ࡱ> VXU` 'bjbj 06 """""""68&$6642VVVVVVVV3333333h5h73"LVVLL3""VV3L"V"V3L3I1""3VJ ~234064 38|8(38"38VVdVVV33^RVVV64LLLL666 666666""""""  Initial Somerset LMC Response to Commissioning a Patient-Led NHS 1.0 Background In his letter of 28th July and the attached programme, Sir Nigel Crisp instructed Strategic Health Authorities submit proposals by 15th October for a reconfiguration of NHS structures to match changes in commissioning. Key points include: Fast and universal roll out of practice based commissioning to cover all practices by the end of 2006. Removal of provider functions from PCTs. A requirement to save at least 15% on management and administrative costs. Matching new structures to parallel changes in ambulance service configuration that will be confirmed in December 2005 A move towards alignment of Strategic Health Authorities with Government Office (Regional) boundaries. Evidence with the submission that interested parties will be consulted. 2.0 Timetable Strategic Health Authority plans should be agreed upon with the Department of Health by the end of November 2005. Consultation will take place locally until March 2006, PCT reconfiguration should be completed by October 2006, SHA realignments by April 2007, and the last changes to PCT service provision by December 2008. It is anticipated that in some areas changes will occur more quickly 3.0 Initial LMC Response to Reconfiguration Whilst the formal consultation process will not start until November, the LMC hopes that the committees views may contribute to the development of the DSHA proposals to be submitted in October. 3.1 Strategic Health Authority Configuration We note that the Government Office for the South West includes the local authority areas presently within three SHAs: Dorset and Somerset, Devon and Cornwall, and Gloucester, Avon & Wiltshire. The implications for Dorset and Somerset of merging with a Health Authority in which Trusts face serious funding issues may be significant. 3.2 Primary Care Trust Configuration The LMC favours a single PCT for Somerset. This proposal offers the maximum cost saving and allows the new organisation to have sufficient staff to build effective teams with appropriate specialists in each area of responsibility. It is also conveniently co-terminous with the social services boundary of the County Council. A possible alternative would be re-organisation into 2 PCTs, broadly aligned to the two main Acute Trusts in Somerset. In particular, a single county PCT allows for the formation of a large enough Public Health directorate to provide a full range of functions and training. 4.0 PCT Provider functions Although further clarification on health and social care outside hospital is promised in a White Paper towards the end of the year, PCTs are expected to divest themselves of provider functions where possible. We note that there is no immediate time pressure for this. The LMCs initial assessment of the options is as follows 4.1 Transfer back to an acute trust Long experience suggest that community services are not best provided be secondary care for a number of reasons. This would be a regressive step and unlikely to be cost-efficient given that at least one Acute Trust in Somerset should achieve Foundation Trust status shortly. 4.2 Establishment of a community trust As these were replaced by PCTs, this would also be regressive, and would also incur significant corporate costs 4.3 Disposal to Private Sector Provider Politically divisive, and unlikely to be a realistic option in Somerset. 4.4 Dispersal to existing provider organizations such as GP practices Certainly at present practices lack the capacity to manage most of the directly provided services, fragmentation at this stage is not to be desired, and this move will blur the commissioner/provider divide as well as carry opportunity cost preventing other developments. May be appropriate for a few circumscribed services 4.5 Community Interest Company/NHS Mutual Organisation These models may be appropriate but are new and largely untested. There are risks in applying them to the provision of essential primary care services such as community nursing. 4.6 Limited Company This appears to be the most flexible model, allowing for a range of options including not for profit and employee partnership. There is a positive local precedent in the establishment of Somerset Care Ltd. out of the directly managed elderly peoples homes of the County Council. 5.0 Practice Based Commissioning The LMC noted with surprise the Ministerial statement, repeated at paragraph 20 in the programme using the words there is a strong desire in general practice to make rapid progress in rolling out Practice Based Commissioning more rapidly (sic). This contrasts markedly with our understanding of the views of GPs both locally and nationally which favour a cautious and progressive approach with little desire for rapid progress. Whilst the LMC is encouraging practices to engage in PBC we are certain that the target of 100% coverage by the end of 2006 will not mean 100% active involvement. Commissioning models will have to accommodate the reality as well as the political desire. Key points on commissioning include: Commissioning may be undertaken by practices or groups of practices. Commissioners will manage a budget delegated from the PCT which covers acute, community and emergency care Contracts will be placed by the PCT, with payment and monitoring undertaken by regional/national hubs. There will be standard national contract models. Commissioning practices will receive management support depending on size (details to follow in October) All NHS Trusts should reach Foundation status by April 2008. It is not clear to what extent commissioners will be able to move progressively towards taking on full responsibility, what the budget has to include ( for example, prescribing costs) and exactly how these proposals fit with existing guidance. It is hard to see how commissioning can be made compulsory without new legislation 5.1 Commissioning Models With a reduced number of PCTs , the LMC considers that it is essential that strong locality based commissioning structures are maintained. We consider that the model needs to be flexible enough to accommodate all the following: Individual commissioning practices. Locality based commissioning. Common interest commissioning. For example rural areas may prefer a particular mobile service whereas urban ones a fixed facility at a DGH or Community Hospital. Commissioning by patient flow into an NHS Trust Large commissioning consortia . For example, the proposal by Taunton Deane PCT practices for a single umbrella commissioning group. Support for practices that do not have the desire or capacity to engage directly in commissioning themselves. Achieving all this will be challenge, but it is evident that different services will need to be commissioned and provided in different ways. The requirements for a cardiac surgery service and those for a community leg ulcer clinic are very different so the model should allow commissioners to configure themselves from a PCT wide group right down to individual practices, according to need. The commissioning structure should be determined by the functions it is required to perform but a devolved model with strong local representation is essential 5.2 Practice Based Commissioning Timetable in Somerset LMC advice to practices remains that they should by now, as a minimum, be sending representatives to PBC study days or masterclasses, and considering what broad commissioning model they are likely to favour. The pace of change will accelerate rapidly from now on. We do not recommend that practices adopt a specific commissioning plan until the Health Authority proposals for PCT configuration are published, reliable budgets are available, and the details of the proposed management support and published in October Harry Yoxall Medical Secretary August 2005 v.3     %HIXmoR `  XZ]AGkN]t|~@K2SFpq¹¹±¦±¦ˆh6CJaJhw"CJ]aJhw"hCJ]aJh6CJ]aJh)CJaJhCJH*aJhCJaJh5CJaJh>*CJaJh56>*CJaJh5>*CJaJhjhU5GHIXM N )  P Q R `  [\^ & F '&#$/''\]ABDFk~@K01^^12S,qwghg h N!!"r"s"8^8 & F & F^qvwi#$$$&&'''''''''''h=jh=Uh5CJaJh)CJaJhCJaJh)CJaJh5CJaJhCJaJs"##$$$%%&&&&'''''''''''^.:pw". 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