April 2011

The path to GP commissioning An analysis of the development and priorities of GP pathfinder consortia

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Contents Introduction ............................................................................................................................................ 3

Summary of key findings ......................................................................................................................... 4

Summary of recommendations .............................................................................................................. 5

Background ............................................................................................................................................. 6

Methodology ........................................................................................................................................... 9

Location and size of pathfinder consortia ............................................................................................ 10

Areas of focus for pathfinder consortia ................................................................................................ 12

Developments in commissioning priorities .......................................................................................... 19

Conclusion ............................................................................................................................................. 23

References ............................................................................................................................................ 24

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List of figures and tables

Figure 1: Percentage of population covered by GP pathfinder consortia ............................................ 10 Figure 2: Consortia population size ...................................................................................................... 11 Figure 3: Average size and number of practices in pathfinder consortia ............................................. 11 Figure 4: Most common areas of focus ................................................................................................ 13 Figure 5: Percentage of consortia focusing on integration with social care ......................................... 14 Figure 6: Percentage of consortia focusing on care pathways ............................................................. 14 Figure 7: Percentage of pathfinder consortia identifying governance as an area of focus .................. 15 Figure 8: Proportion of pathfinder consortia in each wave focusing on governance issues ................ 16 Figure 9: Commonly selected clinical issues ......................................................................................... 18 Figure 10: Issues of consortia focus according to pathfinder wave ..................................................... 21 Figure 11: Level of detail in consortia priorities ................................................................................... 22 Table 1: Key milestones in developing GP consortia .............................................................................. 6 Table 2: Key functions of GP commissioning consortia .......................................................................... 7 Table 3: Comparison of PCT and GP consortia priorities ...................................................................... 19

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Introduction A revolution is taking place in health and social care. Although much of the focus is on the changes proposed in the Health and Social Care Bill and the political debate around them, many of the changes which will matter most to health and social care delivery for patients are already taking place across the NHS. NHS organisations are not waiting for legislation to be passed, nor for a policy consensus to emerge. Already structures from the new world are working alongside those from the old. For example, large areas of the country are now covered by pathfinder GP consortia. These emerging organisations already wield a great deal of power even though they do not yet have a statutory footing. From April 2011, when the pathfinders begin to receive funding to manage the transition, the NHS will begin to witness the true impact of the changes to commissioning structures and processes. MHP Health Mandate is a specialist health policy and communications consultancy, advising the NHS, voluntary sector and commercial organisations on some of the highest profile issues of the day. A key part of our role is to provide organisations with strategic policy consultancy and analysis, transforming their objectives into workable policies and in turn ensuring that their priorities are translated into positive change in the health service. Anyone in the business of trying to deliver change or influence behaviour in the NHS needs to understand the interplay between policy priorities and service delivery, as well as the extent to which the prioritisation of an issue can be expected to accelerate improvements in the quality and efficiency of care and the health outcomes delivered. Although there remains a great deal of uncertainty about the implications of reform, the issues on which pathfinder consortia are choosing to focus provide an early opportunity to examine the areas of health delivery which will pre-occupy the latest generation of commissioners. This report examines the early priorities of pathfinder consortia, looks at how the focus of pathfinders is already evolving and assesses the extent to which they represent a break with the past or a continuation of existing trends in commissioning. MHP Health Mandate has developed two proprietary sources of intelligence: • CommIT – the commissioning intelligence tracker – contains detailed information of the priorities

of health service commissioners in England, as well as the outcomes they achieve and the costs they incur

• ProvIT – the provider intelligence tracker – contains information on the quality priorities of providers to the NHS, as well as the incentive systems which are in place to encourage improvements

CommIT and ProvIT enable MHP Health Mandate to support organisations in: (1) engaging with commissioners and providers on the issues that they care about most, thereby maximising the likelihood of receiving a positive response; (2) conducting bespoke analyses to analyse trends in health service commissioning and delivery; (3) identifying and spreading good practice as well as highlighting examples of poor practice which need to be challenged; (4) encouraging scrutiny of local prioritisation and variations in the outcomes achieved by this; (5)and developing constructive recommendations for improving the commissioning and delivery of health services.

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Summary of key findings

1. The development of GP pathfinder consortia has been uneven across different geographical

areas. The South West Strategic Health Authority (SHA) now has 100% population coverage, whereas the West Midlands only has 40% coverage and the North East 56%

2. There is significant variation in population size among consortia. The smallest consortium (East

Cliff Practice) covers a population size of 14,000, while the largest will commission services for 693,000 (Gloucestershire)

3. GP consortia now cover 70% of the population. Based on this, it can be expected that there will be approximately 260 consortia. This is considerably lower than initial projections about the number of consortia that would be created

4. Despite the commitment to increase transparency in health service commissioning, information

on the priorities of 28 (15%) consortia has not been published

5. The most common areas of focus identified by consortia relate largely to the integration of services, whether it be with social care, community services or improving the care pathway

6. Many pathfinder consortia have opted to focus on issues which could lead to efficiency savings,

although explicit recognition of the role of the Quality, Innovation, Productivity and Prevention (QIPP) programme is limited

7. Some geographical areas have focused on governance issues more than others, indicating that this has either been strongly encouraged by some SHAs or discouraged by others. Governance issues were particularly common amongst commissioners from the second wave, and yet none of the third wave opted to focus on the issue

8. Few of the most common areas selected relate to specific conditions or programmes. However,

mental health was one of the ten most commonly selected areas of focus. Other commonly identified clinical areas included Chronic Obstructive Pulmonary Disease (COPD), dermatology, diabetes, musculoskeletal conditions and cardiology

9. The style and the content of areas of focus identified by consortia are different to the priorities

selected by PCTs. However, it is clear that in some cases the areas of focus identified by consortia could help to achieve improvements against the priorities previously identified by PCTs. The extent of continuity, however, varies according to commissioner

10. Consortia have become progressively more specific in their areas of focus as the waves of

pathfinders have progressed and there has been a step change in the level of detail made publically available in the third wave

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Summary of recommendations 1. The Department of Health should remind pathfinder consortia of their responsibility to publicly

account for their decisions and priorities. In order to promote accountability, all pathfinder consortia should publish the issues on which they intend to focus

2. In order to support the longer term development of consortia, the NHS Commissioning Board should undertake an evaluation of the strengths and weaknesses of different models and population sizes. Consortia should be required to explain to local communities the reasons underpinning their configuration

3. Work undertaken by pathfinder consortia on governance issues should be collated and shared, so as to avoid duplication of effort

4. Given the focus on improving outcomes, all consortia should be encouraged to identify priorities which directly relate to the quality of care commissioned. Those consortia that have only identified governance or process priorities should now identify clinical priorities as well

5. Commissioners should be encouraged to use prioritisation as a mechanism for controlling costs.

The Department of Health should, as part of the commissioning outcomes framework, develop nationally validated outcome indicators which address efficiency issues

6. As part of guidance to support GPs in delivering on future QOF indicators, NHS Employers and the BMA should provide advice on how a GP’s provider and commissioning responsibilities should align on an issue. This will also be important to help GPs avoid any perception of a conflict of interest

7. Consortia should be encouraged to consider clinical areas for improvement when identifying areas of focus. This should be based on an analysis of the needs of their local population

8. The Department of Health should set out in clinical outcomes strategies the measures which commissioners may wish to use in assessing their progress on improving services for different conditions

9. In order to support consortia in identifying appropriate clinical issues on which to focus, the Department of Health and the NHS Commissioning Board should signpost nationally comparable data in commissioning support packs

10. In developing their priorities, consortia should work with local health and wellbeing boards to ensure that progress made on the issues prioritised by PCTs is not lost

11. Consortia should be encouraged to develop detailed identified priorities, enabling an assessment to be made of their success in delivering against them

12. Priorities should be set out in commissioning plans, which should be published as soon as possible

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Background GP-led commissioning is central to the Government’s reforms to health and social care, with the Department of Health arguing that the reform will1

:

• Put patients at the heart of everything the NHS does • Focus on continuously improving those things that really matter to patients – especially the

outcome of their healthcare • Empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare

services Liberating the NHS: Legislative framework and next steps set out how the transition from PCT commissioning to GP-led commissioning will be managed, with the intention that consortia would be responsible for commissioning the majority of NHS services by April 20132

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As a first step towards this goal, pathfinder consortia are being introduced across the country to test different arrangements and aid the transition of commissioning responsibilities from PCTs to GP commissioners3. The approval process for pathfinder GP consortia has been led by SHAs4. Simon Burns set out that SHAs will “approve any group of practices to become a pathfinder if they can demonstrate clinical leadership, local authority engagement, and an ability to contribute to the delivery of the local quality, innovation, productivity and prevention agenda in their locality”5. This is evident in application forms used by the SHAs, which ask for an outline of consortia vision, as well as their plans to work closely with other groups locally and their commitment to the QIPP agenda6

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The first wave of pathfinder consortia were announced in December 2010, shortly followed by a second wave in January 2011 and a third wave in March 2011. Table 1: Key milestones in developing GP consortia The path to GP commissioning: key milestones

White Paper publication day First wave of GP pathfinders The Operating Framework for the NHS in England 2011/12 Liberating the NHS: Legislative framework and next steps

2010 12 July 8 December 15 December 15 December

Second wave of GP pathfinders Health and Social Care Bill introduced to Parliament PCT cluster implementation guidance Third wave of GP pathfinders Working document for GP consortia released Early implementers of health and wellbeing boards announced GP consortia take on delegated authority Shadow NHS Commissioning Board PCT clusters to be formed

2011 18 January 19 January 31 January 2 March 10 March 16 March 1 April 1 April June

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GP consortia can begin to be authorised to take on as much delegated authority as possible (overall accountability still ultimately rests with the PCT) Abolition of SHAs NHS Commissioning Board formally established Local HealthWatch fully established Health and Wellbeing Boards established in shadow form

2012 April April April April April

GP consortia take full control of budgets Abolition of PCTs Health and Wellbeing Boards formally established

2013 April April April

Central to the vision for GP consortia is to “ensure that in future, NHS commissioners have a stronger focus on improving the quality and outcomes of care for patients”7

. All NHS commissioners will be under a duty to improve quality in the NHS and, in order to support this, the NHS Commissioning Board will be developing a Commissioning Outcomes Framework to hold GP consortia to account on their success in improving outcomes for patients.

MHP Health Mandate has already undertaken extensive work examining the extent to which the prioritisation of outcomes can lead to improvements in the quality of health outcomes, as well as the containment of costs. Commissioning in the new world: an analysis of the impact of prioritisation on quality, expenditure and outcomes in the health service found that a focus on outcomes by commissioners can be a highly effective mechanism for driving health service improvement8. It is therefore encouraging to see the recommendations we made about placing the prioritisation and measurement of outcomes at the heart of the proposed commissioning arrangements9

. We look forward with interest to the forthcoming consultation on how the Commissioning Outcomes Framework will ensure outcomes prioritisation is central to the new performance management and accountability system.

Table 2: Key functions of GP commissioning consortia Key functions of GP commissioning consortia The Functions of GP Commissioning Consortia: A Working Document sets out the proposed range of GP consortia responsibilities and functions that will apply to consortia from April 2013 onwards, subject to the approval of the Health and Social Care Bill and subject to individual consortia being established as statutory bodies10

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Consortia will be responsible for commissioning a range of healthcare services from community and maternity services, to commissioning care for specialist conditions such as mental health and learning disabilities. In their commissioning role, consortia have a duty to co-operate with other NHS bodies and local authorities, and must have regard to Health and Wellbeing Boards and the NHS Commissioning Board. Consortia must also involve patients and the public in developing, considering and making decisions on any proposals that would have a significant impact on service delivery or the range of health services available11.

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A consortium’s functions must be laid out in a commissioning plan before the start of each financial year, detailing how it will secure improvement in the quality of services and outcomes for patients. Such plans could include: • Identifying inequalities in access to healthcare services, quality and outcomes • Identifying indicators in the Commissioning Outcomes Framework where there is scope for local

improvement • Redesigning services and/or pathways to deliver improved outcomes • Identifying which services will be most effective and cost effective and planning new

investments Consortia have a duty to monitor the services commissioned with regard to any regulations set by the NHS Commissioning Board and any ‘standing rules’ that may be required under the Bill. Consortia are required to continually secure improvement in the quality and services for patients while operating within a commissioning budget.

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Methodology Although the arrangements for pathfinder consortia are still emerging, it is possible to examine their areas of focus. This report considers the shape of the pathfinder consortia that are emerging, and the quality issues on which they are choosing to focus as they develop their organisational capacity and test their new powers. The MHP Health Mandate team has undertaken quantitative analysis of the size, local and focus of pathfinder GP consortia established by March 2011, including: • Mapping the published priorities of pathfinders • Analysing these priorities for trends according to geography, population size and historical focus • Assessing common priorities and the potential explanations for these Most pathfinder consortia have published details of their initial areas of focus. In total, this analysis includes details of 156 out of the 184 pathfinders that have been approved (85%)12

28 consortia have so far failed to provide information on their areas of focus. This calls into question the basis on which they were approved for pathfinder status. The process for approval has varied across strategic health authorities, as the principles of the national pathfinder programme provide no clear criteria for approval

. Given the debate that has occurred about the accountability of consortia in the new world, it is notable that

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Recommendation 1: The Department of Health should remind pathfinder consortia of their responsibility to publicly account for their decisions and priorities. In order to promote accountability, all pathfinder consortia should publish the issues on which they intend to focus A great deal of autonomy has been afforded to GP consortia in defining their areas of focus and it is therefore not surprising that there is a wide range of terminology and scope in the priorities that have been identified. In order to facilitate a meaningful analysis it has therefore been necessary to categorise some of the areas of focus in to healthcare themes. Further details of the categorisation guidelines adopted are available on request.

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Location and size of pathfinder consortia

Consortia location There are now pathfinder consortia in each of England’s Strategic Health Authorities (SHAs) although some SHA areas have seen faster coverage than others. Figure 1 shows the percentage of each SHA’s population that is covered by pathfinder consortium. The South West has seen the fastest progress, with pathfinders extending across 100% of the region. This compares with only 40% coverage in the West Midlands and 56% in the North East. Figure 1: Percentage of population covered by GP pathfinder consortia

These numbers are likely to change rapidly as further pathfinder consortia are approved by the Department of Health. Based on current coverage of 70% of the population, we project that there will be approximately 260 consortia when the entire population of England is covered by pathfinder consortia14. This number is significantly lower than some of the numbers originally suggested by health commentators and gives an idea of how the commissioning structures may look by April 201315

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Consortia size The Department of Health and Strategic Health Authorities have mandated few criteria for the size and shape of GP consortia, with the express intention to pilot different sizes and structures. As such, there is considerable variation in the size and geography of pathfinders as well as much debate about whether there is an optimal population size. Arguments in favour of larger consortia include greater purchasing power and economies of scale, whereas arguments in favour of smaller sizes include being able to secure a greater focus on the population health needs of particular communities. The Department of Health has recognised the

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variety of views on consortia size and concluded that GP practices should therefore be given flexibility to decide how they come together to form consortia16

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Within the 184 pathfinder consortia already established, there is significant variation in population size. The smallest consortium (East Cliff Practice) covers a population size of 14,000, while the largest will commission services for 693,000 (Gloucestershire). Variation in size is 49-fold, as demonstrated by Figure 2. 25 (14%) of the consortia are greater in size than an average PCT. The average (mean) consortia size is 197,843. Figure 2: Consortia population size

The announcement of the third wave of pathfinder consortia saw a few consortia merging to increase their coverage. Other changes are likely as consortia begin commissioning services. There are also significant variations in the size of consortia according to geographical location. Figure 3 shows the average population size and number of practices covered by consortia broken down by SHA. The consortia in the North East tend to be the largest, with an average population of over 280,000. At the other end of the scale, the average population covered by consortia in NHS South East Coast is little over 128,000. Figure 3: Average size and number of practices in pathfinder consortia

Recommendation 2: In order to support the longer term development of consortia, the NHS Commissioning Board should undertake an evaluation of the strengths and weaknesses of different models and population sizes. Consortia should be required to explain to local communities the reasons underpinning their configuration.

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Areas of focus for pathfinder consortia Commissioning in the new world: an analysis of the impact of prioritisation on quality, expenditure and outcomes in the health service demonstrated that commissioners who prioritise an issue appear to achieve a faster rate of improvement than those that opt not to prioritise the same issue17

. The areas of focus that pathfinder GP consortia choose will therefore have a significant impact on their ability to improve quality and outcomes in their local area.

From April 2013, GP consortia will be under a duty to prepare and publish a commissioning plan before the start of each financial year, “explaining in particular how the consortium intends to exercise its functions with a view to securing improvement in the quality of services and outcomes for patients”. In practice, this could include “identifying indicators in the Commissioning Outcomes Framework where there is scope for local improvement”18

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Although the requirement to publish a commissioning plan will not be a statutory duty on GP consortia until April 2013, pathfinder consortia were asked to state their vision and objectives in the application process19. For most consortia, the areas of focus that they have identified have been made public on the Department of Health website20

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The approval process for pathfinder consortia has allowed a significant degree of flexibility for consortia and so has not been prescriptive on the areas of focus that consortia can choose. As such, the information that has been provided by pathfinders in waves one to three has varied in level of detail and in areas of focus. Some consortia have chosen to focus on particular clinical pathways while others will look at the care pathway more generally. Of the 184 pathfinder consortia listed on the Department of Health website on 14 March 2011, information on their chosen areas of focus is available for only 156. This information contains the basis for the analysis contained in this chapter.

Commonly identified areas of focus Figure 4 shows the areas of focus most commonly adopted by pathfinder consortia. It is notable that the most common areas of focus relate largely to the integration of services, whether it be with social care, community services or improving the care pathway. It is worth noting that the ability of GP commissioners to improve the continuity of care across services was a key argument in favour of GP-led commissioning. The early focus of pathfinder consortia on the issue suggests that this is an area which interests the GP community.

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Figure 4: Most common areas of focus

1. Integration with social care Integration with social care featured in the areas of focus adopted by 40% of pathfinder consortia. This is not surprising given the focus on integration in the NHS reforms. Andrew Lansley set out early on in his time as Secretary of State for Health that integration between health and social care was central to the aims of the reforms, arguing: “we must reform social care alongside healthcare – and deliver closer integration in how services are commissioned and provided”21

. This aim has been evident in a number of reforms, including the overlapping NHS and social care outcomes frameworks and the planned introduction of health and wellbeing boards.

Almost 90% of all local authorities have now signed up to be early implementers of new health and wellbeing boards, creating 'shadow' boards which, subject to legislation, will be operational by April 201322. The health and wellbeing boards are intended to guarantee joined-up commissioning at a local level, with an obligation to prepare joint strategic needs assessments and a joint health and wellbeing strategy spanning the NHS, social care and public health23

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Figure 5 demonstrates the areas of the country where consortia have identified integration of health and social care as an initial area of focus.

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Figure 5: Percentage of consortia focusing on integration with social care

2. Care pathways Care pathways was the second most common of area of focus identified by pathfinder consortia. Again, this has been seen as central to the Government reforms in that without clearly defined national and local care pathways it is difficult to offer patients informed choice or to implement the Any Willing Provider model24

. Figure 6 shows the regional breakdown of consortia identifying care pathways as a priority.

Figure 6: Percentage of consortia focusing on care pathways

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3. Governance Many consortia opted to focus on governance issues relating to their establishment, rather than areas of commissioning which might have a direct impact on outcomes. In total, 49 out of 156 included some aspect of governance in their areas of focus. Priorities included: • “Focusing on role as an independent commissioning practice”25

• “Focusing on developing the organisation and in preparation have completed the organisational development plan”

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• “Focusing on exploring governance arrangements, identifying how to work independently as a federation”

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• “Focusing on identifying how to capitalise on the devolution of management and budget”

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This focus is perhaps to be expected given that a key task for pathfinders is to learn lessons about how GP-led commissioning can be most effective ahead of April 2013 as well as news that the Department of Health has deliberately avoided prescription in relation to the way that consortia should govern or organise themselves29

. However, it is concerning that 12 consortia have focused on governance arrangements alone.

Some geographical areas have focused on governance issues more than others, indicating that this has either been strongly encouraged by some SHAs or discouraged by others. Figure 7 shows that 88% of pathfinder consortia in Yorkshire and Humber identified governance as an area of focus, compared to only 4% of those in London. Figure 7: Percentage of pathfinder consortia identifying governance as an area of focus

However, the focus on governance has varied according to the wave in which pathfinder consortia were approved. Governance issues were particularly common amongst commissioners from the second wave, and yet none of the third wave opted to focus on the issue, as set out in Figure 8.

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Figure 8: Proportion of pathfinder consortia in each wave focusing on governance issues

Recommendation 3: Work undertaken by pathfinder consortia on governance issues should be collated and shared, so as to avoid duplication of effort Recommendation 4: Given the focus on improving outcomes, all consortia should be encouraged to identify priorities which directly relate to the quality of care commissioned. Those consortia that have only identified governance or process priorities should now identify clinical priorities as well

4. Urgent care It is unsurprising that urgent care is a popular issue for consortia focus given the Government’s intention of transferring responsibility for urgent care provision to GPs30. This follows a number of controversies about the quality and nature of out of hours urgent care provision31,32

. With the introduction of new quality indicators for urgent care from April 2011, the quality of urgent care services is likely to be seen as a key early test for the effectiveness of consortia.

Over 15% of all consortia have opted to focus on the issue, with over 30% of the third wave choosing to do so. It should be noted that urgent care is a very broad topic and can refer to a wide range of services, from ensuring out of hours access to primary care to accident and emergency services. This has been reflected in selections by pathfinder consortia, which vary from “developing the locality leadership role for urgent care” to “focusing on further work to reduce A&E attendances”33

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5. Delivering efficiency savings Given the current funding environment for the NHS, it is not surprising that many pathfinder consortia have opted to focus on issues which could lead to efficiency savings. Our previous work, published in Commissioning in the new world, demonstrated the positive impact that commissioner prioritisation could have on cost savings and therefore it is welcome that many pathfinder consortia have chosen to focus on issues which could generate efficiencies.

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At a national level the efficiency drive has been led by the Quality, Innovation, Productivity and Prevention (QIPP) programme34

. Only 5% of pathfinder consortia have actually named QIPP in identified priorities, but a number of other areas of focus set out in Figure 4 also form part of the QIPP agenda. For example, issues such as improving care pathways, focusing on referral patterns or prescribing could all contribute to savings for the NHS.

Among GP consortia that identified prescribing as an issue of focus, few have provided further detail on how they intend to make improvements in this area. However, one consortium set out that it will “develop a comprehensive peer review programme for referrals and prescribing that is supportive and educational”, while another intends to review and streamline prescribing. It is notable that a series of prescribing efficiency indicators are also being developed as part of the 2011/12 agreement between NHS Employers and the British Medical Association (BMA) on the Quality and Outcomes Framework (QOF) of the GMS Contract35

. This could be a good example of how a GP’s provider and commissioning priorities could align.

Recommendation 5: Commissioners should be encouraged to use prioritisation as a mechanism for controlling costs. The Department of Health should, as part of the commissioning outcomes framework, develop nationally validated outcome indicators which address efficiency issues Recommendation 6: As part of guidance to support GPs in delivering on future QOF indicators, NHS Employers and the BMA should provide advice on how a GP’s provider and commissioning responsibilities should align on an issue. This will also be important to help GPs avoid any perception of a conflict of interest 6. Clinical priorities Few of the most common areas identified relate to specific conditions or programmes. However, mental health was one of the ten most commonly selected areas of focus, chosen by 8% of pathfinder consortia. Figure 9 shows the most commonly selected clinical areas, which include chronic obstructive pulmonary disorder (COPD), dermatology, diabetes, musculoskeletal conditions and cardiology.

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Figure 9: Commonly selected clinical issues

The identification of mental health as a priority reflects not only its population impact but also GPs’ direct role in helping manage many mental health conditions. Indeed, this also holds true for COPD, musculoskeletal conditions, dermatology and diabetes, all of which are often managed primarily in primary care settings. It is also notable that a number of these conditions feature prominently in the QOF 2009/10. For example, there are 100 QOF points for diabetes, 59 for mental health and 30 for COPD36

. Therefore GPs are likely to have not only extensive experience of managing them, but also access to local data on prevalence and the effectiveness of care collected through the QOF.

Recommendation 7: Consortia should be encouraged to consider clinical areas for improvement when identifying areas of focus. This should be based on an analysis of the needs of their local population Recommendation 8: The Department of Health should set out in clinical outcomes strategies the measures which commissioners may wish to use in assessing their progress on improving services for different conditions Recommendation 9: In order to support consortia in identifying appropriate clinical issues on which to focus, the Department of Health and the NHS Commissioning Board should signpost nationally comparable data in commissioning support packs

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Developments in commissioning priorities It is possible to identify trends in commissioning priorities, both in comparison to those adopted by predecessor organisations to consortia and between different waves of pathfinders. This chapter examines how priorities have evolved over time. Continuity with PCT priorities Pathfinder consortia will start to assume responsibility for commissioning budgets from PCTs in April 2011. Although there were many weaknesses in PCT-based commissioning, the performance of PCTs as commissioners did improve37. One criticism levelled at GP-led commissioning is that its development could disrupt this progress or undermine efforts to ensure accountability for medium term performance38

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Since 2009/10 PCTs have used the World Class Commissioning assurance programme to identify priorities for their local area39

. The priorities that could be selected by PCTs and the number of identified priorities they were required to have, were prescriptive, unlike areas of focus for the pathfinder consortia. It is therefore unsurprising that, overall, there is little continuity between the priorities of PCTs and their successor consortia.

Table 3 illustrates how priorities have evolved in four randomly selected areas where there are close geographical links between PCTs and consortia. This shows that both the style and the content of priorities tend to be significantly different. Despite this, some consortia show continuity in areas of focus. Others, however, represent much more of a break with the past. Table 3: Comparison of PCT and GP consortia priorities

PCT priorities Pathfinder consortium areas of focus

Comment on extent of continuity

Bassetlaw PCT • Public health • Cancer • Stroke • Hospital

admissions • End of life care

Bassetlaw Commissioning Organisation • Focusing on governance and

working in partnership with the local authority

Bassetlaw Commissioning Organisation gives limited detail on focus. However, a focus on partnership working could contribute to earlier PCT ambitions to improve public health, hospital admissions and end of life care.

Norfolk PCT • Public health • Early diagnosis • Admissions • Healthcare

Associated Infections (HCAIs)

• End of life care

North Norfolk Health Consortium • Reduce health inequalities • Enable people to live longer,

healthier lives • Work with partners to

improve health and wellbeing • Focus on people’s individual

needs • Provide high quality, safe

healthcare services • Provide right care, right time,

There are overlaps between the priorities selected by Norfolk PCT and the focus on the North Norfolk Health Consortium. The consortium’s focus on working with partners to improve health and wellbeing could be seen as a continuation of the PCTs prioritisation of public health and early diagnosis. There is also overlap between the PCT commitment to reducing health care acquired

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right professional • Ensure people are treated

with dignity and respect

infections and the consortium goal to provide high quality, safe healthcare services.

NHS Dorset • Hospital

admissions • Immunisations • Public health • Delayed transfers

of care • Mortality rate • End of life care

Dorset GP Commissioning Consortium • Identifying what the

consortia will do and what it will “buy in”

• Exploring devolution versus federation

• Spreading clinical leadership and ownership of the commissioning agenda

• Exploring the role, function and level of autonomy of localities within consortia

The priorities identified by Dorset GP Commissioning Consortium are largely general and focus on joint working. This links broadly to PCT priorities on public health, hospital admissions and delayed transfers of care. The PCT prioritisation of immunisations, mortality rate and end of life care is not reflected in the areas of focus identified by the consortium.

NHS County Durham • Public health • Cancer • CVD mortality • End of life care • Care pathways

County Durham and Darlington • The role of community

hospital in delivering intermediate care

• QIPP priorities • The COPD respiratory

pathway • Children’s commissioning • Budget for planned care • Purchase of nursing home

beds • Development of streamlined

unplanned care

County Durham and Darlington GP consortium has identified a number of specific focus areas. Focus on the role of community hospitals and the development of streamlined unplanned care will both have an impact on care pathways, a priority identified by the PCT. There is less overlap with other PCT priorities.

Recommendation 10: In developing their priorities, consortia should work with local health and wellbeing boards to ensure that progress made on the issues prioritised by PCTs is not lost

Developments across pathfinder waves The issues on which consortia have chosen to focus vary according to the pathfinder wave in which they were announced. As Figure 10 demonstrates, integration with social care and care pathways were common areas of focus across all three waves of consortia announced to date. Governance, however, was not chosen as an area of focus for any of the third wave of consortia, despite being the most commonly selected area of focus by consortia in the second wave.

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Figure 10: Issues of consortia focus according to pathfinder wave

A focus on community services, urgent care, referrals, prescribing and mental health are all more common amongst the third wave of pathfinder consortia. Consortia approved in the third wave were three times more likely to focus on urgent care than those approved earlier in the process, and twice as likely to focus on community services. The specificity and detail of focus areas selected by pathfinder consortia have also varied across the waves. Some consortia areas of focus has been as general as: “Focusing on cross-boundary working involving NHS and local authorities” whereas others have been much more specific, such as “improving access to high quality primary care services, reducing referrals and avoiding admissions through a number of initiatives e.g. setting up a referral management centre, establishing nurse-led step-up community beds”40

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It is notable that consortia have become progressively more specific in their areas of focus as the waves of pathfinders have progressed and there has been a step change in the level of detail made publically available in the third wave, as set out in Figure 11.

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Figure 11: Level of detail in consortia priorities

Recommendation 11: Consortia should be encouraged to develop detailed identified priorities, enabling an assessment to be made of their success in delivering against them Recommendation 12: Priorities should be set out in commissioning plans, which should be published as soon as possible

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Conclusion The achievements of pathfinder consortia will go a long way to determining the overall success or otherwise of the reforms to health and social care. Therefore the issues on which consortia choose to focus provide an important perspective on the issues which matter to those tasked with implementing the reforms. What is clear is that, despite national controversies and heated debates about the nature and purpose of the reform agenda, local NHS services have been moving ahead with implementing the reforms. Consortia now cover 70% of the population and have already begun work on identifying and addressing their priorities41

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Given the nature of the reforms, it should not be a surprise that there is a high degree of variation in the issues on which consortia are focusing and the way that they choose to describe these priorities. There are also some strong areas of consensus. The GP commissioning community is expressing desire to address issues such as links with social care, improving care pathways and addressing some of the challenges that have emerged in urgent care. All of this will be welcome news to advocates of reform, who have argued that these issues were neglected by many PCTs. Perhaps less welcome will be the lack of specificity shown by some consortia in describing their priorities. Although it is early days, this will add to the concerns of critics of the reforms who argue that the development of consortia could lead to an accountability deficit. Irrespective of an organisation’s view of the reforms, it is clear that change is already occurring in the NHS and that much of this change could not be reversed, even if there was a change in national policy. Understanding the priorities of the new generation of commissioning organisations will be critical to delivering change in the new NHS. Any organisation whose business depends upon engaging with the NHS would do well to understand these priorities.

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References 1 Department of Health, Equity and Excellence, Liberating the NHS, July 2011 2 Department of Health, Liberating the NHS: Legislative framework and next steps, December 2010 3 Department of Health, Liberating the NHS: Legislative framework and next steps, December 2010, p.85 4 Hansard, 19 January 2011, Col.846W 5 Hansard, 10 February 2011, Col.425W 6 NHS London, Pathfinder GP consortia application 7 Department of Health, Liberating the NHS: Legislative framework and next steps, December 2010, p.66 8 MHP Health Mandate, Commissioning in the new world: an analysis of the impact of prioritisation on quality, expenditure and outcomes in the health service, September 2010 9 MHP Health Mandate, Commissioning in the new world: an analysis of the impact of prioritisation on quality, expenditure and outcomes in the health service, September 2010, p.11 10 Department of Health, The Functions of GP Commissioning Consortia: A Working Document, March 2011 11 Department of Health, The Functions of GP Commissioning Consortia: A Working Document, March 2011, p.7 12 Department of Health, GP pathfinder consortia by Strategic Health Authority region, http://healthandcare.dh.gov.uk/context/consortia/, accessed 18 March 2011 13 Dame Barbara Hakin, GP Consortia Pathfinder Programme letter to SHA Chief Executives, 26 October 2010, http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_120895 14 Office for National Statistics, Mid-year population estimates 2009, http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106, accessed 21 March 2011 15 Health Service Journal, Dangers of putting GPs in charge outweigh the rewards, June 2010, http://www.hsj.co.uk/comment/leader/dangers-of-putting-gps-in-charge-outweigh-the-rewards/5015729.article, accessed 21 March 2011 16 Department of Health, Liberating the NHS: Legislative framework and next steps, December 2010, p.54 17 MHP Health Mandate, Commissioning in the new world: an analysis of the impact of prioritisation on quality, expenditure and outcomes in the health service, September 2010, p.9 18 Department of Health, The Functions of GP Commissioning Consortia: A Working Document, March 2011 19 London SHA, London’s GP consortia development programme, 2010, http://www.london.nhs.uk/webfiles/supporting%20changes/London%20GP%20consortia%20development%20programme%201611.pdf, accessed 21 March 2011 20 Department of Health, GP consortia map, 2011, http://healthandcare.dh.gov.uk/gp-consortia-map/, accessed 21 March 2011 21 Andrew Lansley, “A shared ambition to improve outcomes”, 2 July 2010, http://www.dh.gov.uk/en/MediaCentre/Speeches/DH_117103 22 Department of Health, More cohesive care promised as councils back Health and Wellbeing Boards, 16 March 2011, http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_125156 23 Department of Health, More cohesive care promised as councils back Health and Wellbeing Boards, 16 March 2011, http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_125156 24 Department of Health, Liberating the NHS: Greater choice and control, October 2010 25Thanet GP commissioning consortia, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 18 March 2011 26 South Elmsall and Rycroft Consortium, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 18 March 2011 27 East Mendip Federation, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 18 March 2011 28 South Hams & West Devon Commissioning Group, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 18 March 2011 29 Dame Barbara Hakin, GP Consortia Pathfinder Programme letter to SHA Chief Executives, 26 October 2010, http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_120895 30 Department of Health, Urgent and emergency care, http://www.dh.gov.uk/en/Healthcare/Urgentandemergencycare/index.htm, accessed 21 March 2011 31 BBC News, GP out-of-hours 'crisis looming', September 2003, http://news.bbc.co.uk/1/hi/health/3144252.stm, accessed 20 March 2011 32 BBC Radio 4, Call for out-of-hours GP scrutiny, October 2009, http://news.bbc.co.uk/today/hi/today/newsid_8288000/8288288.stm, accessed 20 March 2011

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33 Inner City and East Bristol Localityand Nuneaton & Bedworth, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 18 March 2011 34 NHS Improvement, Quality, Innovation, Productivity and Prevention (QIPP), http://www.improvement.nhs.uk/QIPP/tabid/61/Default.aspx, accessed 20 March 2011 35 NHS Employers, General Medical Services Contract, 2011/12 36 NHS Information Centre, The Quality and Outcomes Framework 2009/10, http://www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2009-10/data-tables, accessed 20 March 2011 37 NHS Confederation, PCT World Class Commissioning Assurance results 2009/10, August 2010, http://www.nhsconfed.org/Documents/PCT%20World%20Class%20Commissioning%20assurance%20results%202009.pdf, accessed 21 March 2011 38 Health Select Committee, Report on Commissioning, Fourth Report of Session 2009–10 39 Department of Health, World Class Commissioning Assurance Handbook, June 2008 40 Surrey Heath and West Norfolk PBC Consortium, Areas of focus, http://maps.google.co.uk/maps/ms?oe=utf-8&client=firefox-a&ie=UTF8&hl=en&t=h&msa=0&msid=214047936381473341741.000497e864392da65b72f&ll=52.241256,-0.065918&spn=6.46052,14.0625&z=6&source=embed, accessed 21 March 2011 41 Department of Health, GP pathfinder consortia by Strategic Health Authority region, http://healthandcare.dh.gov.uk/context/consortia/, accessed 22 March 2011

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