Editor’s blog Monday 27 September 2010: Lansley's letter to GPs and frequently (un)answered questions

Stop press! The answers about Equity And Excellence are here.

OK, that is a small exaggeration.

But you can find Health Secretary Andrew Lansley's letter to all GPs here, and the relevant list of Frequently Asked Questions here.

Lansley's letter confuses practising medicine with commissioning. It also assumes, quite frankly incorrectly, that many GPs are already heavily involved in public health.

It is as clear as mud on management resource - "we intend that ... each consortium will be provided with a management allowance". Big of you, Andrew. On the level of management allowance, "no decision has yet been taken. Waste of paper, then.

The Big Society for the promotion of virtue and the prevention of vice
It is particularly enlightening on GP commissioning consortia: "consortia should be of an appropriate size to discharge their statutory functions but we are not proposing to prescribe from the centre what you are best placed to determine".

Is it me, or do the two halves of that sentance actually contradict one another?

Of the Frequently Asked Questions, none are answered to any significant degree. Perhaps Questions 10, 14 and 15 are worth repeating:
10. Would GP consortia be NHS bodies and NHS employers?
"The intention is that GP consortia will be statutory bodies, with powers and functions set out through primary and secondary legislation. However, we propose that they would have flexibility in relation to their internal governance arrangements, beyond essential requirements for example, in relation to areas such as financial probity and accountability, reporting and audit.

"Further detail on the arrangements for consortia will be developed following the close of the consultation exercise."

14. Would consortia be able to commission GP and other primary care services from themselves?
"The NHS Commissioning Board would be responsible for commissioning primary medical care and holding contracts with individual GP practices in their role as providers. There would be a key role for consortia in driving up the quality of general practice, as the performance of consortia as commissioners will be closely bound up with the quality of services provided by their constituent practices.

"Consortia would have the freedom to make the great majority of commissioning decisions about NHS services in order to achieve the best outcomes with the financial resources available to them. They would need to do so in a way that ensures transparency, fairness, and patient choice. This will be particularly important where a consortium proposes to commission services from one or more of its constituent practices."

15. How do you propose ensuring transparency and fairness in consortia’s commissioning decisions?
"We propose that consortia would have the freedom to make commissioning decisions that they judge will achieve the best outcomes within the financial resources available to them. At the same time, the economic regulator and NHS Commissioning Board would develop and maintain a framework that ensures transparency, fairness and patient choice. Wherever possible, services should be commissioned that enable patients to choose from any willing provider."

In Question 13, it also states of the difference between this proposed system and GP fundholding, "Critics of GP fund-holding point to high transaction costs as a major weakness of the scheme. The subsequent introduction of a standard pricing mechanism for hospital-based care and template provider contracts should lead to lower transaction overheads for GP commissioners".

This raises two key points.

Firstly, the Commons Select Committee from April this year, among others, criticised PCT commissioning for those very same high transaction costs. The associated assumption that it will be possible to save 45% of NHS management costs by 2014 remains heroic.

Secondly, the "standard pricing mechanism for hospital-based care" is about to get much more transaction-costly because of changes like CQUIN and PROMs. Moreover, the White Paper considers that tariff should be a maximum. And once all providers are FTs, we are surely not going to see any more standard contracts - and all will be legally binding.

The direction of travel points to a future of negotiation on price, and legal arguments over quality disputes. Which will be unlikely, in the short-to-medium term, to reduce transaction costs.