Practice based commissioning

1
Practice based commissioning

• A view from an optimistic GP, commissioner and
  substance misuse provider
• Dr Linda Harris - lharris_at_rcgp.org.uk
• RCGP Substance Misuse Unit

2
PBC. Todays aims

• Explore the evidence base for primary care led
  commissioning (PLCL)
• Consider PbC in the present commissioning
• climate
• PbC implementation on the ground how does it
  work
• Consider PbC as an opportunity to enhance
  clinical engagement in service development

3
Commissioning in Context
The traditional commissioning cycle Patient
choice and needs assessment National
targets Local delivery Plans Capacity
planning Service design and development Service
level agreement Performance monitoring
4
PCLC. What is it?
Commissioning is led, particularly by GPs,
using their knowledge of their patients needs
and of the performance of services, together with
their experience as agents for their patients and
control over resources, to direct the health
needs assessment, service specification and
quality setting stages in the commissioning
process in order to improve the quality and
efficiency of health services Judith Smith
HSMC. Birmingham January 2005
5
PCLC. What is the evidence?
Internationally There is strong evidence from
the UK, New Zealand and USA of the effectiveness
of primary care led commissioning (PCLC)
6
The research evidence for PCLC - global

• Little evidence of impact on secondary care
• However, clinicians holding a budget can improve
  responsiveness
• Most impact is on primary and intermediate care
• PCLC increases transaction costs
• Primary care led commissioning what does the
  evidence tell us
• Judith Smith, senior lecturer, Health Services
  management Centre University Of Birmingham

7
The research evidence for PCLC - UK

• GPFH
• Shorter waiting times by 8 (Propper et al 2000)
• Reduced elective hospital admissions by 3.3
  (Dushieko et al 2003)
• Reduced prescribing costs (Audit commission 1995)
• Total Purchasing pilots
• 69 of TP Pilots reduced occupied bed days and
  13 reduced admissions( Wyke et al 2003)
• Locality/GP commissioning pilots
• Improved collaboration between GPs across
  practices

8
PCLC - other research findings

• Real clinical engagement is key (how
  incentivised?)
• PCLC organisations struggle to engage the public
• Proper management support is vital
• Accurate information on hospital activity etc
• direct link with outcomes e.g. no payment
  without discharge information
• There is no ideal size for a commissioning
  organisation
• Arrangements must be given time/stability

9
Leaner meaner and fitter PCTs

• To achieve financial balance
• To push forward reform
• To Implement Commissioning an patient led NHS
• Devolution
• Plurality
• Patient choice
• Investment
• Focus on national health improvement priorities

10
GPs involvement in commissioning

• GP Fundholding
• Multi-funds, total purchasing
• Locality commissioning
• Involvement via PCGs and PCTs
• From April 2005, practice based commissioning

11
PBC what is it?

• Practices /community-based nursing teams manage
  indicative budgets to commission services
• PCTs do the actual contracting, monitoring and
  write the cheques
• Management costs to practices in advance
• Linked to national tarriffs for paying for
  activity through Payment by Results
• Quantity x price income (forms about 30 of
  hospital income 2005/6)
• Savings (freed up resource) used for patient care

12
Desired Outcomes DH view

• Genuinely personalised care ( choice is real
  for patients)
• Services closest to the patient, more varied and
  from different providers
• End of GPs monopoly over GMS
• Increased clinical engagement in developing
  services
• Wider use of NHS resources
• A lever for demand management
• Cost containment, better referral patterns

13
Why PbC? Reality check

• Limited progress to NHS targets
• Priority has been balancing the books
• PCT and Trust debts increasing
• Without GPs the NHS cant manage the demand for
  acute care
• GPs are needed to challenge secondary care on
  patient pathways

14

• HARNESS THE GPs
• - practice insight and overview
• - practices making decisions on referrals
• TO
• - sort out bad pathways
• - make the NHS go further for patients

15

• GPs want to be involved in the action, not the
  bureaucracy
• a GP with a budget is worth 10 GPs on a
  committee
• Jo Whitehead
• Head of PCT Development. DH. March 2005

16
Isnt this just GP Fundholding rebadged?

• NO why?
• PbR/national tariff reduces ability to secure
  preferential rates and lower transaction costs
• Mechanism to produce savings is different
• NSF, National standards, NICE leading to greater
  standardisation
• PECS tasked with balancing strategy with clinical
  engagement
• Capitation budgeting to ease equity fears

17
The New Commissioning Utopia

• Practices ( with support of PCT) identify main
  health needs of population
• Practices in conjunction with local stakeholders
  identify appropriate services to be provided
• Practices must offer a choice no coercion
• 50 of any savings made can be held at practice
  level and 50 held by PCT
• Overspends paid for by PCT in first year but
  will be carried forward with financial balance
  achieved in three years

18
The commissioning reality on the ground?
Activity (hospital) triggers a set tariff
Therefore reducing activity releases savings (
efficiency gains) to invest in services
elsewhere Providing that more demand has not been
generated to fill the gap Also may be a need to
invest to save to in order to create efficiency
savings
19
Key elements of PBC

• Information activity and cost at practice level
• Practice budget moving to fair shares
• Practice plans agreed by the PCT
• Redesign putting plans into effect
• Business plans ( if invest to save)
• Governance PCT responsibility

20
PCT is accountable for implementation

• Engaging with and developing clinicians as
  effective commissioners
• Providing GPs and practices with the information
  they need
• indicative budgets
• data on clinical activity data and historical
  spending patterns
• incentive payments (DES) and support to take on
  PBC
• Set out governance and accountability
  arrangements
• Budget and contract monitoring support
  (negotiation, documentation, monitoring)
• Training
• IT

21
PBC the rules of the game

• Both parties ( PCT and practices) have only
  limited rights and the following rules need to
  be set in advance
• PBC plans that fit strategically (PCT planning
  and priorities)
• Accountability frameworks
• Holding GP commissioners to account, deciding
  which PCT targets can be devolved
• Degree of public involvement and patient choice
• Recommendations to the board as to use of any
  freed up resource
• Probity and transparency of process
• VFM, admin costs, good commissioning practice
• Performance monitoring, sanctions and monitoring
  of spend
• Current guidance identifies PECs as rule setters

22
What are the incentives to take part?

• Financial
• Directly Enhanced Service payment (DES)
• Use of savings to reinvest in services (PbR
  allows BIG savings if you reduce avoidable
  admissions)
• Ability to expand in house provision
• Non financial
• Power, autonomy, collective enterprise, more
  clout to redesign services for patients

23
Other points

• Groups other than practices will be able to hold
  indicative budgets e.g. community based nursing
  teams
• Initial management costs to be provided to
  practices in advance by PCTs but no new money
  for this must come out of PCTs own share of the
  savings

24
PBC emerging models

• Range of models evolving nationally with no clear
  consensuses
• Most likely to be a collective activity ( GP
  consortiums)
• Many operating as ideas generators with
  detailed service design being done at PCT level
• Multi specialist group practices
• Incentives now in place for expanded group
  practices incorporating a range of specialists
• PBR currently incentivises admission avoidance
  highly
• Privately owned corporate chains of
  commissioner-providers
• Commissioning collectives of semi independent
  practices

25
Timetable for implementation

• DH target of 100 coverage of PBC by Dec 06
• 57 PBC implementation
• 65 take up of incentives
• SHA PBC returns as at July 06
• NBPCTs that are meeting the following four
  criteria are said to be implementing PBC
  arrangements -
• Provide practices with indicative budgets
• Provide practices with info re clinical activity
  and historical expenditure
• Offer an incentive and support ( e.g. DES)
• Set out Governance and accountability Framework
  to support work with practices

26
PBC the opportunities

• Guidance intentionally non prescriptive
  reflects govt wish to see early adopters inform
  later devt
• LMCs and Local GPs can be proactice in shaping
  the model
• GPs could control the whole commissioning budget
  ??
• PbC has the potential to develop NHS general
  practice and move resources into primary care
• GPs may be able to provide traditionally hospital
  based services
• Closer working with other practices
• Primary and secondary care clinicians working
  together to plan seamless care pathways
• PCTs become the good guys again with GPs

27
PBC are GPs interested and willing?

• Concerns re management costs may not be
  guaranteed without savings being made
• Overspends - danger of budget being put out to
  tender who owns the tender owns you and
  enhanced service
• Would time be better spent on GMS, QoF and LES
• The need for PCTs to develop APMS is a major
  threat to general practice with fragmentation of
  GP services
• Clinician backfil who will pay and can you
  get it?
• Fears that budgets will be downsized when PbR
  tariff extends from 2008 making savings
  impossible in the future
• lack of confidence in PCTs to handle
  multi-commissioning models
• Loss of focus on health inequalities

28
What will be commissioned through PbC first?

• The least risk for practices
• The ones that practices are most keen to explore
  ( GPwSIs in post)
• Are most efficient in terms of practice/PCT
  managerial capacity
• Give greatest patient reward and potential for
  freed up resource as early as possible
• Offer opportunities under payment by results
• If the PCT offers incentives

• The low hanging fruit
• High volume elective care
• Dermatology, Gynae., ENT GPwSI, minor surgery
• A specific long term condition
• Stroke care pathway
• Community services
• Community suspected DVT pathway

29
Opportunities for clinicians to get involved

• Drawing up of practice plans
• State high level aims and how aligned with
  national and local priorities
• What are its objectives in terms of improvements
  for patients
• How does it address health inequity and equity of
  access
• Detail impact on other services /planning

• Clinical Relationships
• Knowledge of the whole system
• Understanding of workforce capacity skill
  acquisition and skill mix
• Leadership and championship
• Clinical Supervision and quality assurance
• Strong governance and accountability
• Knowledge to develop new and better patient
  pathways

30
How might this all work for substance misuse?

• E.g. Shared care
• PBC consortia receives proposal from lead
  personnel and lead clinician (s)
• Data shared for practice cluster in fields of
  access, activity, quality and cost
• Consortia works in partnership with PCT and local
  stakeholders to develop a PBC plan and a system
  of accountability and governance
• Plan details how freed up resources will be
  utilised to improve local population

31

• Locality prescribing GP, shared care coordinator,
  keyworker/drugs counsellor, pharmacist
• NDTMS data available re number of contacts
  nationally in shared care _at_ xx (tariff)
• GP consortia - average 6 practices 50,000
  patients
• Estimate contacts per year/week/day
• Redesign services based on numbers of
  practitioners required to support anticipated
  activity and introduce supplementary prescribing
  through new pharmacy contract
• Calculate savings from current costs
• Canvass service user opinion of new treatment
  model
• New care pathways reduce waiting times, increase
  availability of supervised dispensing, increase
  numbers able to be treated in shared care due to
  availability of supplementary prescribing
• Freed up resource to be used to extend enhanced
  pharmacy services provision

32
Does the practice plan meet with PCTs approval?

• Presence of GP lead YES
• Evidence of collaborative approach YES
• Does the group contain other relevant contractors
  ( e.g. pharmacists) YES
• Is there an identifiable management resource YES
• Is this a PBC where there are clear aims and
  objectives and links to LDP and national targets
  YES
• Is there evidence of public and patient
  participation YES

33
Alcohol screening and brief interventions

• Utilise local alcohol profiles from public health
  needs assessment to estimate numbers of hazardous
  and harmful drinkers in PCT
• Locality ( 6 practices) approximately 20 of PCT
• Estimate current costs in terms of alcohol
  related admissions (planned and unplanned where
  detoxification takes place)
• Redesign services based on a GPwSI, x primary
  care liaison workers conducting xx community
  alcohol detoxifications per week ( care bundles 6
  10 sessions plus detoxification and aftercare)
• Benefits
• Reduce costs
• Reduce admissions
• Responsive care close to home
• Improved successful long term abstinence rates

34
Suggestions from an optimistic GP

• There is a need for commissioners and clinical
  leads to develop an understanding of how PbC
  could be used as a successful vehicle to increase
  clinical engagement in the provision of services
  to drug users , to enhance and innovate
• As an exercise hypothetical scenarios could be
  developed using current PBC planning criteria to
  determine which areas would lend themselves to a
  PbC solution

35

• Lets get prepared!

36
Further reading

• Kings fund publications 06
• Practice based commissioning
• Social enterprise and community based care is
  there a future for mutually owned organisations n
  community and primary care
• DH PBC engaging practices in commissioning (04)
• DH Practice based commissioning achieving
  universal coverage