Practice Based Commissioning Policy into Practice Dr James Kingsland Chairman NAPC

1. Practice BasedCommissioningPolicy into PracticeDr James Kingsland Chairman NAPC

2. DRIVERS for CHANGE in the NHS • CHOICE • PLURALITY • HEALTH INEQUALITIES • PbR + PBC + PC commissioning • Innovation and Competition

3. Choice PBR Practice Based Commissioning Joined up policy

4. What it is • An opportunity for service redesign • A shift of focus to Primary Care delivery • An attempt to involve all PHC professionals in commissioning services for their patients • A drive to improve equity in the deployment of NHS resource usage

5. What it is not • A return to fundholding • An NHS management reorganisation • An opportunity to increase practice profits • A larger PEC • A new idea • Pay back time

6. Partnership – the Key

7. Strategic Fit • Devolution and Choice agendas • Secondary to Primary care shift • Encourages plurality • Make services responsive to individual patient needs as identified by practice, particularly for supporting patients with LTCs • Use collective experience and knowledge to change services and move resources to new services • None of the bureaucracy of fundholding

8. What is Commissioning ? • “the assessment of the health needs of a population, the contracting for the services which meet these needs (including NHS plan targets) and the accountability for the associated health outcomes” • “PBC is led by PC clinicians who determine the provider service, with the PCT acting on behalf of those clinicians in the contract documentation and financial monitoring”

9. Whither commissioning or wither commissioning? • ‘Demand and Divi’ is over • No more block contracts • Pay for actual activity • Referrer defines service requirement through referrals • Traditional model unsustainable • Resource tied up in existing providers • Without referrer responsibility, risk is greater • Uncontrolled/unchallenged activity • Engagement is key – hence PBC • MS(H) John Hutton: hopes all practices will be in by 2008

11. Practice Based Commissioning in 10 easy stepswww.napc.co.uk

12. 1. What and Why • Clear understanding of policy context • Read the guidance • Information disseminated to full PHCT + patients • Know exactly why you are doing it • Devolution of total PCT budget – indicative at first

13. 2. Data Management • Practice specific • Referral data, elective, OP and emergency • Interrogate and validate • Need to understand all practice patient activity (including private)

14. 3. Service re-design • Start discussions about what can be done differently • Involve full PHCT and patients • How can efficiency in waiting and access, choice and cost be improved ? • Links with enhanced services, QoF and premises

15. 4. What are the costs to the practice ? • Legitimate and necessary costs to clinical and management time to start PBC • Recurring costs to manage waiting list at practice level including choose and book • HR support from PCT at both practice level and administration of contracting • IT requirements

16. 5. Extent of budget use in year 1 and beyond • What are the target areas for service re-design ? • What are the long term plans ? • Staged approach without “cherry picking” moving from indicative/partial to real/total over defined period of time

17. 6. What is the best level to re-design services ? • Practice specific • PBC group – self determined by need and ability to work collaboratively • PCT – what should be blocked back? • Cross PCT commissioning • PARTNERSHIPS at all levels

18. 7. What are the plans for efficiency gains? • Signed off by PEC in pre-commencement agreement • Able to use 100% of resources released through cost effective commissioning • Patient services to be improved • Premises issues

19. 8. Budget Setting • Locally agreed methodology • Based on HES referral data for 2003/04 adjusted for changes with tariff applied (elective activity only) • Should include OP and emergency activity by local agreement (+ Rx and Mx costs) • New national fair shares approach from 2006/07

20. 9. Risk Management • PCT held contingency fund created by top-slicing practice budgets • % top sliced up to local discretion • OR alternative by local agreement • Link to risk created by PbR

21. 10. Pre-commencement agreement • Entry and duration and exit • Between PCT/practice – between practice/organisations • Defines scope and mutual responsibilities • Monitoring and evaluation

22. Ah – But! • PCT in deficit • GP change fatigue • Where’s the financial incentives • Not enough resources • And – there’s an election on the way!

23. Stephen Dorrell, Con. • I wholeheartedly endorse the Government's objectives for what they call practice-based commissioning—they are exactly what we sought to achieve with GP fundholding. I am delighted to be able to endorse the Government's returning to a sensible policy…

24. Risk of Clinicians not engaging • Status Quo – not an option. Concrete will set 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 suck work and money in. • Loss of influence/control in service design and PC-led NHS finally dead and buried

25. Risks for PCTs resisting • Uncertainty in managing financial risk increases with PbR • Practices more 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 and PBC will become a target

26. What next • ‘There is no time to lose’ • PCTs and practices to start dialogue now – SHA facilitate • Data collection – practice specific on referrals and A&E attendances • Explore existing practice • Share best practice locally • Expressions of interest – NOW