Dr Michael Dixon GP, Chair, NHS Alliance explains the implications of operating in a new system of provision for GP commissioning.

1. To Make and Buy or not to Make and Buy GP Pathfinder Consortia Development Conference – preparing for the commissioning challenges ahead Thursday 12 May 2011 The King’s Fund Dr Michael Dixon Chair, NHS Alliance

2. Question: Will commissioning consortia be able to ‘make’ as well as ‘buy’ services?

3. Answer: ‘ Consortia will be commissioning organisations and will not be able to provide services in their own right.’ (Liberating the NHS: Commissioning for Patients)

4. ‘ A consortium could not make or buy all the services that the consortium is required to commission.’ (Department of Health Guidance April 2011)

7. Or in other words:- ‘ It is essential that individual practices or groups of practices have the opportunity to provide new services, where this will provide best value in terms of quality and cost. This will not happen if the muddled and over-bureaucratised approach that has too often characterised practice-based commissioning is allowed to continue.’

8. So:- ‘ Further work will be taken forward in the NHS to develop a framework that allows commissioning of new services whilst guarding against real or perceived conflicts of interest.’

10. He is the best physician who is the best inspirer of hope Samuel Coleridge (1772-1834)

11. The ‘pause’ is an opportunity for GP consortia leaders to flex their muscles. (NHS Alliance listening exercise)

13. The Department of Health would strongly encourage PCTs and Pathfinders that wish to explore innovative arrangements for commissioning of integrated care services. ‘ We propose that, wherever possible, services should be commissioned that enable patients to choose from any willing provider’

14. Solution 1 National templates/contracts Under EC rules it is not compulsory to tender a service where providers are uniquely placed to provide that service. Some services (eg, organising care through complex care teams) depend on the provider having a ‘registered list’. There could be a list of ‘enhanced services’ drawn up as national templates agreed with Monitor. GP commissioning consortia could apply to the NHS Commissioning Board to place such contracts with their practices and NHS Commissioning Board ensuring probity and value for money. Simple but restrictive?

15. Solution 2 GP Practices (as practice federations) might provide non-GMS services as ‘social enterprise organisations’ or community interest companies. Potential for co-ownership and co-production by professionals and public. Problems with Co-operation and Competition Panel?

16. Solution 3 Set tariffs for primary care services and open market to any willing provider. The current government’s preferred model, but can create conflict of interest if GPs refer patients to services provided by themselves from which they profit (GMC issues?). Tariffs can inflate − m aximum tariffs or no tariffs?

17. Solution 4 Open book accounting for all new services commissioned (GP, private and third sector). This makes all details of costs and profits transparent and reveals those who are loss leading or being unrealistic. As a system for awarding contracts or simply becoming any willing provider? Flexible – or restricted to a menu of services or fixed prices?

18. Solution 5 Integrated care organisations – along the lines of Kaiser Permanente. ‘ Make and buy’ much easier under this system. Not regarded by current government as offering sufficient competition, but, in the interests of fairness, should this not be tried out by a few who wish to?