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“2020health is an important and thoughtful contributor to the health debate”

Dr Sarah Wollaston MP, Chairman, Health Select Committee


2020health Roundtable Next Steps for Commissioning with Rt Hon. Stephen Dorrell MP

Jun 09. till Jun 09.

The next steps for commissioning with Rt Hon Stephen Dorrell MP

A 2020health roundtable discussion attended by Rt Hon Stephen Dorrell MP.

June 9, 20102010-06-09T08:30:00 - June 9, 2010 2010-06-09T10:00:00
8:30 AM 2010-06-09T08:30:00 - 10:00 AM 2010-06-09T10:00:00
House of Commons, Westminster

These are the summary notes of a discussion that took place on June 9th and which were shared with the acting Director of Commissioning at the Department of Health on the same day. This discussion followed 2020health's paper last year on 'Practice-based Commissioning: not what it says on the tin' by Dr Jonathan Shapiro and our subsequent involvement with thought leaders on this subject. We will be exploring further the development of Commissioning with other health-care practitioners (HCPs) in September 2010.


  1. Rt. Hon Stephen Dorrell MP
  2. Julia Manning, 2020health
  3. Fiona Calnan, UKSH
  4. Dr John Havard, Commissioning Ideals Alliance
  5. Susan McNulty, Editor Practical Commissioning
  6. Alan Downey, KPMG LLP (UK)
  7. Elizabeth Wade, NHS Confederation
  8. Dr David Stout, NHS Confederation
  9. Dr James Kingsland, NAPC
  10. Ian Manovel Associate, BUPA Health Dialogue
  11. Dr Jonathon Shapiro, University of Birmingham
  12. Dr Shane Gordon, NHS Alliance
  13. Julie Wood National, NHS Alliance
  14. Dr Dennis Cox, NHS Cambridgeshire
  15. Dr Helen Glenister, Humana
  16. Steve Ford, Health Services Journal
  17. Chris Pickard, Pfizer
  18. Nicola Sandland, 2020health

Event Summary


General principles
• We need to focus on functionality and the danger is we focus on structure.
• The NHS problem is equality and choice – “exclusively for everyone”.
• There is still too much that is ‘top down’ and benefits are bought at too great a price. PbC is revolutionary as professionals at the front line will make the decisions.
• Strategic – national operation and but meeting individual needs. Like a vinaigrette – strategic ‘oil’ with the sharp locally focussed ‘vinegar’.
• Whereas Health Authorities have to think strategically/population terms; GPs are individual – it won’t work if try to focus on national strategy.
• Public Health and how fits in to commissioning will have to be considered.
• Conscripts never work as well as volunteers.
• Previously there was a lack of engagement of ‘followers’ in the design process of PbC leading to dissonance.
• Concept of HMO – give them a contract, they deliver some, procure some, happy to make a small profit, so long as on time and acceptable outcomes.
• Mixture of strategic/national level and GPs working together and accountability. Obviate the issue of conflict of interests.
• New Secretary of State wants GPs to take the lead and this is the right thing to do. GPs are independent contractors and have always had to manage their ‘business’ – never just been about seeing patients!

• When we say ‘commissioning’ which bit are we talking about: procurement, evaluation, monitoring, strategic planning?
• Shall we de-commission the term ‘commissioning’?
• Who commissions the commissioners?
• Even a referral letter or prescription is a commissioning decision: it involved cost, clinical outcomes, benefits appraisal, information flow – it all has to be justified.
• Possibly unethical to accept financial reward for a commissioning decision.

Practice-based Commissioning
• There was a lack of clarity regarding roles and no alignment of financial incentives and accountability. Not enough strong effective commissioners in PCT world - will there be enough lead GPs? (Leaders required is usually the square root of the number of people involved – but PbC Consortium represented at this event has 4 leaders for 200 members!)
• New opportunity now for integrated care organisations to arise. Not another round of top down reorganisation but spreading from existing organisations.
• Commissioning doesn’t really work in the absence of true contestability –
• i.e. the system needs more competition.
• PbC is a national brand – don’t throw it away – thousands of GPs still turn up to cluster meetings. GPs still have an appetite and want to see PBC work take value from what already known.
• It will be universal but with local variation – and that is ok.
• Speed at which it is achieved is a success factor – we should press forward asap.

Choice and competition
• Contestability of providers and management of consortium processes key. There is an opportunity here for social enterprise.
• GPs want equity but this will not deliver equality as it will result in “postcode lottery”.
• Commissioning doesn’t really work in the absence of true contestability – i.e. the system needs more competition.
• Need to create opportunity for people within the NHS to get access to capital.

Factors for success
• Partnership between PTC and PBC group has worked where GPs had sense of ownership – clinical decisions aligned with results. Where culture is changed, local leadership flourishes. GPs engaged in those clusters will be the spearhead.
• Tools to do the job - frustrated clinicians have been turned off because they didn’t have them. This includes access to data to inform decision making; expert information and managerial knowledge. Sources of guidance and support need to be available.
• Clarity of understanding necessary – what and to whom are we accountable?
• Successful clusters are where GPs aren’t trying to do everything – where they’re engaging peers (including hospital colleagues) and recognising discrete leadership role. Very few GPs want to be leaders but we don’t need many.
• GPs businesses will grow where they manage it well as patients flow back to them
• Referral management centres – worked when owned by grass roots (reverse subsidiary). Referrals are a crucial thing – where every referral is an advice referral – simple way of doing it; Percentage of tariff is paid for the advice.
• Don’t impose public sector procurement rules on GPs. In private sector, don’t have it and they outsource

• The resources will be less. NHS significantly lower resources than growth in demand, so what else do to drive productivity gains?
• Have to be realistic, but another reality – today announcing public inquiry into Mid Staffordshire – why did it happen, it could happen elsewhere?
• Question of inspection, accountability and commissioning.
• Linking managerial – where there has been too much inspection of probity
• (i.e. financial and legal issues) and not enough of clinical care.
• Why aren’t we using more NHS information to keep people well/healthy?

• Required at every level – needs to be clear ‘for what’ and ‘to whom’.
• Statutory accountability will fail – turn off GPs.
• Separation between public accountability and clinical involvement / focus – that is what keeps GPs interested.
• Need to be accountable for your budget.
• Key bit – who and how is holding the clusters to account for these outcomes.
• If consortium has responsibility, then have the whole lot together.
• Transparency is key – and procurement transparency needs to be worked out carefully.
• Openness around audit – unless clarity around assurance and audit, healthcare professionals may be cautious because they don’t know what the rule book says.
• The consequence of failure e.g. living beyond your means will be having your services taken over by others.
• 3 different accountability systems in the NHS at the moment: commissioning; professional through the GMC and inspection. Which is the main one?

Specialised services
• 5 to 10% of NHS budget – at what level are they in the system and integrated?
• Not part of PbC?

Details that need to be developed
• Need to create opportunity for people within the NHS to get access to capital for growth / takeovers.
• Inequalities due to varying abilities of GPs as business people, and danger of disenfranchising other healthcare practitioners – integrated care organisations could address this.
• PbR will have to be reviewed.
• 4 sorts of rewards: 1. personal; 2. improved care for patients; 3. work – life balance improvements and 4. peer support/recognition. Need a t least 2 rewards to make it work.
• The role of the GMC – it was involved in the review of overprescribing so there is a precedent for it having a role in accountability for Consortiums.
• Procurement transparency.
• Tackling the perceived conflict of interest.
• Assessment of local needs so GPs clinically empowered.
• Overlap between the regulatory roles of inspection bodies which leads to unnecessary duplication of functions and increased cost needs to be addressed.