BMA to GPs – PPI integral to consortia commissioning decisions

The first statement from the BMA’s General Practitioners Committee about consortia commissioning responsibilities appeared last week.  We recommend you read it.

MAC’s verdict

Undoubtedly it’s a good start, but it will have to do better as it goes along especially as some £80bn of taxpayers money is wrapped up in this.  Still, we value the PPI decision making and accountability statement and lay representatives should bang this drum with their local GP commissioners and PCTs as loudly as possible.  And decide what local accountability really means.

The guidance is admirably brief and to the point, especially about patient and public involvement and accountability.

Other aspects could be improved.  Below are some excerpts (italics) we think are particularly important with our views and recommendations as well.

Good for PPI

Public and patient involvement should be integral to the work of consortia. Challenging decisions concerning treatment priorities may need to be taken based on a mutual understanding of the constraints of limited resources, and the obligation to use such finite resources wisely. The consortium must be accountable to patients and the public who will need to participate in such decisions.

This is possibly the most important statement in the whole document, but we need to ask “how will accountability to patients and the public be exercised in practice?”  And a big unanswered question – will lay people want to help GPs take the tough decisions (decommissioning, rationing, etc)?  That is what commissioning must be about, especially in a time of serious financial restraint.

Inequalities

Consortia should be required to consider the implications of their decisions on their local population, patients within other GP consortia and the wider NHS health systems, and wherever possible, consortia should ensure that NHS providers are the providers of choice. Consortia must be committed to reducing healthcare inequality wherever possible.

There is a problem here.  Inequalities in health (eg disparities in mortality and morbidity between people living in different geographical areas) are not the same as inequalities in the spread of healthcare facilities and services.  Health does not equal healthcare.

The NHS itself can do little without partnership working to address health inequalities since these have their origins – and hence their remedies – in education, housing, environmental and other non-healthcare spheres.  That’s the point that needs to be made here.  Simply having more healthcare services in deprived areas might do little to improve things and would certainly consume scarce resources.  A hospital on every street corner would make things worse and ensure bankruptcy.  Consortia should not spend their time spreading out the NHS healthcare resources evenly – local differences are justified – desirable even –  when they are underpinned by robust public health and local engagement. That will take courage and intelligence.

It is also a shame to see the tired old “NHS as provider of choice” mantra trotted out in the GPC’s guidance (and it is probably illegal in EU competition law anyway).  For some things, the NHS is not going to be the best provider and we should face that. Quality, outcomes, safety, patient experience and of course value for money (not just price) are the criteria we must use to make this call in a pluralist “any willing provider” market.  That’s what intelligent commissioning must do, and it is what the best of the PCTs were doing more of to judge from the most recent world class commissioning results .  GP commissioners must learn from that and improve upon it, not take a backwards step.

Underplays local authority role in public health

GPs will take on a wider public health role. This will bring with it responsibilities to engage constructively with other organisations, doctors and NHS staff, including colleagues in secondary care, public health bodies, local authorities, community care organisations, wider healthcare teams and others.

When we think about public health it is local authorities and community organisations that should come first on this list, not be buried beneath health professions and bodies.  We anticipate the coalition’s public health white paper in the autumn will be stern about this.  Is is to local Councils that we must look for the lead in health and wellbeing under the coalition’s proposals.

Ignores the non-NHS sector for managerial expertise

GP consortia must be professionally run organisations; they will rely on the help and expertise of the best NHS managers.

This also makes little sense. Why tell GPs to look inside the NHS for help and advice when it is in many cases – to hear the keen GPs tell it – those very same PCT managers who have allegedly been holding them on too short a leash in the first place?  What are they afraid of?  GPs are businesses too  and should be able to employ whomever they see fit. The best are excellent, but public sector managers hold no monopoly on expertise or enthusiasm.