Making Healthcare Mutual

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Making Healthcare Mutual

• A Mutual Provider for OOH Primary Care
• Cliff Mills
• 4th March 2004
• cliff.mills_at_cobbetts.co.uk

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This presentation

1. Introduction a mutual structure for OOH primary
   care
2. Basic stages in establishing a new mutual
   provider
3. Issues concerning directors liability

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• 1. Introduction a mutual structure for OOH
  Primary Care

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Why are we talking about mutuality?

• Making Healthcare Mutual (Dec 02)
• NHS Foundation Trusts independent
  organisations, modelled on co-operative societies
  and mutual organisations
• Care on Call (Jan 04)

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Mutuality the background

• Traditional mutuality
• Mutual insurers
• Friendly societies
• Building societies
• Co-operative societies
• Self-help movement
• Owned and controlled by local people

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Characteristics of traditional mutuality

• Customers (community) are the owners
• No investor owners
• No distribution of profits
• Commitment to social (community) purpose
• Democratic or representative governance (local
  accountability)

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Mutuality and the NHS

• Mutual societies were the fore-runners to the
  welfare state
• Need for a national health service led to
  state-ownership and control
• Centralised state-ownership no longer considered
  efficient
• Public/private mentality

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Explanation of Cobbetts involvement

• Legal advisors to the retail co-operative
  movement
• Involved in modernisation of mutual law
• Promoters of mutuality and community ownership in
  public services
• Leisure
• Social housing
• Childrens services
• Education

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The Public Services choices

• State ownership
• Private (investor) ownership
• Mutual (community) ownership
• What is the owners priority?
• How do you drive efficiency and success?

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What is ownership?

• Not the ability to sell and realise value
• The power to make the organisation do what you
  want
• Power to influence service and how it is
  delivered
• Power to sack those who fail to deliver
• Accountability
• Ability to drive efficiency and success

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Modern mutual comprises

• Members
• (Customers, local community, staff)
• Strategic Board
• (Elected representatives of members, partnering
  organisations)
• Professional Executive

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Modern mutuality

• Retains
• Customer/community ownership
• No investor owners/no profit distribution
• Commitment to social purpose
• Democratic representative governance
• Adds
• Strategic board as forum for partnership between
  key parties

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Examples of modern mutuality

• NHS Foundation Trusts
• Leisure Trusts
• Football Trusts
• New models in social housing
• Childrens centres and Sure Start

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A model for OOH primary care

• Members, comprising
• GPs
• other employees
• patients and public
• Strategic, board comprising
• Elected representatives of GPs, employees,
  patients and public
• PCTs
• Acute Trusts, ambulance service etc
• Professional executive

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A model for OOH primary care (continued)

• Role of professional executive
• to run the organisation
• Role of strategic board
• to help to shape and to approve strategy, and to
  hire and fire executives
• Role of members
• to elect their representatives, and hold them to
  account

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Role of strategic board

• To be a forum for participating organisations to
  work together
• To provide a voice for customers (patients)
  providers of service (GPs and employees), the
  paying party (PCTs) others involved in and around
  health care

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• 2. Basic stages in establishing a new mutual
  provider

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Stage 1 - new OOH Contract

• Commissioning/Procurement process
• Implementing the nGMS Contract Out-of-Hours (DH
  October 2003)
• PCTs own procurement policies
• Knowledge of provision market
• Value
• Probity

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New OOH Contract

• Parties
• PCT/PCTs (1)
• Newco (2)
• Individual, joint or lead procurement
• Services to be provided
• Time Period
• Variation/Development

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Stage 2 - Incorporation

• Engage relevant parties
• Adapt model rules
• Seek registration/incorporation
• Appoint first strategic board
• Appoint chief executive

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Stage 3 - getting started

• Transfer of current GP Co-ops
• New arrangements

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Transfer of current GP Co-ops

• Premises
• Employees
• Assets

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Transfer process preliminary steps

• Obtain consents
• Premises
• Leases (eg cars, computers)
• Consultation
• Employees
• User groups/commercial clients
• Notification (eg rates)

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Transfer process formal approvals

• Board of transferor(s)
• (Possibly) members of transferor(s)
• Executives and strategic board of new provider

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New arrangements

• Bank account
• VAT registration (?)
• PAYE
• Accreditation
• Professional resources
• Insurances

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Priority continuity of cover

• Managing the transition
• Retaining current knowledge
• Utilising existing resources
• Avoid wastage
• Retaining GP and employee support
• Establishing new partnerships
• Maintaining public confidence

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• 3. Issues concerning directors liability

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Directors liability the current position

• GPs have legal responsibility to provide cover
• By consent GP co-ops meet that responsibility for
  GPs
• If a shift will be under-resourced, co-op can ask
  for additional GP support
• Ultimate protection for co-op directors hand
  back responsibility to GP practices

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Directors liability new position

• PCTs have legal responsibility to provide OOH
  cover
• Can seek by contract to pass on responsibility to
  a provider
• But retain residual responsibility
• PCTs need to consider their own contingency plans
  and insurance

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Directors of new provider

• No legal responsibility until new provider takes
  on a contract
• What responsibility in the contract?
• Specified number of GPs per shift
• Adequate cover
• What should new provider accept in a contract?

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What risks should new provider accept in a
contract?

• Fundamental factors
• Availability of GP cover (risk for provider)
• Cost (risk for PCT or provider depending on
  contract)
• Mitigating factors
• Utilising other support (option for PCT or
  provider)
• Insurance (by PCT or provider)
• Risk management (to minimise premiums)

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Finding a solution

• Acceptable level of risk for both parties
• Ability to manage the risk
• Appropriate back-up (including insurance) costed
  and built into business plan
• Agreeing the new OOH contract

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Making Healthcare Mutual

• A Mutual Provider for OOH Primary Care
• Cliff Mills
• 4th March 2004
• cliff.mills_at_cobbetts.co.uk