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Introducing GP consortia

Country: 
United Kingdom
Partner Institute: 
London School of Economics and Political Science
Survey no: 
(16)2010
Author(s): 
Adam Oliver
Health Policy Issues: 
System Organisation/ Integration
Reform formerly reported in: 
Empowering GPs: a return to fundholding
Developing Practice-Based Commissioning
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Abstract

A central aspect of the new UK coalition government's plans for the NHS is to abolish primary care trusts and replace them with budget-holding GP consortia. The government claims that this is a revolutionary direction, devolving more responsibility to the local level, whilst others see the policy as almost a continuation (or evolution) of previous governments' attempts at giving more financial responsibility to GPs. This report will summarise the policy proposal.

Recent developments

In July 2010, the new coalition government released a White Paper, detailing its plans for the NHS over the coming years. A central aspect of these plans is to abolish PCTs and hand the power and responsibility for commissioning health care services to local consortia of GP practices (each consortia will comprise of a number of GP practices, each of which will presumably employ managers to help them fulfil their responsibilities). The government sees GPs as the best placed people to manage, organise, understand and commission health care services for their local populations and believes that the devolvement of power to a more 'local' level is a key step towards improving quality and value for money in the health care system. Also, the government has committed itself to reduce management costs in the NHS by 45%, and is therefore abolishing PCTs presumably with a view to reducing management personnel at that level, although (as noted above) GP consortia will have to reemploy managers to help in the commissioning of services. The White Paper states explicitly that the need for good managers performing essential functions will remain, but the consortia will be expected to operate within a maximum management allowance.

The government has also announced that it plans to establish an NHS Commissioning Board, which will be given the responsibility of calculating budgets, based on quality-adjusted weighted capitation, and then allocating these to the GP consortia. Like PCTs and GP fundholders before them, the GP consortia will then, within these budgets, provide primary care and negotiate contracts with providers for the provision of hospital care.  

Although the fundholding idea is not as innovative as some are advocating it to be, the government has proposed a new aspect in relation to primary care in that the public will be given greater choice over which GP practice they wish to enrol with, under the assumption that this will drive up quality, due to practices wanting to attract patients. Currently, patients tend to be enrolled with the practice closest to where they live, and although they can ask to be enrolled with other practices, many practices refuse due to their lists being full - the patient's most local practice cannot refuse. GPs are mostly essentially independent businessmen/women, and have up until now enjoyed the right to refuse patients who live further away than other practices if they so wish, so it will be interesting to see how this new choice direction will develop, both in terms of whether a significant number of patients will want to switch practices, and, if they do, whether this will have a substantial effect on the quality of primary  care services provided.  

The government has announced that the GP consortia will be expected to take full financial responsibility for their patients from April 2013. By this point, therefore, PCTs and practice-based commissioning will be abolished, since the commissioning function will have been handed to the consortia, and (in the case of PCTs) the health improvement function will be transfered to local authorities.

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent neutral system-neutral
current current   previous previous

I perceive the degree of innovation as rather traditional, because I think it mirrors very closely the general fundholding idea that has been developed in the NHS over the past 20 years, although some would no doubt disagree with me. I don't think the policy is 'publicly' controversial, but it has clearly created controversy within the sector, given the abolishing of PCTs, the extra responsibilities for GPs, etc. In this sense, the restructuring of the NHS is somewhat fundamental, although the overall structure of the system - centrally tax financed, with delivery and purchasing devolved to the local level - has not changed that much. I don't think this level of policy detail is particularly noticable or of interest to the general public, and the innovation is probably specific to the NHS, although I suppose GPs in many other countries could in theory become fundholders.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no yes no no no no

Initiators of idea/main actors

  • Government: Central government
  • Providers: GPs
  • Payers
  • Scientific Community
  • Media

Stakeholder positions

The coalition government is obviously very supportive of the policy, and their position is strong. The British Medical Association appears to support the policy on the whole, and seems to be co-operating with the government to make it work, but individual GPs have shown, at best, a mixed reaction to whether they believe the reforms will genuinely improve the NHS. As one might expect, PCTs are against the proposals as their managers will either lose their jobs or be forced to reapply for positions that are similar to the ones they already hold. Academics have a mixed view also - some seem to believe that the new direction is revolutionary, others evolutionary, and still others think that it is mostly a recycling of old ideas - old wine in new bottles. The newspapers and TV have tended to report the policies in mainly neutral terms. The details are probably too dry to sell copy or increase viewing figures. The government has promised to ring-fence NHS spending during the life of this parliament, meaning that the NHS is largely immune from the cuts that are being applied to most other sectors. Had the government reduced NHS spending, we could have expected more sensationalist reporting of their NHS policy direction in the media.  

Actors and positions

Description of actors and their positions
Government
Coalition governmentvery supportivevery supportive strongly opposed
Providers
British Medical Associationvery supportivesupportive strongly opposed
Individual GPsvery supportiveneutral strongly opposed
Payers
PCTsvery supportivestrongly opposed strongly opposed
Scientific Community
Academicsvery supportiveneutral strongly opposed
Media
Newspapers/TV etcvery supportiveneutral strongly opposed
current current   previous previous

Influences in policy making and legislation

The plans outlined in the White Paper, including all those listed above, will have to be approved by parliament. They are due to be considered in the legislative programme for the current parliamentary session (autumn 2010). Since the coalition government enjoys a sizable majority, it is very likely that the policy programme will be approved. However, the government may face some legal action from PCTs or unions, because it has been argued that some of their plans were not included in the party manifestos of the Conservatives or the Liberal Democrats before the general election, and therefore lack a mandate.

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Government
Coalition governmentvery strongvery strong none
Providers
British Medical Associationvery strongstrong none
Individual GPsvery strongneutral none
Payers
PCTsvery strongweak none
Scientific Community
Academicsvery strongweak none
Media
Newspapers/TV etcvery strongstrong none
current current   previous previous
Coalition governmentBritish Medical AssociationAcademicsIndividual GPsNewspapers/TV etcPCTs

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

This has all been included above. Clearly, the PCTs are losers, although many of the PCT managers will no doubt be employed by the new consortia, because the managers have the valuable experience of negotiating contracts with the hospital providers. The GPs will be affected, as they will now be expected to exercise more responsibility over the health care budgets, although the extent to which many of them have the time or abilities to do this is debatable. One of the main reasons why the number of PCTs was reduced through mergers in the past was because they were previously too small to negotiate efectively with the large hospital providers. Given that it seems likely that the number of GP consortia will be substantially larger than the number of PCTs that they are replacing, it is possible to conclude that the policy direction is something of a backward step, although, in theory, the consortia will be heavily supported in their commisssioning decisions by the new NHS Commissioning Board, which will (among other things) set commissioning guidelines on the basis of quality standards developed with advice from NICE. Patients and the public are meant to be affected, via a better quality, more efficient health service, although whether this is an eventual outcome of the reform remains to be seen.

Monitoring and evaluation

The policy hasn't been implemented yet, and therefore monitoring and evaluation is many years away. However, a regulatory body called Monitor will be given the power to protect essential services and to help create an NHS 'social market' in which the consortia and patients actively seek the best hospitals to provide health care. Monitor will be given the power to prevent anti-competitive behaviour by both the consortia (who may otherwise 'stick' with incumbant providers) or by powerful health care providers. Moreover, the Care Quality Commission will be given a stronger role in assessing hospitals so as to ensure essential levels of safety and quality  

Expected outcome

The policies have not been implemented yet, so this section is not applicable.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high
current current   previous previous

Far too early to tell of course. If I were to hazard I guess, I don't think the policy will have much effect on the quality, productivity or value for money of the health care system, mainly because previous experiments with fundholding in the 1990s did not have a huge overall effect.

References

Sources of Information

Department of Health. Equity and Excellence: Liberating the NHS. The Stationery Office: London, 2010.

Reform formerly reported in

Empowering GPs: a return to fundholding
Process Stages: Implementation
Developing Practice-Based Commissioning
Process Stages: Implementation, Evaluation, Change

Author/s and/or contributors to this survey

Adam Oliver

Suggested citation for this online article

Adam Oliver. "Introducing GP consortia". Health Policy Monitor, October 2010. Available at http://www.hpm.org/survey/uk/a16/1