepting specialised services)

• Commission services for the “big four” cancers

• Prostate,breast,colorectal,lung

• (except radiotherapy,chemotherapy and specialised surgery) e.g.robotic surgery

• Commission community services

• (e.g. community therapy and nursing)

CCGs

• Commission some locally commissioned GP services

• These are services provided over the core GMS/PMS/APMS contract (except core is non defined)

• (e.g. warfarin monitoring,leg ulcer care)

• Commission psychiatric and learning disability services (often jointly with Local Authorities)

CCGs

• Commission some home care for NHS purposes

• (continuing health care)

• Commission some residential nursing care for NHS purposes

• Commission some charitable services

Local Authorities

• Commission social care and jointly commission psychiatric and learning disability with CCGs

• Commission local Public Health Services

• (e.g. contraceptive services,smoking cessation)

• Commission social care -domiciilairy and residential

• Commission educational services

• (but not free schools)

An ExamplePatient with Prostate

Cancer

• Diagnosed by GP -commissioned by NHSE

• Referred to Out Patients-funded CCG

• TURP -CCG pays

• Robotic surgery,radiotherapy or chemotherapy-NHSE pays

• Hormone therapy -CCG pays for drug and local contracted service for GPs to deliver

Example Patient with Unwanted Pregnancy

enstrual Bleeding

• Contraceptive advice commissioned by L.A.

• Some of this commissioned by NHSE on behalf of PHE in the QOF (LARC advice)

• VTOP commissioned and funded by CCG

• IUS fitting and care in General Practice -commissioned and funded by NHSE-but if fitting was for menorrhagia would be CCG!

So How Do You Join This All UP

• Locally Health and Wellbeing Boards

• These are responsibility of Local Authorities

• Include CCGs,NHSE,LAs,voluntray sector

• They undertake

• Joint Strategic Needs Assessment

• And then coordinate local services to meet these needs

CCGs

• Are membership organisations of GP Practices

• Each GP practice must belong to a CCG

• Each must nominate a lead healthcare professional to liaise with CCG

• Have GPs elected to the Governing body

• Can have a GP majority on Board (but often don’t)

CCG Membership

• In theory GPs have the power to make local commissioning decisions

• But must abide by many national “must dos”

• NHS Constitution,waiting times targets

• GP Practices devolve responsibility for CCG functions to the CCG Board

• They are not accountable for any financial losses

• NHSE hold total reserved powers over CCGs

Who Commissions General Practice?

• NHS England (core GMS/PMS/APMS)

• CCGs

• (Local and national enhanced services, OOH care)

• Public Health Via Local Authorities

• (some contracted services)

• Some nursing homes/private providers

But In Future

• GP commissioning being devolved back to CCGS

• Three levels of this

• Greater Involvement in decision making

• Joint commissioning arrangements

• Delegated commissioning arrangements

And Why This?

• NHS Five Year Forward View is all about integration

• Health and Social Care Act has fragmented commissioning

• General Practice is most locally sensitive part of NHS-NHSE is not!

• NHSE don’t have enough staff!

Co-Commissioning issues for GPs

• Potential for serious conflicts of interests

• A membership organisation commissioning itself?

• But could empower GPs more to move resources into primary care

• And this is what is expected and encouraged

The Five Year Forward View

• “Steps we will take include … [giving] GP-led clinical commissioning GPs more influence over the wider NHS budget, enabling a shift in investment from acute to primary and community services…NHS England is giving CCGs the opportunity to assume greater power and influence over the commissioning of primary medical care from April 2015.”

The Realities for GPs

• No new recurrent funding streams for GPs services

• 66% NHS trusts in deficits

• 33% CCGs in deficit

• Trusts (mostly) on PbR pay as you go contract

• GP contracts cash limited

• Very difficult to get money out of hospitals

Opportunities for GPs in Commissioning

• If your CCG has growth money -use this to redesign care

• Have influence over local service provision and care pathways

• Make impacts at population level for patients

• Move the investment (upstream) into primary care (not necessarily GP’s pockets!)

• Develop business skills and intelligence for GP provision

Risk for GPs in Commissioning

• What will the Daily Mail say?

• Having to front up disinvestment decisions

• Tension with colleagues in their provider role

• Being asked to “do more with the same”

• Professional accountability to GMC for service failings

• Time away from practice -GP shortage

The Future 5YFV

• Multispeciality Community providers (MCPS)

• These are horizontally integrated community providers (GPs/community nurses/therapists/pharmacy/community hospitals

• In time might replace traditional GP practice model

• In time may also take over hospital services

• e.g Bexley ,Whitstable

The Future 5YFV

• Primary and Community Care Systems

• Vertical integration hospitals and GP services

• Could be mutual or “takeover” where GP services failing

• Probably more of an inner city model

• GPs could be salaried (most likely) or in joint ventures with acute trusts

• e.g. Symphony model Yeovil

Spot the Difference

• These look like different entry points to an integrated local provider

• Would run on fixed capitated budgets for a population

• Examples in Valencia Spain,Alzira

• GPs then influence provision from inside rather than in CCG

• Commissioner role becomes more assurance and performance management against outcomes

Capitated Budgets

• Are capped and usually run over time spans longer than a year (up to ten)

• Moves financial risk from commissioner to new integrated provider

• Encourage efficiency big time

• Would drive resource from expensive product lines ( bed based care) to less expensive lines (out of hospital care) where possible

Commissioners in Future

• Devo-Manc solution -budgets transferred to Local Authorities

• This allows merger of health and social care budgets

• Allows local democratic influence

• Integrated providers may effectively do what commissioners currently do

What is The Added Value of GPs in Commissioning

• Uniquely placed with both responsibilities for individual and population health

• Key roles in prevention and health education

• Local knowledge and sensitivity

• Highly educated and intelligent

• Address a broad spectrum of disease and therapeutics

Opportunities

• GPs can make commissioning part of a portfolio career

• Currently CCG require GP board members to be on performer list (can be sessional)

• GPs can just offer time on their interest areas-e.g product champion for stroke

• GPs can progress to full time management careers

• (e.g. Sam Barrel CBE now CEO Musgrove Hospital

But Most Important

• Every decision they make is a commissioning one

• To Prescribe

• To refer

• To treat

• To educate and inform choices

GPs Get 8% of the NHS Budget

• But directly or indirectly commit over 75%

• So aligning responsibility for the budget to whose who deploy most of it makes perfect sense

• But is this the “breath of life” or poison chalice

• Choose wisely!