Giving GPs freedom to innovate while protecting patients will be a difficult balance

As the main primary medical care providers, GPs and their teams are in a unique position to use commissioning to develop new models of care in the community. But will they be allowed to do so when concerns have been expressed about the conflicts of interest faced by GPs as commissioners and providers, and about the policy of encouraging any willing provider to enter the healthcare market?

Many GPs who are in the vanguard of commissioning are strongly motivated by the prospect of providing more care closer to home through general practices and other providers of out of hospital care. This is already being done through practice based commissioning and also by primary care trusts using personal medical services and other primary care contractual routes to support the delivery of enhanced services and other forms of GP led care.

New provider organisations have been established by GPs to support these developments as primary care moves beyond the corner shop model to offer additional services through networks and federations.

These organisations take various forms including private companies limited by shares, private companies limited by guarantee, community interest companies limited by shares or guarantee, and limited liability partnerships.

In establishing these organisations, GPs have strengthened their financial interest in the delivery of services by seeking out opportunities in the evolving market of service provision, while at the same time developing innovative models of patient care.

As both commissioners and providers, GPs will be in the position of deciding whether to “make or buy” services, and in so doing they have the potential to develop a range of integrated services in the community that link the work of practices with that of community providers and some hospital based services and specialists. Over time this could help to reduce reliance on inappropriate hospital care and fundamentally reshape service provision.

Knights or knaves?

If GPs are seen as knights who have the interests of patients at heart, then policy makers would liberate them to take make or buy decisions with light touch regulation. On the other hand, if GPs are seen as knaves who stand to benefit from these decisions, then policy makers would ensure rigorous oversight of commissioning decisions to avoid financial considerations trumping concerns for patient benefit.

The challenge will be to develop a proportionate approach that does not deter innovative GPs from playing a full part in commissioning, while giving assurance that conflicts of interest are being managed effectively.

At a King’s Fund seminar a number of proposals emerged on how this might be done.

These proposals started from the proposition that complex procurement and tendering rules should be avoided wherever possible as the strict application of these rules could dilute the interest in commissioning being shown by GPs in many parts of the country. They may also delay the implementation of decisions that need to be taken quickly as practices rise to the QIPP challenge.

It was also recognised that private and third sector providers should not be deterred from entering the market by a commissioning process that favours incumbent providers.

One way of squaring the circle would be to put in place robust governance arrangements in commissioning consortia. These arrangements might include having patients and the public on the boards of consortia and requiring that decisions on contracts above a defined value should be published.

The general principle of open book accounting could be applied to the work of consortia with an opportunity for aggrieved parties to ask that commissioning decisions should be reviewed, perhaps by the NHS commissioning board. Robust governance also requires GPs to declare interests in providers and not take part in discussions over the award of contracts from which they may benefit.

Another proposal was that some services might be commissioned from practices without having to use tendering processes. This could be done by the NHS commissioning board drawing up a menu of services that practices are able to provide in this way. The menu would constitute a list of enhanced services that could appropriately be delivered through practices on condition that value for money requirements are satisfied.

As the competition regulator, Monitor will have a major part in enabling new entrants to deliver care and develop innovative models of service provision. In seeking to ensure a level playing field between different providers, Monitor will want to ensure the opportunities to develop more integrated models of care are not crowded out by the rigid application of competition rules.

Speakers at the seminar were clear that whatever arrangements are put in place there is a need to avoid the erosion of public trust in the NHS and a perception that GPs are seeking to gain from their involvement in commissioning. At the same time, GPs should be valued as skilled professionals with the emphasis on assumed responsibility rather than earned autonomy.

Finding a third way between light touch regulation and bureaucratic scrutiny will be critical in determining whether the rules on “make or buy” end up making or breaking GP commissioning. The pathfinder programme provides an opportunity to explore the options.