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Implications of White Paper for General Practitioners

In the period since the establishment of the new coalition government, we have seen radical changes proposed for the NHS in England. These are laid out in the new White Paper, Equity and Excellence: Liberating the NHS. These changes will have major implications for GPs and will lead to a period of major organisational change in the NHS in England. This is turn may lead to some general practices having less time to support non-core activities such as teaching and research.

GP contracts
The Government plans to abolish the current General Medical Services (GMS) and Personal Medical Services (PMS) contracts and bring in a new single contract for all general practitioners (GPs) in England. This new contract will include responsibility for commissioning health services. The White Paper also discusses linking GPs’ pay more closely to health outcomes (but it is currently unclear how this will be achieved in practice). The White Paper states that the Government ‘seeks over time to establish a single contractual and funding model to promote quality improvement, deliver fairness for all practices, support free patient choice and remove unnecessary barriers to new provision’. The new contract remains to be negotiated with the British Medical Association’s General Practice Committee (GPC) and hence the detailed content of the contract is yet to be agreed.

GPs to take on responsibility for commissioning 
When the changes proposed in the White Paper are implemented, GPs will take on responsibility for commissioning the great majority of NHS services. Linked to this process will be an attempt to reduce management costs by abolishing SHAs (2012) and PCTs (2013). Under the new arrangements consortiums of GP practices will hold budgets to commission health services. At present, it is unclear how the other non-commissioning roles of PCTs will be carried out (e.g. research governance).

All general practices will have to join a consortium by the autumn of 2012; and from April 2013 will be funded directly by the new NHS Commissioning Board. GP consortiums will be able to employ staff to help them carry out their day to day administrative and management functions. Not all GPs will have to be actively involved in all aspects of commissioning, but every practice will need to take on basic commissioning responsibilities, such assessing the cost of specialist referrals. Each member practice is expected to work within the same financial framework.

Incentives for GP commissioning consortiums 
Although the Secretary of State for Health (Andrew Lansley) has promised ‘powerful incentives’ for GPs to take on commissioning, it is likely that these financial incentives will have to come out of existing resources (unlike for example with the implementation of GP fundholding, when additional resources were made available to participating practices). A proportion of GP practice income will be linked to commissioning, with GPs able to earn a ‘quality premium’ if their consortium hits targets for clinical outcomes and financial performance set by the NHS board. This means that consortiums will have to look closely at the use of resources by their general practices (particularly prescribing costs, referrals to specialists and unplanned admissions). It is also possible that general practices could lose a proportion of their existing income (through failing to achieve the targets to receive the ‘quality premium’ payment) if their consortium overspends. This will create strong pressure on GPs to stay within their allocated budgets.

Management of general practices
The new National NHS Commissioning Board will be responsible for managing GP consortiums. The board will also hold general practice contracts, but may devolve the task of monitoring practice performance to local consortiums. This proposal has been resisted by some consortiums that do not want to take on this policing role. Andrew Lansley has said there will be ‘no bail out’ for GP consortiums, which he expects to take on the financial risk of commissioning. Risk will not, however, be shared with individual practices, who will not be penalised financially in the event of an overspend, other than through the loss of their quality premium. The NHS Commissioning Board will have the power to intervene if consortiums are at significant risk of failure, to impose measures to limit any overspend (such as reducing referral and admission activity), and in extreme circumstances to sanction temporary payments to keep consortiums solvent. Consortiums that overspend consistently are likely to be forced to undergo remedial action and may ultimately be stripped of their commissioning responsibilities. The number and size of GP consortiums remains to be determined.

Conclusions
The changes in the White Paper will lead to major changes in the way in which GPs work and in the management of their practices. In my department, we will be working to evaluate the impact of these changes on general practices, health outcomes and public health.

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