Implementing PRACTICE BASED COMMISSIONING Dr James Kingsland Chairman NAPC

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ImplementingPRACTICE BASED COMMISSIONINGDr
James Kingsland Chairman NAPC
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Re-Organisation

• We trained hard. But it seemed that every time
  we were beginning to form into new teams we would
  be re-organised. I was to learn in later life
  that we tend to meet any new situation by
  reorganising a wonderful method it can be for
  creating the illusion of progress while producing
  confusion, inefficiency and demoralisation
• Petronus AD 27-66

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Our Health, our care, our say a new direction
for community services

• White paper published 30th January 2006 for the
  whole health and social care system
• Better access to GP and community services,
  support for LTCs, care closer to home, putting
  people in control much is dependent on a
  successful implementation of PBC
• Finally a Primary Care led NHS?

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PBC Key Messages

• PBC is here to stay.
• Well presented, timely, comparative data for
  practices is key for PBC essential to get
  started.
• Invest to save should be a guiding principle in
  the evaluation of PBC plans.
• Encourage PCTs to have identifiable management
  support at PCT level for localities/groups of
  practices
• Practices to focus on meaningful PBC activity in
  areas their data tells them will make the biggest
  impact.
• "Opt out" will disadvantage practices and their
  patients.
• Practices and PCTs should agree an
  effective means of checking hospital
  activity, which ensures that reduced use of
  elective and unscheduled hospital services is
  translated in to underspends and savings that can
  be used to invest in more services in primary
  care

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People tend to support best that which they help
create

• Pontins 2006

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INSANITY

• Doing the same thing, the same way and expecting
  a different result

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Future of commissioning in the NHS

• Devolution of decisions about securing services
• Demand and Divi is over
• No more block contracts
• Pay for actual activity
• Referrer defines service requirement through
  referrals
• Traditional model unsustainable
• Uncontrolled/unchallenged activity must cease
• Release resource tied up in existing providers
• Without referrer responsibility, risk is greater
• Engagement is key PCT/PC and PC/SC interface

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Health Reform in England update and
commissioning framework

• Published 13 July 2006
• PCTs will support the development of PBC
• No local monopolies
• Different levels of service provision
• Pump-priming loans and incentive schemes
• No tendering
• Payment at tariff
• Greater flexibility for unbundling tariff

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Contestibility and Competition

• Commissioning PCT need to ensure that contracts
  placed are open to scrutiny and demonstrate fair
  procedures and impartiality in procurement
• Public Contracts Regulations 2006 covering Part
  B services apply. There is no legal obligation
  to hold a competition or tender process
• Whilst PCTs will wish to ensure best value in
  awarding contracts, the threshold at which the
  regulations apply to Part B services is
  currently 236,000 euros

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Models of PBC

• Clue is in the title
• Tiered approach to engaging practices
• Incremental process
• Starts from single practice and builds into self
  determined groupings depending on service
  delivery
• But indicative budget, detailing practice NHS
  resource usage, must be devolved

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What is the practice budget?

• Indicative
• Identifies total practice NHS resource usage
• PCT devolves all budgetary elements it currently
  controls
• It will be flawed and inaccurate in early stages
  of development
• Move from historic activity to fair shares
  approach through new national allocation formula

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Service Redesign

• Changing referral thresholds (eliminating
  referral mx centres)
• Direct access to diagnostics
• Active discharge from OPD
• Challenging current care pathways, unbundling and
  re-bundling tariffs, questioning coding.
• Contracts/SLAs that do not pay for duplication,
  delayed correspondence, Rx ommissons
• Building new PHCTs incl. social carers e.g.
  mental health

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Service Redesign cont.

• Practice based musculoskeletal services
• Hospital at home services e.g. I.V. a/b
• Improving self care in the community e.g.
  warfarin monitoring
• Preventing LTC admissions community matron
  programme
• Integrated community nursing teams
• Extending in hours practice opening to
  support/improve demand Mx in OOHs/unscheduled
  care
• Targeting frequent flyers
• Assessment of impact of local complimentary PC
  services - vfm

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Pre-commencement agreement

• Entry and duration and exit
• Between PCT/practice between practice/organisati
  ons
• Defines scope and mutual responsibilities
• Budget setting and risk management
• Accountability and clinical governance
• Management costs and efficiency gain usage
• Monitoring and evaluation

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The PCT - future role

• Reconfigured into 152 PCTs
• Strengthening accountability and reducing
  bureaucracy
• Strategic role in determining community services
• Commissioning PC services (4 contract options)
• Divestment of provider functions
• Ensuring PH agenda and national priorities
• Reducing health inequalities and focus on patient
  safety
• PBC contracts management
• Monitoring and evaluating PBC

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Risk of Clinicians not engaging

• Status Quo not an option. Policy will be
  developed independently and PCTs will determine
  service design and choice.
• Competition for resources to increase ring
  fencing enhanced services ends 2006
• PbR incentives for Secondary Care to increase
  work and money in.
• Loss of influence/control in service design and
  PC-led NHS finally dead and buried
• Increasing competition to deliver PC services
• Low aspirations for our patients

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Risks for PCTs resisting

• Uncertainty in managing financial risk increases
  with PbR
• Practices less likely to challenge details of
  what hospitals provide
• Loss of control of referrer activity (cf
  prescribing incentive schemes)
• Responsibility for overspends remains with PCTs
  anyway
• Health agenda becomes more difficult to deliver
  and PBC will become a target

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Barriers to Implementation

• Misunderstandings, misinterpretation, lack of
  partnership
• Top down approach
• Stifling innovation, diversity and variety
• Financial balance being more important than
  service development
• Lack of Mx costs/support
• Choice and contestability policy

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Questions ?

• Thank you