Primary care-led commissioning: what does the evidence tell us?

1. Primary care-led commissioning: what does the evidence tell us? Judith Smith Senior Lecturer, Health Services Management Centre, University of Birmingham

2. Our research • Funded by The Health Foundation • A review of the evidence concerning the effectiveness of primary care-led commissioning • Attempt to identify and describe good practice • Literature review • Interviews with 34 key informants • Two stakeholder workshops • Synthesis into report launched today

3. Agenda • The impact of primary care-led commissioning • Developing primary care-led commissioning • The continuum of commissioning models • Choosing a mix of commissioning models • Policy messages

4. The impact of primary care-led commissioning • Little evidence that shows PCLC (or any other approach) to have made a significant or strategic impact on secondary care • PCLC, where clinicians have influence over budgets, can improve responsiveness • PCLC has made most impact in primary and intermediate care

5. The impact of primary care-led commissioning (2) • Given a sustained opportunity to innovate, highly determined PCL commissioners can achieve innovation in working practices • Primary care-led commissioning increases transaction costs in commissioning

6. Developing primary care-led commissioning • There is no ‘ideal’ size for a commissioning organisation • A single organisational solution is neither appropriate nor possible • Meaningful clinical engagement is key • But a balance to be struck with public and management accountability • PCLC organisations have struggled with public engagement

7. Developing primary care-led commissioning (2) • Adequate management support is vital and has a relationship with outcomes • Timely and accurate information is crucial, and routine data could be used much more • PCL commissioners need headroom to commission according to local priorities • Relationships with providers need to avoid being cosy – ‘contestable collaboration’ • A degree of stability of organisational arrangements is needed

8. The continuum of commissioning models • Primary care-led commissioning should not be considered in isolation • Part of a continuum from which PCT/funding body chooses according to local health needs/ service configuration • Challenge is how to select an appropriate mix of commissioning approaches, and having a rigorous process for this

9. The continuum of commissioning models in the UK Level of Commissioning Individual --- Practitioner --- Practice --- Locality --- Community --- Region --- Nation Primary Care Organisation /PCT commissioning National commissioning Multi-practice or locality commissioning Patient Choice Single practice-based commissioning Lead PCT/LHB/HB commissioning Joint commissioning

10. Choosing a mix of models – assessment criteria Ability of the model to: • shape different types of services • offer a degree of choice of provider, contestability & responsiveness • manage budgets and financial risk • minimise transaction costs • develop and sustain clinical engagement • address health needs and tackle inequalities • improve and govern clinical quality

11. Policy challenges • How do we rigorously select an appropriate mix of commissioning models? • What does this mean for the role of the PCT? • How do we find more powerful and sophisticated ways of exerting change from hospital providers? • How can we build on the experience of PCLC innovation in primary/intermediate care? • How will we systematically assess the impact of practice-based commissioning?

12. Policy challenges (2) • Will PCTs be allowed the degree of organisational stability required to achieve sustained changes to service quality? • How will commissioners be supported in acquiring new skills and competences for these more complex commissioning arrangements? • How will clinicians be incentivised? • How will the legitimacy of practice-based commissioning be made clear?