The optimal size for a GP-commissioning consortium is a significant bone of contention. While the government plans to take a 'hands' approach and leave the development of consortia to be decided locally, many people feel that size matters and that guidelines should be provided.
When GP commissioning was announced, the media suggested there might be large numbers of these new, smaller organisations. Current thinking has now moved towards suggesting there should be fewer numbers of much larger consortia – for example, the BMA's General Practice Committee is suggesting a minimum population size of about 500,000 patients. A recent article in PULSE heralding a number of 'trailblazing' GP consortia suggest that early adopters will develop in a range of sizes, though mostly smaller groups than existing primary care trusts (PCTs).
So who is right? Is there an optimal size? Here are a few issues to consider in the debate.
The ability to manage risk
If GP consortia are to take on statutory responsibilities for the majority of patient care, including mental health services, then the evidence suggests that a population of at least 100,000 is required to manage insurance risk.
Getting buy-in from GPs
The evidence from previous GP-led commissioning schemes shows that smaller groups of like-minded GPs – say no more than 30,000 patients strong – have tended to be more successful in achieving GP buy-in. These groups also seem more engaged in designing beneficial changes to patients in their practices and enjoying the autonomy to do so.
Working with reduced management costs
Despite the rhetoric that large swathes of management bureaucracy can be cut from the commissioning budget, all the evidence suggests that PCTs did not have the skills, capacity and resources to deploy their functions effectively. Effective commissioning in the future requires well-organised and well-financed management support services with sophisticated IT systems, analysts and contract managers. With 45 per cent cuts to be made in management costs over the next few years, GP commissioners will have to take advantage of economies of scale to ensure that commissioning is managed efficiently. That might well require the use of a support agency covering a large number of GP consortia – in the same way that commissioning support units are currently run across London and Birmingham. These organisations might support commissioners across at least 1 million patients and potentially more. There is a genuine fear from the front line, however, that such organisations might end up with all the power and so direct and restrict how GP consortia operate – a case of the 'tail wagging the dog'.
Purchasing power and transaction costs – making decisions for patients at the 'right' level
GP consortia will need to operate at a range of different levels depending on the nature of the services being commissioned. For example, they would need to be able to have credible interaction with local authorities and to have influence over acute trusts. At the same time, they would need to be local enough to help support the development of primary and community care services and/or enable patients to wield personal health budgets.
The obvious conclusion from this is that 'no one size fits all' when it comes to commissioning. The intelligent commissioner must recognise that it has to operate at multiple levels. It also stands to reason that the intelligent commissioner needs to be a highly effective networker in managing these multiple relationships. This is why research on commissioning consistently shows that building long-term relationships between commissioners and providers is key to success, and that large-scale structural reform leads to deterioration in productivity and performance. The intelligent commissioner needs to understand the art of collaboration and negotiation as it's not simply a technocratic exercise in purchasing services and holding providers to account.
If the approach to be taken is that all GP consortia are to become fully risk-bearing, a more flexible, stepped process is needed to ensure that the impact of structural reform is minimised. So for example, consortia may start small but take on more responsibility gradually. Only time will tell whether this process will be initiated successfully.