Practice Based Commissioning - Setting the Local Agenda

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Practice Based Commissioning- Setting the Local
Agenda

• 15th July 2005
• Oliver Phillips, Head of Systems Reform
• Julie Flower, Programme Manager

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What wed like to cover

• The potential of PBC
• The local picture
• Setting the local agenda
• Support
• Workshop sessions

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Referral Pathways prior to System Reform
Primary care
Secondary Care
Few alternatives to secondary care
DEFICIT
Little financial incentive for Trusts to treat
patients
Choice of Secondary Care Provider not offered
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System Reform without PBC
Foun Hosp
Primary care
ISTC
Incentive for Trusts to treat patients
Priv Prov
Choice made explicit for patients
.but still few alternatives to secondary care
DEFICIT
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System Reform with PBC
PBC provides incentive to prevent referrals to
secondary care
Foun Hosp
Comm Prov
Primary care
CAS
ISTC
DEFICIT
Resources (through PbR) available to establish
alternatives
Priv Prov
GPwSI
Patients receive treatment where it is most
appropriate and cost effective
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What PBC is about

• Greater engagement between PCTs and clinicians in
  planning and developing services
• Working together to plan to meet the needs of
  local patients
• Service development
• Managing demand effectively
• Incentivising the right kind of behaviour
• Value for money

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What PBC is not about

• Direct contracting/procurement of secondary care
  services
• Fragmentation of service development or adverse
  impacts on other local services
• Spiralling transactional costs
• Rationing of services
• Personal gain

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Key messages May 05

• Most PCTs have an (agreed) overall approach
• Clinical engagement is varied but often low
• Few have detailed work on budgets and governance
  to underpin plans
• No active budget-holding currently
• 2005-6 is about engagement and preparation
• Detail of plans for development and
  implementation varied
• Strategic positioning

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Approaches

• Majority pursuing a type of locality model, with
  varying levels of engagement among and within
  PCTs (top down?)
• Locality commissioning boards or smaller groups
  support locality structures
• Many PCTs in process of signing off and agreeing
  structures
• Potential for budgets to be held at different
  levels, according to service

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Clinical engagement

• From 0 to 100 active engagement
• Current engagement includes active participation
  in locality meetings and agreement to be
  involved, based on PCT plans
• Many PCTs have limited active engagement and some
  have developed detailed plans in relative
  isolation
• Some plan gradual, phased engagement in locality
  structures
• Others based on initial participation in specific
  improvement schemes

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Budget-setting

• All plan in-year availability of indicative
  budget information to practices
• Many using local methodology based on 04/05 usage
  or 05/06 SLAs
• Some cover just secondary care others wider
  (including non-PbR)
• Activity information to come from Trust data,
  bespoke systems, RMS
• Some concern over capacity to support finance and
  information requirements
• 1 mention of moving to capitation

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Governance

• The area with least detailed information
• A number of local committees beginning to operate
• Key role of PEC in governance
• Understanding of wide challenges, including
  cherry-picking, service inequities, risk, SLAs,
  conflict of interest
• However, lots to be addressed very few
  solutions or detailed underpinning work
• Incentives to be agreed or adaptation of
  national guidance. 1 aligned with RMS.
• Risk sharing where approached, top-slicing
• Little mention of LDP and commissioning plans,
  accountability agreements, service development,
  use of savings

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Barriers to development

• History of engagement
• Lack of perceived incentives for clinicians
• Limited scope of PbR in 2005/6
• Competing pressures and initiative fatigue
• Lack of capacity and capability
• Information
• Lack of clarity in national guidance
• Potential impact of PCT reconfiguration

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What does this mean for us all?

• Ensuring readiness approaches, tools, knowledge
  and understanding
• Focus on clinical engagement - realism
• Sharing experiences and tools
• Building support networks
• Fit with future configuration and priorities
• Balance between top-down and bottom-up

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What we do want to do

• Move PBC up the agenda
• Ensure a minimum state of readiness
• Build on good practice
• Facilitate sharing of ideas and experiences
• Provide building blocks

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What we dont want to do

• Dictate type of approach
• Stifle local pace and innovation
• Produce top down approach
• Implement policy for the sake of policy

X
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Setting the local agenda
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Structure and approach
By September 2005
Formally agreed overall structure and approach
High level governance arrangements
Agreed level of PCT support
Development and implementation plan
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Budget-setting and information
By September 2005
Regular sharing of costed activity information
Calculation of total initial indicative budgets
Ongoing
Agree scope of budgets to be held
Monitoring information
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Governance and accountability
By October 2005

• Governance framework
• role of PEC
• incentives and use of savings
• management costs
• resolution of conflicts and disputes
• risk management
• service development

• Accountability agreements
• roles and responsibilities of practices,
  localities and PCT
• annual timetable

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Commissioning Planning
From October 2005

• Commissioning Planning
• Roles and responsibilities in commissioning
  process
• Local priorities
• Existing arrangements to be taken into account
• Inclusions and exclusions in indicative budgets
• What services will be commissioned at each
  level
• Business cases for reinvestment of savings and
  other service development
• Budgeted activity profiles

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Clinical engagement
Ongoing

• Aim
• To engage clinicians in what PBC could help them
  achieve for patients
• To promote clinical leadership to drive service
  redesign and encourage peers
• Potential approaches
• Regular sharing of referral information and
  dialogue
• Personal visits by PCT CEs, Directors and PEC
  Chairs
• Local GP forums and events
• Direct dialogue with practice managers
• Development of schemes that incentivise
  complementary behaviours

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What support needs did you identify?

• Learning sets and sharing of good practice
• Technical support re budget-setting and
  information
• Shared work and support on governance
• Training for GPs and practice managers
• Training and support for PEC
• Financial resources/capacity to support
  implementation
• Clearer guidance and direction
• Closer working between neighbouring PCTs

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Support
Interpretation

• Policy briefings
• Presentations to SHA-wide groups

Ideas sharing

• Learning Set
• Email discussion group
• Extranet repository

Joint working

• Working Group SHA and PCTs
• Guidance and thought leadership
• PCT/SHA collaborative groups

Integration

• Procurement agencies
• PCT configuration
• S4 outcomes

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Any questions?
?
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Workshop groups

• Clinical engagement
• Budget-setting and information
• Governance (clinical and corporate)
• Commissioning planning and realising change

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Group work

• What has worked well locally? And why?
• What has worked less well? And why?
• What is still to be done how can it be
  approached?