ࡱ> egd -bjbjT~T~ 4F66%   SSSSSggg8<,gAccc+A-A-A-A-A-A-A$C2FzQASc__ccQASSXfA8c^SS+Ac+An\;#?0^.iVg> AAHA>FF@??8FS?$cccccccQAQAcccAccccFccccccccc :  LMC Policy Paper on the Configuration of GP Commissioning in Somerset  1.0 Introduction Although the White Paper Equity and Excellence: Liberating the NHS is formally out to consultation until October, it is clear that GP commissioning, one of its central principals, is non-negotiable. Although there are some sketchy suggestions as to how GP commissioning bodies might look, there is nothing prescriptive. Compared with the urban areas upon which health policy is usually based, scattered rural communities need a different configuration of services to provide the most effective service model and the LMC believes that there is a now a window of opportunity to establish a structure that will work for Somerset before more directive guidance is issued that may push us into something less suitable. 2.0 Background 2.1 The Somerset Health Community Primary Care in Somerset is unusually coherent. A single PCT relates to a single LMC, with one practice based commissioning organisation (WyvernHealth.Com) and one Confederation of GP provider groups. There is a single community health services provider. About 60% of secondary care is provided by Taunton & Somerset NHS Foundation Trust, 30% by Yeovil District Hospital FT, and the rest by out of county providers. There is a single mental health trust. Relationships between NHS organisations in the county are generally good. 2.2 Demography The 560,000 population of the current county is spread between a number of small to medium sized towns, none larger than about 50,000 people, with thinly populated rural areas in between. This means relatively small localities have a definite sense of identity. 3.0 Commissioning Considerations As commissioning moves from being a managerial to a clinically driven activity, the criteria by which organisational success is judged will change. To be effective, the new bodies must not be wedded to hierarchies, structures or locations but must be self organising, developing teams based on function. Intelligent use of communications technology means many people will not need to have a fixed office base for commissioning work. Without the burden of preconceptions, organisational form can genuinely follow function, heavily influenced by some key relationships: 3.1 Social Services The requirements of QIPP, the development of integrated care, and the potential benefits of skill mixing mean that there will be a central and growing relationship with social care commissioners and providers. Most importantly, Somerset County Council Social Services who are co-terminous with the current county NHS organisations. There are real potential benefits in better joint working with social care providers, notably Somerset Care, the social enterprise formed when the County Council was required to divest itself of social care provision. There are presently five social services localities in Somerset. 3.2 Acute Hospitals The acceleration under QIPP of a movement of care provision out of secondary care arguably means that relationships between commissioners and hospital providers will need to be closer rather than more distant, as patients will need to be able to move across the primary/secondary care divide often and without resistance. Commissioners will need to be able to organise themselves in to groups that relate to each relevant DGH. 3.3 Somerset Community Health Although no presumption should be made that SCH will necessarily be the provider of all the existing or future community health services in the county, the size of the organisation, its substantial infrastructure base, comprehensive geographical coverage and existing intimate working with general practice means there will be a need to relate to SCH as a county wide body. Better use of resources between community and primary care will depend on close liaison at practice and locality level. There are currently eight SCH localities in the county. The PCTs preferred hosting arrangement for SCH under Transforming Community Services is a social enterprise model, and this may well offer opportunities for much closer integration of the two service streams. 3.4 Somerset Partnership Although the opportunities for service reconfiguration and pathway redesign involving primary care are fewer for patients with enduring mental illness and learning disability, an effective relationship with the county wide Somerset Partnership is nonetheless important. 3.5 Physical Geography and Population Distribution With the population structure of the county, there has always been a risk that NHS activity is concentrated in population centres leaving the relatively sparsely populated rural areas between disadvantaged. Communications links, notably the M5, A303 and A37, also determine the most efficient locality configuration. North to South roads are slower than East to West links, and some areas are relatively isolated by the landscape: Exmoor is the obvious example, with some constraints for the levels and into the Mendips. 3.6 GP Provider Federations It is interesting that the Provider groups have fallen into a very similar pattern to the original GP out of hours co-ops set up in the 1990s. These reflect a combination of demography, natural community and established working relationships sometimes based on community hospital services and sometimes on secondary care referral pathways. There are nine federations in Somerset. 3.7 Cross Boundary considerations Although it is suggested that consortia will not be commissioning regional and sub-regional services, there will be a need for adjacent organisation to work co-operatively to ensure there are no gaps in service and resources are used to best advantage. At the same time, boundary practices will wish to align themselves with different consortia according to the service being commissioned. 4.0 Organisational considerations Although the details of the structure of commissioning groups has not yet been announced, if they are to take on the legal responsibility for commissioning, certain functions will inevitably be required. These tend to favour the establishment of larger rather than smaller groups 4.1 Management A single county wide group would reduce duplication of tasks and allow for a greater degree of strategic management. However, decisions tend to be made further from front line clinicians, leading to a dilution in the patient voice. 4.2 Contract management There are considerable disadvantages in more than one commissioner negotiating and establishing contracts with major providers. At the very least a lead commissioner needs to be established and commissioning decisions made in advance of any meetings with the provider concerned. 4.3 Statutory Functions The Accountable Officer role and other required functions are best undertaken on the largest practical scale. 4.4 Risk Sharing Data on NHS costs is based on formulae that have some validity with large populations but which were never intended to be broken down to small populations. There are considerable differences in current practice spend, only some of which can be accounted for by undesirable variations in clinical practice. Sharing risk by aggregation allows us to concentrate on improving clinical processes and the patient experience rather than chasing statistical quirks and demographic change. 4.5 Clinical Time GPs already have a problem in finding time for non-clinical work. As the demands of the day job have risen inexorably, practice incomes have fallen and locums become harder to find we need to be realistic about the amount of GP time that can be released for commissioning work. This must be used as effectively as possible. 4.6 Public Involvement Developing a comprehensive understanding of the NHS in general and the commissioning process in particular, takes a long time. At the moment the only really effective lay involvement with the NHS is through the County Council Scrutiny and Oversight Committee. 4.7 Accessibility For GPs, practices, and other clinicians to become enthusiastic about commissioning they need to know that their suggestions and proposals will be heard and implemented within a realistic timetable., that the people making the decisions understand their local circumstances, and that changes are made taking into account the needs of all the patients and practices in the county. There is a complex balance to be struck between localism and centralism with neither being allowed to predominate. 5.0 Conclusions Primary Care in Somerset has a justified reputation for co-operative and integrated working, and the current health and social care structures support this. Practice Based Commissioning at a county level through WyvernHealth.Com has been very effective in producing high level change, certainly compared to most of England. However, maintaining the involvement and enthusiasm of practices has been challenging. A county wide formal organisation for GP commissioning in Somerset offers important structural benefits. There is no single smaller size for commissioning groups that makes a good fit with all potential partners and providers. 6.0 LMC Proposal On the basis of current information, the LMC supports The principle of a single overarching county wide GP commissioning body for Somerset, incorporating A structure of constituent locality clinical groups reflecting local priorities and clinical networks. The commissioning ability to deliver effective changes in clinical pathways rapidly. The managerial ability to deliver underpinning organisational skills such as HR and financial management. V 2.1 Final 15 09 10      "#HIJKLP]v} ^ _ ) - 8 < Z    ! 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