The government has set out its vision for GP commissioning that will push decision-making closer into the community and ensure that it is “underpinned by clinical insight and knowledge of local healthcare needs”.

The Department of Health has now launched a hotly-anticipated public consultation on its proposals - as first laid out in the white paper Liberating the NHS - that gives greater detail on its move to hand over commissioning responsibilities from Primary Care Trusts to local groups of GPs.

Under the plans, groups of primary care practitioners will lead commissioning consortia and thereby play a key role in the clinical design of local services, working hand-in-hand with a wide spectrum of other healthcare professionals to ensure that commissioning decisions genuinely reflect local needs.

Every GP practice in the country will be required to form part of a consortium and to contribute to its goals, but, crucially, consortia will also be able to employ external staff or support to help analyse local health needs or manage provider contract, for example.

The new consortia will have the freedom to make decisions on which elements of commissioning are undertaken in house and which need collaboration across several consortia, and will be supported by the new NHS Commissioning Board in developing commissioning guidelines, model contracts and tariffs, the government said.

Consortia will take over commissioning for the majority of NHS services, including elective hospital care and rehabilitative care, urgent and emergency care, most community health services and mental health and learning disability services, but will not purchase primary medical services, which will be the responsibility of the NHS Commissioning Board instead.

The Board will also take on responsibility for purchasing dentistry, community pharmacy and primary ophthalmic services, as well as national and regional specialised services, maternity services and prison health services, but with the help of GP consortia, to ensure input at the local level.

In terms of finance and accountability, as expected the Board will set practice-level budgets (separate from practice income) and allocate these directly to consortia, which in turn will be responsible for managing their own purses and ensuring that expenditure does not overshoot their allocated resources.

The NHS Commissioning Board will be held to account by the Health Secretary “for managing the overall commissioning revenue limit and for delivering improvements against a number of measures of health outcomes”, the DH said, and will hold consortia responsible for outcomes and financial performance, which will then hold individual practices responsible, creating a clear chain of accountability in the new system.

The DH is also proposing that the NHS Commissioning Board develop, with support from the National Institute for Health and Clinical Excellence, a commissioning outcomes framework to provide clear information – available to the public - on the quality of services commissioned and the management of resources.

Under the proposed timetable, GP consortia will begin to come together in shadow form by 2010/11 and a comprehensive system, as well as a shadow NHS Commissioning Board , should be in place by 2011/12, so that, by the following year, both are formally established and, by 2013/14, GP consortia are fully operational. PCTs, which will no longer have a new role in the new system, will cease to exist from April 2013, the government said.

Commenting on the consultation, Hamish Meldrum, Chairman of BMA Council, said there are still many questions that need answering. “The proposals contain both opportunities and threats,” he said, but added that the BMA “is committed to try to find workable solutions that will fully engage both primary and secondary care doctors and the public so that by working in partnership they can achieve the best outcomes for patients”.

“It will be a real challenge for GPs to take on the role of commissioning so many of the services provided by the health service at a time when there is already a need for the NHS to find around £20bn of efficiency savings,” noted Jo Webber, NHS Confederation deputy director of policy, and she stressed that “they will need the support of skilled managers both during the period of transition and afterwards as well, if this new vision for health is to be made to work”.

Democratic accountability
In a separate consultation, called Local democratic legitimacy in health, the DH has also proposed an expanded role for local authorities in underpinning patient choice and boosting commissioning efficiency, via the creation of new health and wellbeing boards.

The key aim of the health and wellbeing boards would be to “promote integration and partnership working between the NHS, social care, public health and other local services and improve democratic accountability”, the DH said. “The local authority would bring partners together to agree priorities for the benefit of patients and taxpayers, informed by local people and neighbourhood needs,” it added.

“Providing for greater involvement for local decision making in the NHS in this way could make a real contribution towards improving patient confidence in the care they receive or can expect to receive from their local health service,” the NHS Confederation’s Webber said.

Both consultations will run until October 11.