Fears raised over two-tier commissioning system

Revised reform plans say all clinical commissioning groups – the new name for GP consortia - will be created on 1 April 2013 and primary care trusts will be abolished. But where the groups are not ready their powers and budget will be passed back to the NHS Commissioning Board.

No date has been set for when all consortia should be in control of budgets, in accordance with Liberal Democrat demands.

Norman Lamb, chief political adviser to deputy prime minister Nick Clegg, told HSJ he saw the transition as “following the sort of model” of foundation trusts and academy schools where “you don’t need to have one size fits all… you can allow a momentum to develop”.

However, HSJ understands the DH still intends a “clear end point of localism” with a significant majority of groups taking control in 2013.

Supporters of the policy believe the board will have to hand over power or risk damaging criticism that it is centralising rather than localising, and has created a two-tier system.

Leading commissioners said the DH or NHS Commissioning Board must set target dates or full handover will not happen.

One senior commissioner helping shape the policy said: “It [looks] like the foundation trust pipeline [that] means some will never get there. You can just about tolerate a two-tier provision system but we can’t operate two-tier commissioning.”

The commissioner called for NHS operating frameworks to set timetable targets, or “target windows”.

PCT Network director David Stout said: “Where some groups are going slowly there will be some pressure and expectation – without using the ‘T word’ [target] – to achieve a reasonable timescale.”

He said if general practices had the option of not taking on responsibility by a set date they would need new incentives to do so. This could include GPs being paid the proposed “quality premium” bonus only where they are fully responsible.

The government said revised reforms would also include new tests for CCGs to be authorised including greater say for health and wellbeing boards – which can be dominated by councillors – and for new clinical senates, a new sub-regional network of clinicians (see diagram, opposite).

There are also new governance requirements and a plan to “strengthen and emphasise [CCGs’] duty to promote choice”.

However, HSJ understands the real extent of the roles announced for clinical senates and health and wellbeing boards might have been overplayed.

A senior commissioning source warned: “Either it doesn’t really work like this [as announced] or it will be a feverishly expensive bureaucracy. The only people the groups should be accountable to is the Commissioning Board or this is going to be the biggest fiasco in history. Systems go wrong when there are unclear lines of accountability.”

The source said the combined new requirements for CCGs would push up running costs and “drive a nail” into the idea of groups covering populations smaller than 300,000.

Leading clinical commissioners were alarmed by some of the new requirements. The document said CCGs’ boundaries should not normally cross those of local authorities, and must commission care for unregistered patients.

Shane Gordon, a commissioning consortium chief executive in Essex and an NHS Alliance lead, said the wording of the announcement was “strong” and warned senates could “dictate” commissioning.

He said: “If they end up being dominated by hospital doctors we’ll end up with the status quo.”

National Association of Primary Care chair Johnny Marshall said the ability of the Commissioning Board to keep control of budgets could be seen by GPs as a “get out clause” to avoid signing up.

He said: “PCT clusters and the NHS Commissioning Board have to be focused on the local development of commissioning groups. If they get distracted by carrying out their commissioning functions, we’ve got to think that through.”