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Gatekeeping and the PCT: make or break time. Jonathan Shapiro University of Birmingham May 2004. Gatekeeping and commissioning. Most patient care happens in the community 99% of activity, 30% of cost self care (90%) general practice and community services (9%)

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Gatekeeping and the PCT: make or break time

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Gatekeeping and the pct make or break time

Gatekeeping and the PCT:

make or break time

Jonathan Shapiro

University of Birmingham

May 2004

[email protected]


Gatekeeping and commissioning

Gatekeeping and commissioning

  • Most patient care happens in the community

    • 99% of activity, 30% of cost

      • self care (90%)

      • general practice and community services (9%)

  • Most cost is incurred in institutional care

    • 1% of all health care activity, 70% of cost

  • Institutional care depends on referrals

    • approx. 70% from GPs

      • rest from A&E, walk in centres etc

[email protected]


The generic shape of services

Centre

The generic shape of services

Health

‘authority’

GP

GP

GP

GP

Institutional sector

[email protected]


The shape of services 1990

Centre

The shape of services: 1990

DHA

GP

GP

GP

GP

Purchaser

Provider

Institutional sector

[email protected]


The shape of services 1996

Centre

The shape of services: 1996

Health

authority

Purchaser

Provider

GP

GP

GP

GP

Institutional sector

[email protected]


The shape of services 1998

Centre

The shape of services: 1998

Procurer

Health

authority

Provider

PCG/T

PCG/T

PCG/T

Institutional sector

[email protected]


The shape of services 19981

The shape of services: 1998

Centre

StHA

Commissioner

PCT

PCT

Provider

Institutional sector

[email protected]


Gatekeeping and the pct make or break time

but…

  • Contracting  purchasing  commissioning

    • Contracting for items

      • I want to buy this, how much do you want for it?

    • Purchasing from a selection

      • I’d like the table d’hôte, but with chips please

    • Commissioning de novo

      • I’ve had an idea for a house…

  • Commissioning is about populations

    • ..and needs powerful organisations

  • referrals are about individuals

  • It’s the dissonance that matters

  • [email protected]


    To refer or to commission

    To refer or to commission?

    • Referrals concern one patient at a time

      • the role of a ‘champion’

        • it’s what clinicians do all the time

    • Commissioning is strategic

      • can appear heartless to an individual patient

        • a real culture shift for any clinician

          • but is it a desirable one?

    • The effective organisation combines both

      • strategic decisions informed clinically

    [email protected]


    Tools for effective commissioning

    Tools for effective commissioning

    • Size and clout

      • management of risk

        • clinical, technical, financial, legal

      • power

        • or perception of power

      • capacity and capability

    • Co-ordination

      • increases all the above

    • Maturity

      • commissioning is what grown-ups do

      • testosterone and acting out don’t help

    [email protected]


    And so pcts have to

    …and so PCTs have to…

    • Grow up

      • develop capacity and capability

        • probably by co-ordinating and sharing

      • change the clinical culture

        • maintain autonomy while developing corporacy

      • changing culture can’t be done by coercion

    • Combine clinical and managerial expertise

    • Come to terms with internal commissioning

    • Believe they are grown ups

      • perception is reality

        • for them and their partner organisations

    [email protected]


    If pcts don t evolve

    If PCTs don’t evolve..

    • Commissioning will be confiscated

      • PCTs will be relegated to pure provision

    • StHAs will become more operational

      • some already have itchy fingers

        • …they failed to control acute sector last time

    • Acute sector will continue to drive system

      • Foundation Trusts already in ascendency

    • Basis of NHS will be threatened

    [email protected]


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