Scenario 4: Claims that gPs can’t be commissioner and provider

What’s happening

PBC clusters may have been set up with a commissioning role in mind but what happens when they make the leap into providing services as well?

There is misunderstanding around whether practices or consortiums can act as both commissioner and provider, when ultimately GPs have been doing both roles since long before PBC began.

Expert opinion

Dr Mike Dixon, NHS Alliance chair, agrees that there is a conflict between the commissioner and provider role but says it is overplayed.

‘PCTs have been commissioners and providers all along so to suddenly focus in on the conflict between commissioning and provision at the practice level seems a bit post hoc. Necessarily, practices are going to do both and that’s how it should be.

‘We need to accept there’s dichotomy but we need strong leadership to stop the whole thing becoming needlessly bureaucratic and there needs to be an element of trust.

‘One of the problems we see is that practices give up on the commissioning role and just look at their provider role, which is a real pity,’ he says.

A simple solution, says Dr Dixon, is to set up what are in effect two different companies, so the cluster has a commissioning arm and a provider arm.

‘You can have practices having different roles, with a commissioning face and a provider face and many are doing that initially.’

The other way to avoid the issue is by setting up a community enterprise.

‘If you are explicitly putting profits back into the local community, it seems to me you can be a provider as well as a commissioner – and that’s a model I would personally advocate.

‘If you go with a limited company you have to split into two.

‘But there’s no problem and frankly it’s quite preferable if the membership is the same because you’re lining yourselves up nicely for integrated provision of care in the same organisation,’ he says.

The guidance to quote

Clinical commissioning: our vision for practice-based commissioning, 2009

‘PCTs need to have clear frameworks for procurement of new services (in line with the Principles and Rules for Cooperation and Competition and the PCT Procurement Guide), including arrangements for declaring and documenting interests and protecting against real or perceived conflicts. It is also essential to ensure any service is governed by a clear contractual relationship and that there is clear clinical accountability for the service.

‘A robust system of governance should, however, enable PCTs to meet these requirements whilst drawing strength and power from an enhanced role for clinicians in both commissioning and providing services.’