Originally published by Independent Nurse, Feb 21, 2011.
The Health and Social Care Bill is set to transform the NHS, wiping out PCTs and handing their health commissioning role to GPs, writes Joe Lepper.
As the bill progresses through parliament the government is already trialling this new form of commissioning through 141 pathfinders, which were set up in December and January.
But nurses’ role in this new commissioning structure is unclear. The bill offers no guarantees of a place on consortia’s management boards, or that nurses should even beconsulted on local commissioning decisions.
Among pathfinders there is evidence that nurses are involved at a senior level. In Nottinghamshire the local commissioning pathfinder Principia has nurses on its management board as well as in advisory roles (see case study box).
Other options being considered are to have a small GP led management board with nurses advising it through ‘a clinical senate’.
Lynn Young, the Royal College of Nursing’s primary care adviser says that ‘nurses can get too hung up on getting a place on the board ‘ adding that, ‘they could find themselves with more say as advisors.’
She says: ‘Large boards with lots of different factions can end up being talking shops where nothing gets done. There are certainly merits in having a small board with some kind of expert panel advising it.’
NHS Alliance chair Dr Michael Dixon is seeking to reassure nurses they will have a strong voice in local commissioning under the planned changes.
‘To be successful they have to involve the experts for each service, whether that be physiotherapists or nurses,’ he says.
He also agrees that having a nurse on consortia’s management board may not bring greater power to the profession. ‘What you need is a system that channels their expertise, not a system that is gunged up with old thinking and obsessing with who has a seat on the board,’ he says.
However, he does acknowledge in some areas nurses are feeling isolated from the work of the pathfinders. ‘But that is because many consortia are being formed from practice based commissioning groups. Once the structures are sorted then nurses will see themselves much more heavily involved,’ says Dr Dixon.
Ms Young hopes that a benefit for the profession under GP commissioning will be greater funding for nurse led services.
‘We saw this under GP fundholding and I can see it going the same way under thismodel,’ she says.
Charlie Keeney, programme director for GP commissioning support at the NHS Institute for Innovation and Improvement, says the squeeze on NHS budgets is also likely to lead to more nurse led services being commissioned by consortia.
He says: ‘What GPs need to be looking at closely is reducing acute budgets and seeing what more can be done in the community and surrounding prevention. This is where nurses are the experts.’
Support is being offered to consortia by the Royal College of GP’s centre for commissioning, which is run jointly with the Institute.
Taking place this year is a series of roadshows to explain more about the commissioning process. Within months a series of training modules for consortia will also be published.
A priority of the centre is to encourage more GPs and other clinicians, such as nurses, to get involved with consortia.
Mr Keeney concedes that ‘it can seem daunting, but we are trying at our roadshows to make it more manageable and take away some of the fear.’
But Ms Young believes many GPs will remain unconvinced and will struggle to find the time to become a commissioner.
She believes that a likely scenario is for GPs to drop out completely in some areas and hand over responsibility to more experienced commissioning managers currently working within PCTs.
She says: ‘There are lots of GPs that were not interested in practice based commissioning and I can’t see them being interested in GP commissioning either. I think it will be likely that no GPs at all will be involved in commissioning in some areas.’
Dr Dixon believes clinicians will still take the lead but concedes that in some areas they may be little change around commissioning. ‘Where a PCT already works well with local clinicians there probably won’t be much change. The consortia will want to keep the expertise of PCTs and the same people will continue to work together commissioning,’ he says.
However, in some areas where the relationship between PCTs and GPs ‘is less good’ he can see GPs turning more to ‘the corporates’ for that management and commissioning expertise.
Somerset is among those areas where commissioning pathfinders are being set up, with the county exploring a two-tier model.
Wyvern Health, formed from the county’s practice based commissioning group, local medical committee and PCT, will look at regional commissioning covering an area of 75 practices and half a million patients.
It will then link up with two smaller pathfinders, of 11 practices in Bridgewater and three in East Mendip, which will advise Wyvern on specific commissioning needs in their areas.
Wyvern Health chair Dr David Rorke, believes this could become a popular model in rural areas like Somerset. ‘It makes sense to have a county wide commissioning focus and smaller commissioning groups being set up that really know their local population,’ says Rooke.
Wyvern is now consulting on the consortium’s structure, with Dr Rooke favouring a small board with a clinical senate advising it. ‘This could reduce bureaucracy and mean decisions can be taken more quickly,’ he says.
He agrees that under the GP commissioning, primary care nurses could be in greater demand in Somerset. Already in Bridgewater GP practices have set up a complex care pilot working in nursing homes.
‘This is the kind of local service with a strong nurse involvement that we as clinicians are looking to commission,’ says Dr Rooke.
Dr Rooke is also adamant that nurses will have a strong voice in commissioning in Somerset, whichever management structure is agreed. He says: ‘It would be impossible for us to commission services for areas such as long term conditions without nurses’ expertise and involvement.’
As practice nurse leads at Principia, which was named as a GP commissioning consortia pathfinder for the East Midlands last December, Diana Buck and Sarah Hartley see themselves as champions for all practice nurses in the region.
They have been working in similar roles for the last five years advising commissioners at both PCT level and Principia, which was set up as a GP, nurse and community led social enterprise to commission health services in Rushcliffe in 2006.
Nurses are also represented at a more senior level at Principia, as a health visitor andcommunity matron sit on its management board.
Ms Buck says: “Our job is to convince the commissioners of the benefits of investing innursing. It is difficult in the current climate as they do not have money to spend, but we have made some progress.”
Among projects and services Ms Buck and Ms Hartley have helped commissioners develop have been a Bank agency scheme for practice nurses, to help practices cover sick leave. They also organise nurse training sessions, with a recent course covering the treatment of asthma.
“It is difficult though. We couldn’t get the money from the commissioners for a recent training course, so we ended up turning to the pharmaceutical industry,” says Ms Buck.
Ms Buck remains sceptical that GPs as clinicians are best placed to commission local health care and believes they will find it difficult without drafting in management expertise from PCTs.
She says that both her and Ms Hartley are struggling to keep within their seven and half allotted hours work for the consortia on top of their clinical roles. Ms Buck works as senior practice nurse at the county’s HMP Whatton and Ms Hartley is a practice nurse through the Bank scheme.
“To attend the meetings, look closely at training and the other work, we either need more hours or more of us,” Ms Buck adds.
by Joe Lepper