ࡱ>  @ :bjbj)) KzKz0;88<LzDZ"|EEE LLLLLLL$ORZQ3L#"E3LHLJJJ4 LJ LJJDDG8 :E&KL^L0LF,J$EEE3L3L $"(Appendix 3 APRIL 2007 (UPDATED JULY 2007) Framework for procuring external support for commissioners BMA briefing and position statement (England only)  1 BACKGROUND The framework for procuring external support for commissioners (FESC) is a relatively new development, first announcements of which were made in June 2006 and then again in July 2006 (originally termed as the commissioning services framework) in the Department of Health (DH) document Health reform in England: update and commissioning framework. Essentially it comprises of a list of private sector companies from which PCTs can buy in the necessary support services in order to fulfil their commissioning function. Following the conclusion of a national procurement exercise, the FESC has now gone live and PCTs have been sent details of the successful companies accordingly. However, the Department of Health has yet to make this list publicly available, although an official announcement is anticipated shortly. A policy statement on the FESC from the DH issued in February 2007 remains the most up to date information available on the framework and can be found online at the following address:  HYPERLINK "http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4143055&chk=y3WUAY" www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4143055&chk=y3WUAY 2 HOW IT WILL WORK The following summary has been informed by the DH policy statement referred to above: It is for PCT Boards to decide whether or not to buy in any of the skills secured via the framework (paragraph 5). Commissioning remains a statutory responsibility of the PCT Board and the range of procured services do not extend to provider services (paragraph 13). If the PCT does wish to access services under the framework, they will conduct a locally managed competitive bidding process for which all suppliers (where appropriate) are required to bid. The subsequent contract between PCT and successful supplier will be referred to as an External Support Services Agreement (ESSA) (paragraph 12). The four categories of services built into the FESC are: (1) Assessment & Planning; (2) Contracting & Procurement; (3) Performance Management, Settlement & Review and (4) Patient & Public Engagement (paragraph 16). There are three levels of service that a PCT can access: (a) a single service (micro); (b) one or more related group of services (macro) and (c) a complete package (end-to-end). An end-to-end package should only be bought in exceptional circumstances, with SHA approval and final sign-off by the Director General of Commissioning (paragraphs 20-21). The management of contracts with suppliers will be overseen by PCT Boards. This will include financial management, analysis of the quality of services being provided by the supplier and clinical standards. A specific group should be set up within the PCT, with clinical representation, to report to the Board accordingly (paragraph 25). The framework will outline five different payment models from which PCTs will determine the most appropriate for any procurement of services. [Note that further detail on these payment models has yet to be made available.] For end-to-end services, only two of these payment models, those transferring the least risk to the supplier, will apply (paragraph 27). Where a payment model includes the potential for the supplier to take a share of savings, this will be dependent on the achievement of Operational Performance Indicators (OPIs), which will reflect national performance (paragraph 28). Four areas where potential conflicts of interest may arise are identified; the most relevant being where suppliers may be contracted to commission services when they already provide clinical services in the PCT area. Where such a conflict exists, the supplier in question will be excluded from the local procurement process (paragraphs 32 & 34). Where other material conflicts of interest are identified, mitigating actions should be agreed and adopted. PCTs will have a right to exclude any supplier from bidding for a contract where no other appropriate mitigating actions can be taken (paragraphs 32-33). Suppliers under the FESC will be required to encourage practice based commissioning (PBC) participation and will work within existing demand management protocols as agreed with GPs and the PEC (paragraphs 28-29). Payment of savings made by GP practices and/or suppliers through commissioning activity will not be duplicated (paragraph 29). The DH policy statement makes reference to the latest DH guidance on PBC (Practical implementation November 2006) which places renewed responsibility on PCTs to provide adequate management support to practice based commissioners. It goes on to say that GP practices, in agreement with PCTs, may wish to obtain support in particular functions by using the FESC (paragraph 9). 3 IMPLICATIONS AND CONCERNS The services provided under the framework may enable some PCTs to buy in pockets of expertise that are otherwise lacking among existing PCT personnel. This may then lead to an improvement in the overall standard of PCT commissioning which in turn would facilitate more successful development of practice based commissioning (PBC), ultimately to the benefit of patient care. However we believe that the negative implications of the framework will outweigh any potentially positive outcomes as outlined below. Privatisation of commissioning The framework appears permissive of privatisation and in view of the extensive nature of a complete package of or end-to-end services this may be seen by some PCTs as an opportunity to contract out large portions, or even almost all of its existing commissioning management functions to the private sector. Although the FESC stipulates that this must only happen in exceptional circumstances it is yet to be seen how this will be defined and managed in practice. The gravest consequence of any move towards privatisation of PCTs commissioning management functions would be the potential for a private company to commission/purchase services from itself without check, regardless of the clinical appropriateness and cost-effectiveness of those services and without consideration of other commissioning and/or provider arrangements in the area. Again, the FESC seeks to set out some measures which will avoid such a situation arising, which we welcome, but whether or not these will be effective and adequately stringent in practice is also yet to be seen. (ii) Validity of private sector involvement Lessons from secondary care show that purchasing from the independent sector is not necessarily better, or cheaper, and in some cases, can prove detrimental; there has been similar experience at a primary care level, for example with PCT turnaround teams. We are also unaware of evidence to suggest that organisations with little or no experience of the NHS are able to do improve on the outcomes of the NHS. (iii) Timing and compatibility with PBC It could be argued that until the current transition of a large portion of commissioning responsibility from PCTs to GP practices is complete, it will not be possible to identify areas of real need for additional, third party involvement. The ordinary functioning of PCTs is still in a state of disruption, particularly following PCT reconfigurations in 2006 and any further distractions preventing PCTs from working effectively with GP practices in order to put in place PBC arrangements should be avoided. In addition, it is likely that the introduction of suppliers through the FESC will give rise to new areas of disagreement between GP commissioners and PCTs. In the first instance, there may be a difference of opinion as to whether or not there is actually a need for PCTs to use the framework or disagreement over the level of services that should be bought in. By introducing a third party into the commissioning process, further complications could arise. For example, it may prove difficult to determine whether a budgetary under-spend can be attributed to the work of local PBC groups and decisions of local GPs or that of suppliers under the FESC. In addition, there is a danger that suppliers will not adhere to or be mindful of the commissioning arrangements being put in place by local practice based commissioners, which would undermine PBC. (iv) Extra demand on limited resources PCTs will need to find resources within existing allocations in order to use the FESC and therefore we are concerned about the effects of resulting, additional budgetary pressures. Whether or not this can be seen as a legitimate use of limited NHS funding is also questionable. It is as a result of these uncertainties and from a belief that the commissioning of patient care is a key function of the NHS, that the BMA has major concerns over the introduction of the FESC. 4 PRINCIPLES AND SAFEGUARDS The BMA was not consulted on any aspects of the FESC and as stated earlier in this document, we currently anticipate the list of suppliers to be released towards the end of May 2007. The stronger the local commissioning arrangements, the less of a need there will be for PCTs to access the services under the FESC. However as there will be some areas where PCTs will wish to make use of the framework, we have set out the following principles and safeguards which, if adhered to, may help to minimise the risks associated with contracting out aspects of the commissioning process to the private sector. There is close working with LMCs and GP practices undertaking practice based commissioning and, where appropriate, secondary care clinicians, in order to ensure that the services that are bought in are fit for purpose and compatible with other local commissioning arrangements. The buying in of services is done openly, transparently, is a cost-effective use of NHS funding and should only take place where such intervention is essential. Any purchasing and management details should be in the public domain. There must be no political pressure or even passive expectation on PCTs to make use of this resource and the DH must not make any guarantees, financial or otherwise, to suppliers under the framework. Any contracts PCTs put in place with suppliers under the framework should be flexible in order to avoid their being tied-into long-term arrangements for services that are no longer required. The latest DH guidance on PBC sets out that all aspects of the PCT budget should be devolved indicatively to GP practices. Practices will then hand back elements of this notional, whole practice allocation to PCTs, including clearly identified funding for a central (PCT) management team. By virtue of the process of handing back to the PCT funding for central management, practices have legitimate authority over how these resources are used. Therefore, if the PCT wishes to use part of this funding to buy in services from the FESC, the agreement of practices should be sought accordingly. PCTs must ensure that good relations are developed between local GP commissioners and any contracted suppliers under the framework and that any potential areas of cross-over or conflict are clearly set out, discussed and resolved. In the long-term, any use of services under the framework should seek to build and develop skills within the NHS rather than de-skill the NHS. Measures are put in place at a local level to ensure that conflicts of interest, especially those relating to the commissioner/provider conflict, are avoided at all costs. A package of end-to-end services is reserved for genuinely exceptional circumstances and the agreement of local clinicians that this is the only option is sought accordingly. Where the contract of a supplier under the framework gives access to personal and/or population data, there must be safeguards in place that ensure that this will not be harnessed in the commercial interests of that company in the future. Essentially, if a private company is to handle NHS data, ordinary commercial freedoms must not apply and the duty of confidentiality that binds the NHS must apply equally to the independent sector.  Audit Commission and National Audit Office (2005) Financial Management in the NHS London: The Stationery Office Limited; House of Commons Health Committee (2006) Independent Sector Treatment Centres London: The Stationery Office Limited.  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