Practice based commissioning: towards integrated care?

1. Practice based commissioning: towards integrated care? Dr Jennifer Dixon Nuffield Trust London

2. NHS reform architecture IT HR Funding Providing Transactions Commissioning Privatesector Foundation NHS Trusts Third sector NHS Trusts Primary care Community services PbR Choice PCTs PBC (FESC) Regulation Health Care Commission Audit Commission CSCI Monitor

4. General practice services • Free at the point of use (except drugs) • Patients registered • General practice: mainly group practice, independent • All practices computerised medical records • Approximately 50 practices in a primary care trust (geographically defined) • Payment: nationally agreed contracts and half practice income achieved through pay for performance • No direct regulation of quality of services provided

5. Reform history of PBC Timeline 1990-96 1996-97 1998 2000 2004 Policy GP fundholding; total purchasing pilots; GP led commissioning with health authority purchasing Locality commissioning pilots Primary care groups Primary care trusts First PBC guidance issued

6. Features of PBC May be undertaken by a single GP practice or cluster (normally geographically defined) An indicative budget is held on behalf of the registered population Support from the Primary Care Trust received and an incentive payment Accountability and governance arrangements agreed with the PCT Voluntary scheme Implementation largely left to local discretion

7. Differences between PBC and earlier models No national framework Implementation largely left to local discretion PBC not governed by legislation PCTs remain responsible for contracting No dedicated and prescribed management resources Political consensus

8. Key elements of an indicative budget Element Secondary care Elective Non-elective Outpatient Prescribing Community and mental health services Description Planned hospital treatments Unplanned hospital treatments Consultation(ambulatory) Prescription drugs in primary care In hospital or in the community

9. Financial incentives Direct: national/local payment for undertaking PBC Indirect: use of budgetary surpluses, opportunities to act as providers Non-financial incentives Direct: Higher levels of autonomy Indirect: potential for improving patient care Incentives for GPs to adopt PBC Source: Lewis R, Curry N, Dixon M. Practice-based commissioning. King’s Fund, 2007.

10. Expected benefits of PBC for patients Better access to care A greater choice of treatments An increased range of services locally provided More home based services Alternatives to hospital admission Reduced inequalities of outcome

11. Expected benefits of PBC for PCTs Better commissioning of services through clinical involvement Better management of referral of patients to hospital by GPs Better information on which GPs base their decisions Better management of demand and financial risk Contestability of community services

12. Early results Audit Commission: Early lessons from implementing PBC (2006) Audit Commission: Putting commissioning into practice (2007) King’s Fund: Practice based commissioning: from good idea to effective practice (2007) NPCRDC: Practice Based Commissioning: Report of a survey of Primary Care Trusts (2007)

13. Results I (2006/7= 2nd year) • Uptake of incentive payments high • Variable engagement – progress hindered by PCT reorganisation in 2006/07 • Many practices organised into consortia • Quality of underpinning financial infrastructure variable • Budget setting process opaque • Some not receiving a budget more than quarterly • Methods to manage financial risk unclear • Poor information on activity and costs • Arrangements for sharing or using savings unclear or criticised (especially when PCT in debt)

14. Results II • Redesign of services and transfer from 2 to 1 care slow • Practices more interested in using budgets to provide new services than to commission others • Governance arrangements not always clear (potential conflict of interests) • Ownership of shared objectives with the PCT is variable

15. Results III • Survey 257 people • 70% practice managers, 25% GPs • 89% receiving information about secondary care use (55% helpful) • 3% said their PCT involved them in strategic decisions to a great extent, 21% to some extent • 33% rating support by PCT as poor • 25% not receiving budgetary of financial information • Of those with a budget, 37% do not fully understand how it was set • 73% committed to PBC • 41% thought that contracts had not improved quality of care • 39% thought the biggest barrier to successful implementation was lack of PCT support and excessive bureaucracy Source: Lewis R, Curry N, Dixon M. Practice-based commissioning. King’s Fund, 2007.

16. Results IV • PCTs using incentives beyond DES • In most PCTs practices operating PBC via clusters (typically 4) • 10% PBC have formal legal status • 60% PBC have budgets narrower in range than suggested by guidance

17. Results V • Clinical priorities: long term conditions, high volume elective care • Budgets: still largely set on past activity • Most with 30:70 savings ratio (PCT: practice) • Poor clinical engagement

18. Issues • Practical financial issues need sorting • Accurate budgets (risk adjusted) • Clarity on savings • Better information on activity, costs and outcomes • Are practices really interested in commissioning or provision? • PCT weaknesses in commissioning • Secondary provider strength, and incentives in payment by results to drive up admissions • Huge agenda to improve care for people with long term conditions (integration)

19. The future? • Moves towards integrated clinical care • Suggestion of integrated health care providers managing a risk adjusted capitated budget (payer/providers) • May be step too far for policy now, perhaps piloted