What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West

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Providers are starting to hold hands

Getting healthcare providers to work together a lot more, and in some cases join completely, runs through commissioning strategy across England.

The vision is that our current archipelago of trusts and FTs will join in alliances of island nations; while the disparate dinghies of general practice club together and buy nice new ships, or at least form flotillas.

There are of course some CCGs or councils which are wary of their local hospitals joining forces or of GP practices being pressed into bigger groups. Many also doubt the benefits of merging trusts but there is now a menu of other options: Chains, alliances, sharing leaders, or franchise.

In general, payers in the NHS have good reason to support consolidation, and it certainly has strong backing from NHS England.

A string (or chain?) of developments in the acute sector in the past few days caught my eye.

Some patches (these ones among them) have a surfeit of independent trusts and FTs which is getting in the way of sensible decisions on services, and pushing up costs. They have been crying out for consolidation.

There is a danger that the channelling of £1.8bn “sustainability” money towards hospital trusts, and other measures being taken to take the heat off providers in 2016-17, could result in these types of discussions slowing down.

But, while it would be far too starry-eyed to conclude that the acute sector is getting somewhere, there seem to be a growing number of providers willing to at least hold hands with each other, if not move in together.

In general practice, consolidation is happening too – but it feels like there’s a very long way to go. HSJ, the Nuffield Trust and others have documented a recent rush to form more GP federations, but not enough direction in what the groups are doing.

The leader of one of England’s biggest federations (by practices covered) shared his frustration at a lack of national support with HSJ this month. This might be a case of special pleading, but there has been a notable absence of national direction for primary care since a new, voluntary contract for large GP providers was proposed by the Prime Minister five months ago.

We should expect movement soon, though: A package of measures to help GP practices, labelled the “GP roadmap”, has been stuck in traffic since January, but is expected to arrive in the next few weeks. This is likely to include next steps to encourage joint working, and an overdue update on the Prime Minister’s Challenge Fund. More likely to be of popular interest, if it comes to be included, is the prospect of a promise to ease up on CQC GP inspections.

This week in: The Commissioner feedback

Last week I covered the issue of conflicts of interest, which can often be relied upon to get backs up. To recap:

  • Developments over the past year might mean we are heading for a new tougher line on conflicts in commissioning from NHS England and government.
  • There is a fairly widespread and substantial blending of GP provider and commissioner roles in CCGs, which some in and around the NHS have always been very uncomfortable with.
  • However, there has been little evidence so far of conflicts in CCGs actually being acted on or abused for personal or business gain.
  • Since the extent of conflict in CCGs has been well known for a long time – and accepted as part and parcel of GP engagement – it would be a bit phoney for senior national figures to now present it as a new discovery which they have a big problem with. But they might do that.
  • If there is to be a tougher approach, the options available include tighter rules on declarations and governance; watering down the role of GPs in CCGs; and looking to new models of commissioning to help.

The latter option was put forward in a Times leader, but as discussed in the Commissioner last week, the introduction of lead provider or “accountable care organisation” type models could bring at least as much additional risk of conflict as it does to eliminate it.

One reader commenting anonymously on HSJ.co.uk makes a similar point more forcefully:“Whilst GPs and hospital consultants can be singled out for having a PERSONAL conflict of interest and financial or research ties, the idea that new models of care or local government partnerships solve this, that a hospital or local authority leader is less conflicted, is nonsense.

“Personal conflicts of interest are the tip of a much bigger iceberg of INSTITUTIONAL conflict of interest distorting decision making affecting commissioners, providers local authorities, and, don’t forget, regulators.”

Another says the whole debate is an overreaction: “Vested interests of provider-commissioners (GPs in CCGs) were anticipated… and can be managed with sensible governance. GP-led commissioning is a walking conflict of interest. What’s the problem?”

I’m going to be on holiday for the next two weeks - see you in mid April.

Dave West

Senior bureau chief

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