Dr Michael Dixon, NHS Alliance Chair, looks at the practicalities of GP commissioning using primary care examples from his own GP practice.

1. Realising the potential of GP commissioning – enabling more cost effective services closer to home Tuesday 9 November 2010 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: No ‘ Consortia will be commissioning organisations and will not be able to provide services in their own right’ (Liberating the NHS: Commissioning for Patients)

4. ‘ 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.’

5. ‘ 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.’

9. What are the solutions?

10. 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 the NHS Commissioning Board, ensuring probity and value for money. Simple, but restrictive?

11. Solution 2 GP practices (as practice federations) might provide non GMS services as ‘social enterprise organisations’. Problems with competition and co-operation panel?

12. 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 − Maximum tariffs ?

13. Solution 4 Open book accounting for all new services commissioned (GP, private and third sector). This makes all details of costs and profit 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?

14. 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.

27. Is this better than an integrated care organisation that both commissions and provides?