Paul Brown, Director of Health Services at RSM Tenon discusses the future of GP commissioning and the emergence of Social Enterprises within the NHS.
What is the change?
The NHS is about to embark on one of the biggest shake ups in its history with the recent publication of Andrew Lansley’s ‘Liberating the NHS’ white paper. The role of a GP is set to become centre stage and responsibility of commissioning will shift to groups of GPs, moving responsibility away from Primary Care Trusts.
Not only are GPs able to provide healthcare services, they are now being empowered to take a lead within commissioning. The Royal College of General Practitioners has commented on a split between GPs as to which route to take; providing or commissioning. Ultimately, all GPs want to play a role in improving patient care; however this can be achieved through both commissioning and providing. The main objective for clinicians will be to ensure patient care improves as a result of the proposed changes.
What does this mean?
Critics of the proposed change could argue that the NHS will simply rebrand itself with the same personnel in post, albeit with the inclusion of GPs, under a different name. We think the changes will be a lot more profound and the opportunities much wider. There will be winners and losers. The winners will be those who are prepared to embrace the changes.
Large scale private companies are now entering markets that were previously untouchable, which brings an added element of competition for local healthcare providers. There is a risk that smaller practices may be absorbed by these large companies and lose their influence in shaping the local healthcare economy. To compete on a level playing field against these large corporations, GPs need to work together and form alliances.
The white paper offers GPs a chance to collaborate together and form ‘federations’ and consortia to be either commissioners or providers of care. An obstacle for many GPs is finding the time to concentrate on developing these federations or consortia. Furthermore, for these groups to be successful there needs to be strong management providing clear direction and strategy for the future. This can be extremely time consuming if done in isolation, however the benefits are clear for all to see.
The challenge of setting up and running these groups can be overcome by learning from other successful GP groups. There are numerous examples already of clinicians collaborating to form new organisations, with differing levels of size and success. Success can depend upon the personalities of local clinicians, but also on the ability of clinicians to act as ‘managers’. Most importantly, the new organisations must give all local clinicians an equal voice, allowing for true collaboration.
What can clinicians do?
After the publication of the NHS white paper, a key question for many clinicians is - what do we do? Do we wait to see what will happen in our area? Do we form private companies, partnerships or a social enterprise now? Furthermore, there is an added worry that if clinicians wait too long, they may be forced to join a group regardless of whether they want to.
Emergence of Social Enterprise
Of the options available, we have seen a number of clinicians forming locality-wide social enterprises. Instead of pursuing the traditional partnership or limited company route, clinicians are considering the potential of forming a ‘social enterprise’. The term ‘social enterprise’ is not new, however its application within the public sector has started to become much more common.
One of the key attributes of a Community Interest Company (a type of social enterprise) is that it must reinvest at least 80% of its profits back into the local healthcare economy. This differs from traditional private companies where a greater emphasis is placed on shareholder return. It is this attribute that makes commissioning social enterprises to deliver services much more appealing for the local community.
A YouGov poll in 2007 found that over 60% of patients would actually prefer healthcare to be provided by social enterprises. Since then, we have seen an increasing number of these organisations being formed within healthcare. Indeed, the new NHS white paper aims to ‘create the largest and most vibrant social enterprise sector in the world’. This can only happen by the NHS commissioning social enterprises to provide healthcare.
Delivery through Social Enterprise
The key feature of reinvesting profits in the local community is appreciated in the current economic climate. Typically lower margins and the inability to pay large dividends to shareholders may put off some individuals wishing to form a social enterprise.
There are however, many advantages of social enterprises which can benefit the local health economy, patients and shareholders. To achieve these benefits, the social enterprise could be based upon a collaborative model, whereby all local healthcare providers collaborate together to form both a support network and a new service provider. The model suits those motivated by a service ethos and a commitment to ‘put something back’ into the locality.
The Collaborative Model
The collaborative model works on a ‘hub and spoke’ basis, whereby all shareholders form a central hub in which knowledge and best practice is shared. The collaborative then acts as a support function for all GP practices and healthcare providers within the network. In addition to supporting local healthcare providers, the collaborative is a centre for developing new, innovative services based on this combined knowledge. Once established, the collaborative can also bid to run Health Centres and provide community health services.
The primary aim of the collaborative is to raise the standard of healthcare across the entire locality, not just within one specific practice. Any system is only as strong as its weakest link; the collaborative model seeks to address weaknesses by sharing best practice and providing education, support and training where needed. This is not reinventing the wheel; it is common sense which is sometimes overlooked in highly bureaucratic organisations.
By combining knowledge centrally, there is a huge opportunity to tap into local knowledge and develop services to benefit the local health economy. In addition to this, the central ‘hub’ can be a provider of non-healthcare related support functions such as Finance, HR and IT. This will help all local healthcare providers to reduce their management overheads and absorb the impact of any potential fall in income.
A seamless service can be developed through the collaboration between GPs, nurses and local healthcare providers. As the collaborative would develop services as a group, communication would be improved through bringing together groups of healthcare professionals that would normally be working in silos due to historic working practices. Therefore it may be possible for care pathways to be improved, as the collaborative will allow for greater integrated working to identify opportunities for change across the entire patient pathway.
There is further potential to link individual collaborative social enterprises into a national network, allowing each collaborative to benefit from economies of scale of a large organisation, without compromising its ability to influence the local community. By forming a network of collaborative organisations, clinicians will be able to compete with large private companies whilst retaining control over local healthcare provision.
The collaborative model itself facilitates ‘bottom up’ innovation led by frontline staff, instead of ‘top down’ orders imposed by non-healthcare professionals. In this model, each local primary care collaborative would be owned by healthcare professionals from the area. A social enterprise can be set up so that every shareholder has equal power within the organisation, issuing one voting share per person. Furthermore it is not uncommon for the management board of social enterprises to be voted in on an annual or less frequent basis.
What next?
The momentum of change will undoubtedly pick up in the coming months; GPs and other clinicians in the primary care field face the risk of being left behind and forced to change. It is now an ideal opportunity for you to talk with neighbouring practices to understand how collaboration could work in your area, without being forced to accept changes in the future. This is an exciting opportunity for clinicians to have a greater influence over patient care and help improve upon the services already delivered in local areas.