5 Primary Care Groups

going with the grain Key themes development of primary and community health care family doctors and community nurses in the lead a spectrum of opportunities beyond fundholding The first line of support and care 5.1 The family doctor or community nurse is often the first port of call for patients when they need health advice or treatment. Primary care professionals are also the way into the rest of the NHS for most patients. They understand patients' needs and they deliver most local services. That is why they will be in the driving seat in shaping local health services in the future. New Primary Care Groups will be established in all parts of the country to commission services for local patients. They will have control over resources but will have to account for how they have used them in improving efficiency and quality. They do not affect GPs' independent contractor status. 5.2 The new role envisaged for GPs and community nurses will build on some of the most successful recent developments in primary care. These professionals have seized opportunities to extend their role in recent years. Practice nurses are taking on new disease management roles while community pharmacists are increasingly a source of advice for both GPs and patients. GPs have been developing new services within their surgeries. Health visitors, school nurses, and district nurses have enhanced the delivery of care in homes, schools and the community. 5.3 Community health services have been able to take account of the special health needs of black and minority ethnic patients. They have also been able to help people not in regular contact with other parts of the health services, such as homeless people. Community health staff, such as midwives, can also draw attention to the wider health needs of the community, where the real solution may lie in action on education, housing, transport or reducing air pollution. Locality commissioning groups Groups of GPs who work closely with their Health Authority to plan and commission services. GP fundholding A GP whose practice manages a budget for its practice staff, certain hospital referrals, drug costs, community nursing services and management costs. Multifunds Groups of GP fundholders who agree to pool their budgets and work together. Total purchasing projects Total purchasers comprise groups of GPs who together purchase hospital and community health services outside fundholding on behalf of their patients, working closely with their Health Authority. Legal responsibility for these services remains with the relevant Health Authority. GP commissioning group pilots Pilot projects preparing to go live from April 1998. Based around groups of fundholding and non-fundholding GPs, will manage a prescribing budget. Will work closely with their local Health Authority to develop health strategies and advise on service developments for local populations. Going with the grain 5.4 Extended roles in providing primary and community healthcare have been matched by greater influence in shaping hospital services. Multifunds, locality commissioning groups, individual fundholders, and total purchasing projects all have helped lead the way. Each has undoubtedly brought benefits to patients. The new GP commissioning pilots will extend the range of opportunities. The Government's plans go with the grain of these developments. 5.5 Despite its limitations, many innovative GPs and their fund managers have used the fundholding scheme to sharpen the responsiveness of some hospital services and to extend the range of services available in their own surgeries. But the fundholding scheme has also proved bureaucratic and costly. It has allowed development to take place in a fragmented way, outside a coherent strategic plan. It has artificially separated responsibility for emergency and planned care, and given advantage to some patients at the expense of others. 5.6 So the Government wants to keep what has worked about fundholding, but discard what has not. The potential of primary care commissioning will continue to be developed using mechanisms that evolve far beyond single practice standard fundholding. The argument between fundholding and non-fundholding is yesterday's debate. The time has come to move on, taking the best of both approaches. 5.7 All of the local community should benefit from the best that primary and community health services have to offer. It is at this level - close to patients and the community - that decisions can best be taken on using the resources of the NHS to meet the health and healthcare needs of individual patients. 5.8 The Government therefore intends to establish Primary Care Groups across the country, bringing together GPs and community nurses in each area to work together to improve the health of local people. Primary Care Groups will grow out of the range of commissioning models that have developed in recent years but will give a sharper focus to their work. They will have the benefit of strong support from their Health Authority and the freedom to use NHS resources wisely, including savings. With these new opportunities will go the need to account for their actions. They will be subject to clear accountability arrangements and performance standards. Community health services Community health services are provided for people wherever they are, such as in homes, schools, clinics and even on the streets. Examples are health visiting, school nursing, chiropody, speech and language therapy. Services such as district nursing, community psychiatric nursing and physiotherapy can enable people with short or long term illness or disability to be cared for in their own homes. Functions 5.9 The main functions of the new Primary Care Groups reflect the approaches which are already being adopted in many parts of the country. Primary Care Groups will: contribute to the Health Authority's Health Improvement Programme on health and healthcare, helping to ensure that this reflects the perspective of the local community and the experience of patients promote the health of the local population, working in partnership with other agencies commission health services for their populations from the relevant NHS Trusts, within the framework of the Health Improvement Programme, ensuring quality and efficiency monitor performance against the service agreements they (or initially the Health Authority) have with NHS Trusts develop primary care by joint working across practices; sharing skills; providing a forum for professional development, audit and peer review; assuring quality and developing the new approach to clinical governance; and influencing the deployment of resources for general practice locally. Local Medical Committees will have a key role in supporting this process better integrate primary and community health services and work more closely with social services on both planning and delivery. Services such as child health or rehabilitation where responsibilities have been split within the health service and where liaison with Local Authorities is often poor, will particularly benefit. Local Medical Committee The statutory Local Representative Committee for all GPs in the area covered by a Health Authority. The Health Authority has a statutory duty to consult it on issues including GPs' terms of service, complaints and the investigation of certain matters of professional conduct. Structure 5.10 The precise form of Primary Care Groups will be flexible to reflect local circumstances. In some areas there are already well established GP-led groups of commissioners or fundholders, while in others, community NHS Trusts have taken a lead role. Successful local arrangements will be built upon, not discarded. The approach will be bottom-up and developmental. 5.11 There will be a spectrum of opportunities available for local GPs and community nurses. Primary Care Groups will develop over time, learning from existing arrangements and their own experience. None will affect the independent contractor status of GPs. There will be four options for the form that Primary Care Groups take. They will: i at minimum, support the Health Authority in commissioning care for its population, acting in an advisory capacity ii take devolved responsibility for managing the budget for healthcare in their area, formally as part of the Health Authority iii become established as freestanding bodies accountable to the Health Authority for commissioning care iv become established as freestanding bodies accountable to the Health Authority for commissioning care and with added responsibility for the provision of community health services for their population. 5.12 Primary Care Groups will begin at whatever point on the spectrum is appropriate for them. They will be expected to progress along it so that in time all Primary Care Groups assume fuller responsibilities. Some Primary Care Groups may proceed directly from option ii to option iv. 5.13 The Government will bring forward legislation to establish a new form of Trust - a Primary Care Trust - for Primary Care Groups which wish to be freestanding (options iii and iv) and are capable of being so. Such Trusts may include community health services from existing NHS Trusts. All or part of an existing community NHS Trust may combine with a Primary Care Trust in order to better integrate services and management support. Annex A sets out further details of how Primary Care Trusts might work. (Elsewhere in this document, the term Primary Care Group is used to cover both Groups and Trusts, unless the context makes it clear that Groups alone are covered). 5.14 The new Trusts will not be expected to take responsibility for specialised mental health or learning disability services. On mental health, where health and social care boundaries are not fixed and where joint work is particularly important, and where an integrated range of services from community to hospital care is required, specialist mental health NHS Trusts are likely to be the best mechanism for coordinating service delivery. Primary Care Trusts will be well placed to develop strong links with such services. In this way, specialist NHS Trusts, Primary Care Trusts and social services will be able to make complementary contributions to delivering the full range of care. Similar considerations apply in the case of specialist learning disability services. 5.15 Whatever functions they take on there will be a common core of requirements for all Primary Care Groups. Each Group will be accountable to the Health Authority and required to: be representative of all the GP practices in the Group have a governing body which includes community nursing and social services as well as GPs drawn from the area take account of social services as well as Health Authority boundaries, to help promote integration in service planning and provision abide by the local Health Improvement Programme have clear arrangements for public involvement including open meetings have efficient and effective arrangements for management and financial accountability. Local Medical Committees will continue to be consulted on, and have a key role in, ensuring that general medical services resources are used wisely. 5.16 The intention is that Primary Care Groups should develop around natural communities, but take account also of the benefits of coterminosity with social services. Practices based close to the borders of a Group will be able to choose to join with others in the way which makes best sense locally. Primary Care Groups may typically serve about 100,000 patients. But there will be flexibility to reflect local circumstances and emerging evidence about the effectiveness of different size groupings. Primary Care Groups will generally grow out of existing local groupings, modified as needed to meet the criteria set out above.

Finance 5.17 Each Primary Care Group will have available their population's share of the available resources for hospital and community health services, prescribing and general practice infrastructure. These resources will allow the Group and its members to commission and provide services. Within this single cash limited envelope, the Group will have the opportunity to deploy resources and savings to strengthen local services and ensure that patterns of care best reflect their patients' needs. 5.18 For the first time in the history of the NHS all the primary care professionals, who do the majority of prescribing, treating and referring, will have control over how resources are best used to benefit patients. By cutting through the artificial barriers that have been erected between drug budgets, hospital referral budgets and emergency admission budgets the Government will give real choices about how GPs and community nurses deploy their cash. In this way Primary Care Groups will extend to all patients the benefits, but not the disadvantages, of fundholding. By virtue of their size and financial leverage, they will have far greater ability to shape local services around patients' needs. Unified Primary Care Group Budgets Hospital and Community Health Services Prescribing: the cost of drugs prescribed by GP and nurses GMS infrastructure: the current 'GMS cash-limited' budget which reimburses GPs for a proportion of the cost of their practice staff premises and computers. 5.19 Groups, rather than individual practices, will reach service agreements with NHS Trusts about the quality and level of care that should be provided in hospitals for their patients. Primary Care Groups will also work with their practices to ensure the best use of resources for their patients. Over time, the Government expects that Groups will extend indicative budgets to individual practices for the full range of services, but no individual element will be artificially capped. It will be open to the Group to agree practice-level incentive arrangements associated with these budgets, approved by the Health Authority, where this helps promote best use of resources. Initially every practice will have a prescribing budget, as most do now. Management cost 5.20 Primary Care Groups will have their own dedicated management support, but will be expected to share, not duplicate, functions. In particular, they will work closely together and with their Health Authority to share scarce expertise such as public health skills. Where support functions can most cost-effectively be delegated back to Health Authorities, Primary Care Groups will be expected to do so. 5.21 A combined Health Authority and Primary Care Group management cost envelope will be set for each Health Authority area. The Government will support the development of Primary Care Groups in all parts of the country by fairly redistributing, over time, the management costs that have supported GP fundholding as well as those that have supported Health Authorities' direct commissioning role. GP fundholding only covers part of the country and part of local health services, so by cutting the number of commissioning bodies and scrapping both short-term contracts and individual case contracts, the new arrangements will also cut transaction costs and bureaucracy. That will allow management resources to be used more effectively. It will also help all practices to develop the information systems needed for integrated health care. 5.22 Redeployment of the GP Fundholding Practice Fund Management Allowance will provide about £3 per head of population to support the running costs of Primary Care Groups as part of the overall Health Authority/Primary Care Group cost envelope available locally. Further management support costs will be redeployed over time from Health Authorities as Primary Care Groups take on more responsibilities. GPs who take on key responsibilities within Primary Care Groups will have their time appropriately reimbursed from within the Group's management support. 5.23 Where a Primary Care Group merges with a Community NHS Trust the management cost envelope will be further adjusted. The Government will require such mergers to bring significant overall savings in management costs as functions, overheads and support services are combined. Accountability 5.24 Primary Care Groups and Primary Care Trusts will be accountable to Health Authorities for the way in which they discharge their functions, including financial matters. This will ensure that they work within the Health Improvement Programme and that financial discipline and probity are maintained. In addition the Health Authority and the Primary Care Group will agree targets for improving health, health services and value for money. These will be set out in an annual accountability agreement. 5.25 Before securing increased responsibility, Groups will need to satisfy the Health Authority that they have adequate management arrangements (including designation of an Accountable Officer), risk management plans for their budgets, and a proper range of partner and public involvement. 5.26 No barriers will be placed in the way of Primary Care Groups which are making good progress. But where a Primary Care Group is falling behind its peers Health Authorities will need to support it through closer monitoring, advice and guidance and greater direction. In the rare event that a Primary Care Group got into serious difficulty the Health Authority would have the power to withdraw some or all of the devolved responsibility or require a change in its leadership and management. Commissioning better services 5.27 The arrangements set out above will give Primary Care Groups the responsibility as well as the tools and incentives with which to develop prompt, accessible and responsive services for local people. They will be encouraged to play an active part in community development and improving health in its widest sense. Health visitors and health promotion professionals will have a strong contribution to make in identifying health needs and implementing the programmes that best address them. Other primary care professionals, such as dentists, optometrists and pharmacists, will need to be drawn in to contribute as appropriate to the planning and provision of services. This must be a coming together of equals with each profession recognising the distinctive contribution of the others. Dentists, pharmacists and optometrists also have their own separate and distinct contributions to make to the NHS and the Government will continue its dialogue with them about how they can best develop it. 5.28 As part of the commissioning process, Primary Care Groups, Health Authorities and hospital clinicians will agree whether a service should be commissioned for the whole population across the Health Authority, or more locally. Quality standards, service protocols and agreements should be set by direct discussion between clinicians to ensure primary and secondary care services are properly integrated and programmes of care developed to reflect patient needs. 5.29 National Service Frameworks, and guidelines issued by the new National Institute for Clinical Excellence, will help ensure greater local consistency between Health Authorities and Primary Care Groups in the provision of top quality services for major diseases and conditions. In this way devolved commissioning will go hand in hand with greater equity for the most important services, so that two-tierism becomes a thing of the past. 5.30 Primary Care Groups will be able to make choices about cost-effective patterns of services and will be free to switch resources over time to support them. They will redeploy savings to meet local needs and promote local developments. Developing primary and community services 5.31 The internal market has over-emphasised the role of primary care as commissioner of hospital services, at the expense of improving the provision of primary care services themselves. Primary Care Groups will set that right. They will be encouraged to use their freedoms to improve primary and community health care for their patients. The independent contractor status of GPs will continue. Working with Health Authorities, Primary Care Groups will be able to use the NHS (Primary Care) Act to pilot local flexibilities in delivering general medical services. Health Authorities will have reserve powers in respect of payments made by Primary Care Groups/Primary Care Trusts to GP practices, for example from general medical services allocations and payments under Section 36 of the Primary Care Act. Primary Care Act Pilots Under the NHS (Primary Care) Act 1997, different more flexible ways are being piloted of providing primary care to attune it better to local needs. Pilots will be established from April 1998 to: improve the quality, range and accessibility of services tackle unmet need for specific groups of people improve the recruitment, retention, and develop skills of GPs, nurses and other clinical providers establish new organisational models for better providing integrated primary and community healthcare. 5.32 Primary Care Trusts will be able to run community hospitals and other community services. By integrating primary and community healthcare, Primary Care Trusts will provide a focus for improved rehabilitation and recovery services. Too often in the past community hospitals have been sidelined. Their potential contribution to managing the pressures of rising emergency admissions has often been ignored. Patients will be able to use local community hospitals to the full rather than having to travel to more distant acute hospitals. This will be particularly significant in rural areas. 5.33 Primary Care Groups will be expected to help primary care professionals to enhance the quality of their care. There is much on which to build. Clinical audit is now becoming well established in general practice and the NHS Executive is working with the profession to develop indicators to assess the effectiveness of primary care at national and Health Authority level. 5.34 But more is needed. As part of the development of clinical governance in the NHS (discussed in more detail in chapter 6) each Primary Care Group will nominate a senior professional to take the lead on standards generally and on professional development within the Group. To extend this approach through primary care, individual practices will be encouraged to identify lead responsibility on the same basis. Many practices are very small organisations, however, and it will be important to apply the principles of clinical governance sensitively. In order to achieve Primary Care Trust status, Primary Care Groups will need to demonstrate that they have a systematic approach to monitoring and developing clinical standards in practices. This requirement will also be applied to community health services included in the Trust. Beyond fundholding 5.35 Primary Care Groups build on best of existing practice. They offer an opportunity for innovative GPs and community nurses to spread the benefits of their experience more widely. This will ensure that those who are willing and able to lead can do so in a way which benefits all, without requiring every GP to take on a lead management role. 5.36 Primary Care Groups are where the future lies for GP fundholders. The Government will discuss with those concerned an orderly transition covering: future arrangements for services currently funded through the fundholding scheme so that those that are cost-effective, including those in GP practices, can continue to be provided, and spread to others arrangements for fundholding staff, currently supported from the Practice Fund Management Allowance, so that those skilled in primary care commissioning are wherever possible retained at the practice, Primary Care Group or Health Authority level arrangements for winding up Practice Funds, including how savings can be used for the benefit of patients subject to appropriate value-for-money tests. 5.37 The Government will bring forward legislation to provide for the move from GP fundholding to Primary Care Groups and to create the new Primary Care Trusts. Subject to the availability of Parliamentary time for the necessary legislation, Primary Care Groups will succeed fundholding from April 1999. In the meantime, there will be no new admissions to the fundholding scheme. 5.38 In parallel the NHS Executive will: explore with all interested parties what can be learned from existing commissioning models, drawing on the extensive programme of research and evaluation currently underway ensure Health Authorities work with primary care and community health services locally to develop Primary Care Groups, build on existing local initiatives, and devolve responsibility as new Groups demonstrate the capacity to take it. Milestones The development of Primary Care Groups will be evolutionary, building on existing models and the convergence which is already apparent. 1998 GP Commissioning Group pilots begin early action will concentrate on the transition to the new Primary Care Groups 1999 new Primary Care Groups in place GP fundholders, Total Purchasing Projects, multifunds, and locality commissioning GPs will move on to Primary Care Groups and, subject to legislation, the fundholding scheme will be wound up Primary Care Groups will take on additional responsibilities at a pace to be agreed locally.

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Prepared 8 December 1997