Understanding the Process at the Coal Face
Consultant Scott McKenzie looks at the problems faced by health professionals in the implementation of Practice Based Commissioning, and suggests that improved patient care and efficiency gains will only be achieved if a bottom-up approach is adopted within PCTs.
WITH THE CHANGES arising from Practice Based Commissioning being of significant interest to pharmaceutical companies, it is important that they appreciate the problems being faced by the NHS professionals involved in bringing about the change. Only then will they understand why PBC is not yet firing on all cylinders and what is stopping PCTs, and practices, from moving more rapidly to the 100% universal coverage desired by the Government.
Scott McKenzie is a consultant working with NHS organisations to help solve their problems. He thinks that the answer lies in the way practices/consortia are being engaged. The guidance from the Department of Health clearly states that we require “a radical shift in emphasis from top-down targets and performance management (from PCTs), to bottom-up leadership and innovation” (by GPs), yet, in the main, this is not happening.
This poses the question: is it all then the fault of PCTs? Clearly not: PCTs have been handed the difficult task of implementing PBC with very little help and guidance to drive the process, and this has led to huge variance across England in the way PBC is being implemented; however, much of the blame does lie with them. Many of the consortia still, in August (a full five months on from when they were supposed to have them), did not have any historic data or indicative budgets. Without these, practices cannot be considered to be engaged within PBC.
Two opposite approaches to PBC
The engagement of GPs by PCTs within PBC ranges from PCTs who want to run everything to very supportive PCTs who have taken a step back. These supportive PCTs have allowed the GPs to form consortia, provided data and indicative budgets, and potentially some up-front management costs, to allow innovative planning, and then offered help and support to implement the plans. Where this has happened practices are now up and running with PBC, engaged in making the changes required to improve patient care, while also driving efficiency gains within the system. At the opposite end of the scale we see PCTs imposing structures and plans from the top down, with little idea of whether or not what they are demanding is achievable. Where this is the case, PBC will not be happening in robust enough formats to make any sort of difference. Put simply, people find it easier to buy into what they help to create. A top-down approach to PBC by PCTs basically leaves the PCTs in charge, in exactly the way they are currently, and this in turn makes it highly unlikely we will see any difference in outcomes. GPs/practices are unlikely to be engaged in the process in a meaningful enough way, or with enough incentive, to make them want to make the changes in processes that will drive the efficiency gains the NHS requires to achieve financial balance.
The risks
There are risks for both GPs and PCTs not engaging. This is particularly so against a backdrop of increased competition, both from within the NHS (established consortia) and the private sector. If GPs don’t engage, the policy is likely to be developed independently, meaning a loss of influence and potentially a Primary Care led NHS finally dead and buried.
For PCTs, the risks lie in the uncertainty brought on by trying to manage the financial risk associated with Payment by Results. The practices, if not engaged, are highly unlikely to challenge anything coming from hospital. In addition, control of referrer activity will be very challenging and, ultimately, the PCT will remain responsible for any over-spend and be held accountable for the overall financial position.
Dr Hamish Meldrum, Chairman of the BMA’s GPs Committee, recently commented that: “Implementation of PBC is very patchy at the moment. While we support it in principle, we hear of far too many barriers being put in the way of GPs taking on a commissioning role. If the Government seriously wants PBC to get off the ground in all parts of the country they need to take a close look at these barriers, which include PCT deficits, and instruct local bodies (PCTs) to work with and support practices, instead of blocking the way ahead.”
The irony in the current position is that there is no plan ‘B’; PBC must be implemented successfully; the status quo is therefore not an option. So where do we go from here? Clearly, it is hoped that the new PCT structures coming in to place now may make a difference; the new guidance, ‘Health reform in England: update and commissioning framework,’ should also make a difference. We now have better definition of what is expected from PCTs, and how they should set about implementing PBC, although the guidance is far from being practicefriendly. At the same time, we need to see more innovative GPs coming to the fore, forming consortia and then taking control of, and driving, the agenda.
The rules of engagement
The best way to go forward is for GPs to form consortia with like-minded practices, without any imposition from the PCT. They then need to advise the PCT of the direction they are going in and the timescales they intend working to. This requires skilful negotiation; it is not ‘them versus us.’ Successful implementation of PBC will take three-way working between GPs, PCTs and hospitals in order to drive the very best outcomes for patients and the NHS.
At this point, anyone setting up a consortium will require “rules of engagement” for all member practices. It is recommended that they have rules which cover:
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• Membership
• Risk share
• Liability
• Entry / Exit strategy
• Scope / range of commissioning
• Performance Management
• Working Principles
• Define Practices’ involvement / commitment
• Indemnity
° Is it required?
° What limits?
• Management costs
• Running costs
• Education and training
• Communication pathways
• Reporting structures
• Use of freed up resources
• Clinical Governance
• Safe clinical practice
• Patient choice
• Patient / public involvement
• Conflict of interest
• How will you choose providers?
To do this successfully practices should:
• Ensure every practice has appointed a PBC lead – a GP, Practice Manager or other member of the practice team responsible for driving the agenda internally and externally
• Appoint a steering group / consortium board from the practice PBC leads
• Develop shared principles and objectives
• Keep everyone involved through consultation.
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Once up and running with the rules, the next step is to draw up a Consortium Commissioning plan; here again they should seek support from the PCT, but make their own decisions.
Analysis of the historical data, in order to ensure priorities are based upon data rather than ‘gut feeling,’ aligned to the available skill sets within the practices, will drive the very best outcomes. There is little to be gained initially in tackling high referrals where the skill set to change the outcomes is not available within Primary Care.
While one particular disease area may be an obvious priority, if the skill set to deliver the required outcomes does not exist within the consortium, they should put it on hold, and plan to train/develop skills for the following year. Whatever they do, they absolutely must avoid setting up in a way that guarantees they will fail; in future, poor service is likely to become contestable. If this approach to PBC is taken and successfully implemented, we may yet get a Primary Care led NHS.
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