How will GP consortia be held accountable for their commissioning activities?
The white paper has left no doubt about the government’s resolve to transfer responsibility and accountability for the lion’s share of NHS commissioning directly to GP consortia. This unambiguous transfer of accountability has meant the debate about how GP consortia might marshal management capability has, more recently, widened into discussion about how to ensure they are robustly governed.
Holding consortia to account rests on access to effective managerial capacity
The white paper and consultation document tackles one of the governance questions head on, requiring consortia to include an accountable officer as well as a chief financial officer. Clarification is welcome, but governance is not limited to ensuring effective financial stewardship.
The National Leadership Council’s The Healthy NHS Board: principles for good governance identifies three governance roles: formulating strategy; ensuring accountability; and shaping culture. The foundations of these are understanding context, the availability of sophisticated intelligence, and an effective approach to stakeholder engagement.
The guidance describes durable principles for what constitutes governance that transcends organisational form. These evidence based principles have been drawn from a review of literature that considered more than 170 sources.
The new commissioning proposition needs to stack up when tested against this comprehensive view. The National Leadership Council has asked Foresight Partnership and King’s Patient Safety and Service Quality Centre, authors of The Healthy NHS Board, to apply the model to the proposed arrangements. If the new arrangements are to be transformational, then their approach to formulating strategy must be genuinely centred on patients and carers while achieving world class quality and outcomes. They must also be intolerant of unsafe and substandard care, eliminate discrimination and reduce inequalities in care.
Ensuring GP consortia have the intelligence to support their strategies is critical, but is no substitute for governance capable of making complex strategic judgements.
GP consortia will be able to work in creative partnership with health and wellbeing boards and HealthWatch to deliver this transformational approach. Clearly defined roles and strategic leadership will be crucial to the success of this partnership.
Local Democratic Legitimacy in Health, a DH consultation launched on 22 July, proposes an approach to strategic needs assessment and facilitating greater alignment between health and social care commissioning, the patient and public perspective and health improvement concerns. However, there are competing interests at work here. In reality, patient preferences at the most local level (perhaps reflected by their GP consortium) are often at odds with equitable, effective, efficient and safe investment of health resources when viewed at a larger scale.
Managing these tensions will demand skilful strategic leadership from those in governance roles - leadership that goes far beyond financial probity. Governance of consortia, between consortia and across the whole system will need to be equal to this challenge. If not, we risk sclerosis in strategic decision making and commissioning that is transactional, fuels fragmentation and drives inequality.
In The Healthy NHS Board, ensuring accountability is seen both as holding to account and ensuring adequate control systems are in place. The roles envisaged for the national commissioning board - holding the consortia to account for stewardship of NHS resources and for outcomes - and consortia - holding practices to account against these objectives - begin to unpack the accountability challenge ahead.
However, questions remain. Holding consortia to account rests on access to effective managerial capacity. Provision is made for “lead commissioner” arrangements in relation to, for example, large teaching trusts, but GP consortia hold statutory accountability and, as such, will need to maintain governance oversight over these processes.
GPs certainly bring expertise and professional judgement in relation to clinical quality. But this does not automatically translate into a systematic approach to ensuring the quality and safety of commissioned services or general practice itself.
Consortia will need to develop mechanisms to maintain overall “systems of control” and probity - including risk and assurance. The accountable officer and chief financial officer roles are critical, but consortia will also need to evolve an approach to aspects of this governance role that have so far relied on non-executives in a more traditional board - notably in the audit committee role and in the oversight of external and internal audit.
Health secretary Andrew Lansley said there is no intention to set out “detailed or prescriptive requirements in relation to the internal governance of consortia”.However, The Healthy NHS Board offers a framework to tease out these and other questions.
As well as attending to strategy and accountability, consortia will wish to shape a culture that exemplifies the values of quality, patient choice, transparency, engagement and partnership, which are so powerfully articulated in the white paper.
Developing a spectrum of models to support and inform local GPs and their partners could help to produce local arrangements reflecting the kind of robust governance that - in the words of The Healthy NHS Board - will give us all “confidence that health and healthcare are safe in their hands”.
- Adrienne Fresko and Sue Rubenstein are the founding directors of Foresight Partnership. To contribute to the discussion visit www.foresight-partnership.co.uk/gpcommissioning