Make or Buy ?A particularly wicked issue

Dr Paul Zollinger-Read

What’s at stake?• We have a golden opportunity to put in place a more

effective system clinically led model of commissioning

• GP commissioning aligns clinical and financial responsibility and empowers GPs to be innovative

• Patients will have more power to make informed choices about their healthcare − this will drive up quality and cost effectiveness

Innovation

• GP commissioning encourages organisation around interests – eg: the federation model

• GPs want to be innovative and shift services into the community

• PBC innovation was partly through local provision

Why become a federation?

• Strengthening the capacity of practices to develop new services out of hospital

• To form an entity that can tender for services offered by a future GP commissioning consortium

• To improve local service integration across practices and other providers

• To enhance the capacity of practices to compete with external private sector companies

Patients• Patients will be given greater choice, information and

involvement

• They want care closer to home

• Patients expect doctors to work collaboratively across primary and secondary care

• Wicked issues………. Choice, Competition, GP Engagement

Current examples

Anglia Community Eye Service (ACES)

• Community-based ophthalmic service (including cataract surgery)

• Clinically led (local GPs and Ophthalmic Surgeons)• First patient seen September 2007• Patient at heart of service – from design of service to

care received• Mr B, Nr Spalding: ‘Your care and concern during a

stressful time is much appreciated…and the results are amazing! The relaxed atmosphere that I felt, on all three occasions of attendance at your clinic, made the whole ordeal seem positive and bearable.’

Harlow Improving Health and Well Being Service

• Nurse-led clinics in sheltered housing complexes, residential homes and other community settings

• Nurse-led memory service to identify and support those with mild to moderate dementia and their carers/families

• Develop an enhanced primary care service that acts as a bridge between primary care and community services

Colchester

• Community 24hr/7 day ECG commissioned as a LES from local practices

• Five additional community matrons commissioned as a contract extension from provider services

• AF screening at flu vaccination commissioned as a LES contract variation from primary care

AWP

• Community physiotherapy• 15 providers• Poor demand management• Over-spent £200K

What’s the mechanisms?

• Local enhanced service• AWP• Tender• NHS contracts

Options

• Equal footing: transparency − all details of investments in your own services open and transparent

• A primary care AWP model, with significantly lower barriers than the hospital model (ie: not gummed-up with onerous contracts / separate CQC and Monitor registration)

• A fund-holding type menu of things you are allowed to do• Some national reference costs for primary care/community

services

Five factors that influence if competition is healthy

• What is relevant market share?• What is minimum economic scale?• What is minimum clinical scale?• Are there significant barriers to market entry

exit?• Are there significant barriers to switching?

Competition

Uncontested Monopoly

Contested Monopoly

Oligopoly

Active Competition

Tertiary

Non elective and complex care

Less complex hospital

Out of Hospital

Procurement rules

• ‘Make or buy’ decision is taken in the context of competition regulation and procurement law– will ‘making’ the service create conflicts of interest or

potential competition/choice issues? • No legal reason not to commission and procure from one place

– historic PBC arrangements • GPs need transparent and robust separation between roles• GPs cannot direct choice• Any willing provider will allow greater choice and competition

Questions for consortia

• Need to understand the relevant market is it: developed, immature, non-existent?

• Can you take cost out by working with providers rather than taking it to market, which incurs cost and takes time?

• Commissioner should, as good practice, consult with the system or market in the design of service specifications

• Commissioner wants, in most areas, plurality of provision within the market to maximise choice for patients.

Questions for consortia 2

• The decision to ‘make’ could be because there is not a developed market or the ability to innovate and develop an alternative solution

• In some areas demand will not support significant plurality of provision

• From either commissioner or provider perspective you will need to know that the market can sustain the number of providers and that there are effective systems in place to manage demand

Procurement pitfalls

• Potential to stifle innovation and change, particularly the shift to primary care

• White Paper promised less bureaucracy• This is about improving patient care –

therefore we need to find a fair but flexible system However let’s use Pathfinders and Learning

Network to test out

What’s the question we seek to answer

• Value– Value = Quality/Cost effectiveness

• GPs seek to manage the pathway– Cambridge: Nine strategic work streams

with joint clinical chairs

Managing conflict of interest

• Probity in decision making• Openness and transparency• Real choice for patients• Patient and public confidence in decision making• Consistency with standards of professional practice

required of GPs

Any breach needs to be dealt with rigorously

Secretary of State, 3 Nov

‘We’re intending to have extended tariff arrangements out into the community by 2013.

‘So general practice won’t be able to take an excess profit , there will be transparently and also have to demonstrate they have met quality standards and the price available from other providers.

‘When GPs do that referral, part of the contractual obligation will be to provide patients with choice. So they have to offer the choice and demonstrate they’ve offered choice,.

Do we need to worry?

Outcomes and satisfaction levels will make the decisions