The new NHS
After a lengthy legislative process that saw the Health and Social Care Act 2012 become law. GPs, practice managers and others in primary care now face the reality of a new NHS landscape.
But how does that landscape look from the perspective of your typical general practice?
The reforms emphasise outcomes based services, with the bulk commissioned by groups led by GPs and, to a lesser extent, other clinicians and primary care professionals. The NHS Commissioning Board will be commissioning primary care services provided by GP practices.
Here we give a concise overview of the new arrangements, with a focus on the changes that affect GP practices as providers.
Meet your prospective new commissioners
1. The NHS Commissioning Board
While the board will have a wide range of functions as the effective driver for improving outcomes in the new NHS and promoting the NHS Constitution, for GP practices a key role will be its direct commissioning of most medical services situated in primary care.
It will manage the contracts for essential, additional and directed enhanced services.
From April 2013 it will also assume responsibility for commissioning other primary care for dentists, community pharmacies and optometry services. The board will also commission some specialist services including prison health, armed forces and their families and designated specialist services.
The board will commission some public health clinical activity, including national screening and immunisation programmes.
It will work through four regional offices and area teams, the latter being intended to foster close working relationships with both practices and with clinical commissioning groups (see below).
For a more detailed account of the board’s role and powers see https://www.england.nhs.uk/about
2. Clinical commissioning groups
The 211 clinical commissioning groups (CCGs) will replace primary care trusts from April 2013 and commission the majority of services for community and secondary care.
• Urgent and emergency care
• Elective hospital care
• Community health services
• Mental health services.
GP practices will be members of their local CCG, with each group’s board including significant GP representation. This, together with the requirement for each board to have a nurse and hospital consultant from outside the board’s geographical area, is the central element of the government’s claim that the reforms will ensure a clinically-led NHS.
CCGs have a role to drive improvement in the quality of primary care. They also need to work with their members so that the impact they have on the wider system supports the achievement of their aims. Although GPs make micro commissioning decisions with every referral they make and every prescription they write, this activity is part of a bigger commissioning picture. CCGs are beginning to understand that without the engagement of their member practices enacting population-wide commissioning plans will be difficult if not impossible.
CCGs will commission a wide range of services including community-based so called “wraparound” services. There is a huge opportunity for practices to be able to provide some of these services.
Developing their dual roles as CCG members and providers may be a challenge for practices, particularly those that remain to be convinced about the new commissioning arrangements. CCGs will need to work with their members to ensure that commissioning processes are clear and transparent and that all parties understand how potential conflicts of interest can be avoided.
3. Local authorities
A large slice of the national public health budget has been handed to local authorities and ring-fenced to prevent them diverting money to the wide range of services they are responsible for. Under the leadership of a director of public health your county, city or unitary authority will now be commissioning a significant proportion of local public health activity. This includes:
• NHS health check
• Sexual health
• Children’s public health
• Obesity and nutrition programmes
• Drug and alcohol misuse
• Smoking cessation.
Authorities are likely to want to put their own stamp on public health and potentially link it to other services that indirectly affect health such as housing, employment and education. They are also bound by their own procurement processes. Practices seeking to provide some of the services listed above need to be aware of the approach being taken by their local authority and if any of their income is at risk for 2013/14.
New accountability and funding flows
Under the structure now being dismantled, GP practices liaised with their local PCT on issues of performance, outcomes and funding. PCTs reported up to strategic health authorities who were in turn answerable to the health secretary.
As providers, practices will be answerable to the NHS CB (for the core contract) and their local CCG which will have a statutory duty to improve primary medical care. Some practices may also have contracts with the local CCG to provide additional services in the community.
The current NHS financial regulator, Monitor, will ensure that these arrangements are not anti-competitive.
Overall the new arrangements will have the effect of opening up to competition many of the services previously provided by practices.
Monitor will also license providers.
The Care Quality Commission will have a regulatory role over the quality and patient safety of services delivered by practices.
The new arrangements for public health also mean for the first time practices may be answerable to local authorities for services that now fall within the remit of public health.
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See also PCC’s Introduction to the NHS e-learning course.
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