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Practice based commissioning


PbC implementation on the ground how does it work ... 'Leaner meaner and fitter PCTs' To achieve financial balance. To push forward reform ... – PowerPoint PPT presentation

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Title: Practice based commissioning

Practice based commissioning
  • A view from an optimistic GP, commissioner and
    substance misuse provider
  • Dr Linda Harris -
  • RCGP Substance Misuse Unit

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
  • Consider PbC as an opportunity to enhance
    clinical engagement in service development

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
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
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)
The research evidence for PCLC - global
  • Little evidence of impact on secondary care
  • However, clinicians holding a budget can improve
  • 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

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

PCLC - other research findings
  • Real clinical engagement is key (how
  • 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
  • Arrangements must be given time/stability

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

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

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

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
  • Wider use of NHS resources
  • A lever for demand management
  • Cost containment, better referral patterns

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

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

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

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
  • PECS tasked with balancing strategy with clinical
  • Capitation budgeting to ease equity fears

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

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
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

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
  • Set out governance and accountability
  • Budget and contract monitoring support
    (negotiation, documentation, monitoring)
  • Training
  • IT

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

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
  • Ability to expand in house provision
  • Non financial
  • Power, autonomy, collective enterprise, more
    clout to redesign services for patients

Other points
  • Groups other than practices will be able to hold
    indicative budgets e.g. community based nursing
  • 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

PBC emerging models
  • Range of models evolving nationally with no clear
  • Most likely to be a collective activity ( GP
  • 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
  • Privately owned corporate chains of
  • Commissioning collectives of semi independent

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

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

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

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

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
  • 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

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

  • 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
  • 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
  • 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

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
  • Is there evidence of public and patient
    participation YES

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

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

  • Lets get prepared!

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