As a previous corrspondent has said, there will be those GPs who will welcome the change but there will be others who see this as an extra administrative burden. In the 90s this led to tensions between GP practices on the strategies to be followed, and obtaining consensus was difficult and time-consuming. I do not imagine that it will be any different this time, as GPs try to form themselves into consortia, and then consortia endeavour to co-operate in order to improve their purchasing power.

One of the reasons why the internal market collapsed in the 90s was the possibility that acute hospitals may lose sufficient work that they became financially unviable and would have to close. The politicians took fright at the possibility of them having to explain to their electorate as to why their district general hospital was going to close. Are the current crop of politicians prepared to face up to that possibility this time? I think not.

No matter who does the commissioning, I shall take a bet that the amount of bureaucracy will not diminish. NHS Head office and the DH civil servants will still insist on receiving a raft of reports, so that they have the information to hand, just in case a minister has to answer a Parliamentary question.

Will this lead to a reduction in the number of interims? Personally I think not.

Many GP practices will not willingly embrace becoming part of a Consortia, and taking on these new managerial and financial responsibilities, few have any depth in terms of resources and management expertise, so the process involves the setting up effectively from scratch new organizations, shadowing (PCTs) in 2011/2012 (I wonder how that will work).

Whilst there are many good Commissioners and Managers within the PCTs (I read a comment recently in the HSJ that suggests the best SHA and PCT managerial staff are already lining up top jobs with GP consortia), however my experience is that presents relationship PCts and GPs are often adversarial, as they are with SHA’s . It seems likely to me that the new Consortia will buy in private sector expertise including Interims of all disciplines using this opportunity to build lean responsive organizations without baggage. This will probably not happen until the first quarter of 2011.

Regardless of where Commissioning is carried out, within the PCTs as now, or the new GP Consortia, it has be done, and the volume of work, the complexities of contracting for service provision, with more private sector providers and every Acute having foundation status are immense, so I not see the NHS dispensing with Interims, there use is likely to grow in the medium, long term.

The 3 big challenges are:
1. Cut 10% of clinical activity – nationally £15-20bn
2. Keep the business going
3. Help set up GP commissioning

And do this with 45% less staff!! But that’s what we interims bring – radical ideas, can do attitude and delivery.

Some thoughts to ponder:
1. Likely management cost envelope per commissioning consortium = 0.85% (deduced from White Paper numbers)
2. Lack of expertise and willingness amongst GPs – burnt by ending of Fundholding and PbC
3. No organisational future for current PCT/SHA staff

Smart staff starting to think about setting up social enterprises (under right to request)to provide services to consortia locally – and maybe further afield. Pick yoiur bets and brightest colleagues – get PCT help to form SE – start working with GPs now as part of the day job. By the time “guidance” has been issued you’ve got on with helping set up consortia and started to define the offer based on inside knowledge of what the GPs want. Food for thought!!

Many GPs are anti-private sector health organisations. How much commissioning will be done in the new world? Maybe a lot of de-commissioning? GPs won’t have to worry about the future viability of local Trusts (that’s for Monitor). Lots of local procurements.

So I suspect there will be work for good interims who know what they’re doing. Rates will be under pressure but what’s new in downturns. Need to understand the local situation and get in with key players.

1. How can patient pathways be redesigned to drive value, outcome and single accountability.
2. How will information be gathered and harnessed across the three dimensions of Outcome, Quality and Experience.
3. The management of the critical transition period.

GP consortia will need resources and guidance to deliver what’s required from these challenges. To be honest, that experience does not lie consistenly through the NHS. GP’s have a mixed appetite for commissioning and traditionally have been excluded from the process by PCT’s. Managers with key skills, but more importantly vision for how to execute, will be valuable both during the transition and early stage implementation.

Although there is clearly tremendous support for promoting from within, aka jobs for the boys, that is also true in the private sector. How many clients are far sighted enough to admit interims can transfer their skills across sectors? Very few. However if the NHS continue not to challenge the status quo and to hire their own, many of whom are ex-employees who have miraculaously morphed themselves into contractors/interims, the phrase “doctor heal thyself” springs to mind and medium term it is not a solution.

imho the more broad minded within the NHS realise they need to introduce private sector skill, but are not close enough to the cliff edge to turn this into action. Again this is not so different from private sector employers. They forget problems do not heal themselves with ageing!!

I do not believe day rates to be a big issue. Consultants have crawled over the NHS for years and taken many millions of pounds for providing reports. Hopefully the NHS will realise sooner than later the benefits of interims and actually take a little more risk. They certainly take medical risks often enough, why not business risks. There are apparently far too few people with commercial knowledge in the NHS – profit and loss, cost per patient/action taken, waste removal, cost cutting and performance management need to become their new lexicon.

Change in the way the NHS introduce it equals, and has equalled for years, disorganised intiative driven chaos. Similar to change being introduced into the private sector a decade ago before a process for change was identified and practiced by professional interims and their provider associates.

So short term patients – sorry patience – medium term opportunities…………….

In your blog, you talk about existing NHS staff and the impact their career decisions will have on the demand for interims. Given that the consortia are intended to be formed and start operating in shadow form during 2011-12, I think that many NHS staff will need to decide whether they want a career move to the consortia during 2011-12, and therefore there will be fewer chances of just waiting out a redundancy package until 2013. The main staffing consortia modus operandi and the key staffing for the consortia will need to be addressed by 2011-12.

There are presently circa 500-600 consortia in England. It can be argued that this is will be inefficient, and that there will have to be far fewer to achieve economies of scale and hold sufficient purchasing power with providers. However, the white paper is quite clear that GPs will have the deciding vote on how they structure, and GPs may very well see the priorities differently. They may place more emphasis on localisation and forming small, more manageable groups of GPs.

In this scenario, the interim commissioning opportunities increase because the NHS will need 500-600 commissioning groups (contract management, performance management, information, finance, procurement etc etc). The permanent staffing for this volume does not exist today and some of the existing staff will want to move on. Other than the the Dirs Commissioning and the ADs Commissioning in the existing PCTs, I cannot see that the other existing staff (in general) have the skill base to set up and run a new commissioning operation alongside GPs.

Whilst DH is promising to empower the GPs (via consortia), there will also have to be very strong governance to hold the consortia to account for both performance (experience, quality, outcomes etc) and budget. To achieve this, there will have to be top down definition of how this will work, and that in turn will tell us to what extent existing senior commissioners will have to lead the GPs to organise as effective consortia, versus GPs taking the lead themselves. I see a real opportunity for interims taking on roles in the short term working with GPs and leading or programme managing the consortia formation and set up.

The promised paper from DH on the GP Consortia model should reduce some of these variables.

At a political level, the cliche is always to slash management costs, as if the health service was populated by a vast tribe of managers who sat around and twiddled their thumbs all day. In practice, the 3% of NHS budgets spent on management is below the European average and certainly not excessive. Yes, it could be reduced by simplifying targets and procedures, but beware distortions in the system from losing one set of practices but gaining another.

The secret for interims is to adapt faster than the service. As Benjamyn correctly states, we have to provide evidence that our service offering can fulfil a need consortia cannot readily fill through any other means, and in so doing consortia will need to build their bureaucracy and change practices in order to survive.

The white paper makes it clear that, should GP consortia feel it necessary, they have the “freedom to decide what commissioning activities they may choose to buy in support from external organisations, including private sector bodies”. The reforms, may therefore, create a management void in many areas of the country ??