The coalition government’s basic idea for its reorganisation of the NHS in England is that responsibility and budgets for commissioning health care will move from the Primary Care Trusts (PCTs) to groups of GP practices – or local ‘consortia’.
When the scheme is up and running, a consortium will have the budget to provide a hip replacement operation and will find the best place within that budget for the patient to have the operation. In doing so they will have to balance the expertise available and its costs with the patient’s newly strengthened right to choose their treatment.
As plans for our local consortium are worked out, Dr Jonathan Glover of the Marlborough Medical Practice will be attending the negotiation meetings in place of Dr Richard Hook who is about to take a sabbatical. Dr Glover told Marlborough News Online about the advice they’ve been given about their consortium’s size.
“So far we have been advised that the bigger the better. The more patients you have in your commissioning group, the louder your voice and the more say-so you will have about what you can ask on your patients’ behalf locally.”
The precise map of the consortium to serve the Marlborough area is not yet settled. But it looks as though the consortium will stretch from Ramsbury in the east to Corsham, Yatton Keynell and Sherston in the west and run south to take in Pewsey. It may even include Devizes.
That’s large – larger than the ‘local consortia’ the White Paper signalled.
“Snap. I was really quite excited about the prospect and thought that what we were going to have was perhaps the equivalent of a slice of cake coming out of Swindon with Wroughton, Chiseldon, Ramsbury, Bedwyn, Burbage, Pewsey and Marlborough. I was really quite excited about a consortium of that size with maybe a hundred thousand patients, but in effect we’re going to be more like 180,000 patients.”
“But the advice from the rest of the country is that if you are much smaller than that you won’t have a voice.”
It is also thought the size of consortia is being set by the need for economies of scale to achieve the government’s promise to cut NHS admin costs by 45% over the next three and a bit years. The average size of consortia already set-up is about 200,000. One in Somerset is said to involve 76 practices and cover 539,000 people and, at the other end of the scale, the one serving the Newquay area of Cornwall covers just 28,000 people.
When the reorganisation was launched, GPs were told that they’d have to take over commissioning whether they liked it or not. As Dr Glover puts it:
“If there’s a ship going, it’s better it leaves with you than without you. So it doesn’t entirely have our blessing but we feel that if it’s going to happen we want to have more of a steering than a passenger role.”
“That’s the reason for our involvement – not because we give it our wholehearted blessing but we feel it’s going to happen anyway.”
Dr Glover is “twitchy” about Health Secretary Andrew Lansley’s open support for the wide privatisation of services: “He’s pro it – that needs reining in a little bit.”
And although the NHS Bill’s progress through parliament has been put on pause by the prime minister, work on forming the consortium continues.
“We’re carrying on simply because standing still and waiting for the politicians to make up their minds isn’t really a viable option. We need to be, in part, driving a change if anything’s going to succeed.” The alternative would be “a wishy-washy change that is subject to failure because of lack of drive.”
So far the consortium is being funded by a payment of £2 per patient. It’s not yet clear whether this is a one-off payment. There’s also money available from the savings GPs are currently required to make – some of which will go towards the new admin costs.
2011 is supposed to be the year the consortia shadow the doomed PCTs. So consortia will soon have to start employing people and setting up headquarters.
“You recruit the best team you can and reward them appropriately. Some will be GPs, some existing practice staff and some will come from PCT staff.”
How would Dr Glover react if after this unusual pause in the Bill’s progress, changes were made to get it through the House of Lords that included putting councillors or patients’ representatives onto the consortia’s executive boards?
“I think that’s going to happen anyway. I don’t think that’s out of the question. I don’t know the mechanism, but I’d have no beef with proper community representation – even with voting rights.”
The coalition’s health White Paper laid great stress on putting ‘patients at the heart of the NHS’ stating that ‘Shared decision-making will become the norm: no decision about me without me.’ Might not this cause some bitter conflicts between patients and doctors as choice hits the budgetary wall?
“I think we’re quite well placed as GPs to explain about budgets. The difficulty comes when the change made to one patient’s treatment is there to facilitate another patient’s treatment and that’s where patients will undoubtedly question our decisions – which is everyone’s right.”
So far there are no details of how patient participation groups (which Lansley wants to call Local Involvement Networks or LINks) will be set-up. But Dr Glover believes they must be designed with real ‘teeth’.
Whenever there’s change in this area’s health services the question arises about the future of Savernake Hospital: “We don’t know what’s happening with that at all. It’s much too early. Suffice to say that as a practice we’d like much greater use made of it.”
Dr Glover told Marlborough News Online that from July more use is to be made of it. The out of hours service will be extending the duty doctor’s time there and will be basing a visiting car at the hospital too. This is a re-balancing of the out of hours care between the areas covered from Swindon and from Marlborough.
But Dr Glover adds: “I don’t think we’re going to be given the free rein to run Savernake.”
Top to bottom reorganisation of a huge and multi-layered, multi-skilled body such as the NHS in England is vastly complicated. Dr Glover explains that because of the pause for listening to people’s doubts about the Bill before parliament – if not for re-thinking it – the area’s GPs need to take care as they carry on making their plans.
“We need to be sensible about what we do and not incur excess expenditure in progressing change which might be rewound later. But we still need to look at devising a consortium because otherwise the time will be upon us and we won’t be ready.”
“Even though the political process has — I don’t think it’s reached an impasse but it’s run into treacly sort of ground and we’re going to have see what happens over the next months.”
