How well will the transitional governance arrangements work at the local level? The King's Fund's Board leadership programme recently encouraged board non-executive directors (NEDs) to invite their GP colleagues from pathfinder consortia to a discussion on GP commissioning.
To begin with, the mood was bleak. There were deep concerns about the impact the PCT cluster model would have on governance. While all the core functions will be delivered at cluster level, the formal line of accountability still resides with the PCT boards.
However, in most cases there will no longer be separate PCT boards – the change in regulations last December means that PCT NEDs will become members of more than one board, who are capable of acting for all the statutory organisations at one time.
Many of the NEDs were concerned about confused lines of accountability and potential conflicts of interest between PCTs and clusters – how could they hold the executive of the cluster to account for expenditure and performance at PCT level, for example?
Provider NEDs also had concerns: they were seeing early signs that PCT clusters, GP consortia and trusts were working to different agendas and priorities, particularly around the reconfiguration of services, and were not clear how to resolve this.
An intervention from one of the pathfinder leaders changed the mood of the meeting. He talked eloquently about the emerging clinical consensus in his sector coming from a clinical senate that involved both GPs and consultants. He said the consortia in his PCT area were also signed up to and fully owned the local QIPP (Quality, Innovation, Productivity and Prevention) plan. This moved the debate on to a more constructive discussion about using the transition period well and ensuring governance structures were in place to help GP consortia be as effective as possible.
From the discussion a number of things became clear. NEDs felt inspired by the benefits that clinical engagement in commissioning could bring in terms of quality and patient experience; they also felt that the GPs talked in a language they could understand. However, NEDs retained some concern about the robustness of prospective governance arrangements within GP consortia. They were not sure that GPs were yet aware of the implications of being accountable for their actions as commissioners and dispensers of large sums of public money.
At the end of the meeting, the NEDs agreed that the transition period offered an important learning opportunity for the GP consortia. They believed that budgets and responsibility should be devolved rapidly; this would help their relationships with boroughs and sector level commissioning boards and would make clear to them the importance of robust risk management arrangements for the financial, clinical and reputational risks they may face.
Remarkably, given the mood at the beginning of the meeting, many NEDs left feeling more enthusiastic and hopeful about the potential for GP commissioning consortia. But this should not detract from the important messages about the risks that the health system faces in this time of transition. Strong clinical and managerial partnerships will be critical to ensure there is no confusion about lines of accountability and decision making.