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White paper in focus: what does the future hold for primary care?

Tom Clarke
Independent Medical Writer

Over the next two years, as part of the white paper reforms, general practices will be handed around 80 of the £100m NHS budget and put in charge of organising local services. But it is not just all about GPs ...

By 2013, primary care trusts (PCTs) and strategic health authorities (SHAs) will have been abolished and GP consortia will have received budgets to buy local services, based on the patient list of each practice. Practices will receive additional income from a "quality premium", paid to consortia that manage their budgets well and improve outcomes for their patients.

It will be up to individual consortia to decide how these bonuses are distributed among their practices and, as with the quality framework, it will be up to GP partners whether they pass on any of this extra cash to their staff.

Practices will be expected to reign in prescribing and scrutinise referrals to help their consortia stay within their budget, and the best performing practices will receive a greater share of the quality premium.

A new National Commissioning Board will set consortia's budgets, monitor their performance and issue guidance. The amount consortia can spend on management costs and admin is going to be capped and likely to be drastically smaller than the amount survived on by PCTs.

The Royal College of Nursing (RCN) has called for assurance that senior nurses will be properly represented on the boards of these new consortia. The NHS Alliance, a group representing GPs and NHS managers, is also concerned that the white paper overlooked the key role nurses play in primary care. "The white paper fails to acknowledge that nurses carry caseloads, prescribe medicines, make referrals and may be seen by their patients as their 'primary care giver'," the body's consultation response says.

The white paper does state that all health professionals, including primary care and community nurses, should have the chance to influence decision-making in their local consortia. Health secretary Andrew Lansley said recently: "Primary care is a multidisciplinary team. This is not just about GPs. It will be primary care led."

Howard Catton, RCN Head of Policy, said he has seen evidence of the Department of Health's (DH) desire to identify nurse leaders and help them join developing consortia. England's Chief Nursing Officer, Christine Beasley, has set up a group to encourage nurses to get involved in the commissioning and Dame Barbara Hakin, the DH's Director of Commissioning, mentioned nurses' roles in the reforms in an open letter to NHS managers. The RCN is also setting up working groups to help nurses get involved in the reforms. But is there any appetite among nurses to get involved in commissioning? Mr Catton says it is varied, with nurses in some areas already heavily involved in commissioning and some likely to want to stick to clinical work.

"We absolutely have had discussion with some groups of nurses who are passionate about organising services. They are keen to get involved in discussions about how GP consortia will work. But we see that usually where the relationship between GPs and nurse is already close and productive."

Nurses in the community are the least likely to be involved as many are in the process of transferring to another employer under the Transforming Community Services programme, says Mr Catton.

"They are understandably worried about their immediate job prospects," he says. But he urges all nurses to take an interest in commissioning.

"Primary care nurses' input will be especially useful for designing nurse-led clinics and organising care pathways," he says.

The white paper has also raised hopes that, once GPs are in a position of power, they may employ more primary care, community and specialist nurses and place them in the most appropriate locations and roles. They may also be able to reverse recent moves to locate health visitors and district nurses away from GP practices.

But what about the nurses that do not want to take commissioning decisions? Lynn Young, Primary Care Adviser for the RCN, says the average practice nurse "may not notice much difference' during the sweeping reforms, unless they volunteer to take part.

"What will the difference for the average practice nurse be? Well it depends if they want to get involved.

"Let's assume only a tiny percentage of GPs will actually get involved in leading commissioning. I think it will be the same for nurses - nurse practitioners may want to take on leadership roles and start designing clinics, but many won't."
Ms Young does fear that primary care nurses could bear the brunt of patient's anger when GPs start making tough decisions about services.

"The big neurosis is that it is primary care that will be the one saying 'we won't be providing these services.' It's always been the case that primary care gets the moaning and the complaints about problems and waits in secondary care - but that might get worse.

"I find it difficult to predict what will happen. The heavy spending days are over. And general practice will have to find a way of dealing with it."

Giving primary care staff the power to take commissioning decisions makes sense on paper. But it should not be forgotten that these reforms also propose a huge a risk to the NHS. Many organisations have expressed concerns about the pace and scale of the changes, at a time when the NHS needs to focus on making between £15-20bn in efficiency savings.
Influential think tank the King's Fund says GP commissioning needs to be piloted and rolled out carefully, retaining PCTs and SHAs in areas where consortia are not ready to take over.

The NHS Confederation, which represents NHS managers, warns that there is little evidence for the reforms, and says during the transition period, managers "will be distracted from the immediate task of managing the huge financial challenges facing the NHS."

The RCN has also warned that once PCTs and SHAs are abolished, there will be no overarching structure to organise and champion nurse education and CPD.

There is also likely to be a battle over maternity services and how they are commissioned. The white paper states that maternity will be one of a number of services commissioned centrally, by the National Commissioning Board. However, the BMA's GP Committee, the NHS Alliance and the NHS Confederation all recently said it made much more sense to let GPs organise local maternity services.

The health secretary admitted recently he is 'still deciding' whether to change his mind. Charities have also warned that GPs will not have the knowledge to commission specialist services, yet if they are organised centrally through a national board, they will fail to meet local needs. 

Worryingly, the NHS Confederation predicts that once the DH slashes management costs, the allowance consortia are left with for admin and staff costs will be tiny. Dame Hakin recently said that most of this management allowance will have to be spent on compensating practices for the time their staff spend at commissioning meetings. Again, whether practices are prepared to free up tome to allow their nurses to attend consortia meetings is likely to depend on the relationship within the practice.

The consultation on the white paper and GP commissioning is now over, but there is plenty still to be decided. Practices have until April 2012 to form themselves into consortia and nurses must make themselves known now if they want a voice in these organisations in the future.

GPs must support their staff to join in these early conversations before structures are established and nurses feel locked out of discussions.

For the first time, it seems each and every primary care nurse in England has a chance to design local services the way they think best.

But with that power comes responsibility. General practice will take over running NHS services as budgets contract for the first time in a decade - and primary care nurses will increasingly be the ones that take the flack if patients are dissatisfied.

The opportunity to influence the health service for the better is there, but it is up to nurses to decide how much they will contribute.