1. 1 Practice-based Commissioning Dr Richard Lewis Independent Healthcare Consultant & Fellow, King’s Fund

2. 2 What is practice-based commissioning? What makes commissioning practice- based? What makes commissioning practice- based? –Identification of practice-level activity –Practices involved in the design of services used by their patients –Practices face incentives related to performance against agreed objectives –Does not have to include contracting function

3. 3 Why do it? Patient benefits Patient benefits –Care can precisely meet individual needs –Incentives to shift from treatment to prevention Efficiency benefits Efficiency benefits –Managing demand Political benefits Political benefits –Engagement of primary care –Accountability of primary care

4. 4 Brief Look at the Evidence Little evidence that commissioning makes a lot of difference to delivery of hospital care (Smith et al 2004) Little evidence that commissioning makes a lot of difference to delivery of hospital care (Smith et al 2004) GPFH (later evidence more compelling) GPFH (later evidence more compelling) –Shorter waiting times by 8% (Propper et al 2000) –Reduced elective hospital admissions by 3.3% (Dusheiko et al 2003) –Reduced prescribing costs (Audit Commission 1995) But –Transaction costs high (Goodwin 1998) –Inequitable funding (Dixon et al 1994)

5. 5 Brief look at the evidence (2) Total Purchasing Pilots Total Purchasing Pilots –Relatively modest impact (Wyke et al 2003) –69% of TP pilots reduced occupied bed days and 13% reduced admissions (Wyke et al 2003) –Single-practice and small TPs better at risk management than large TPs (Baxter et al 2000)

6. 6 Brief look at the evidence (3) Locality/GP commissioning pilots Locality/GP commissioning pilots –Improved collaboration between GPs across practices –New corporate management arrangements –Peer review-based approaches to prescribing (Smith et al 2000) –Smaller increase in prescribing costs (McLeod et al 2000) –Obstacles included workload for clinicians, lack of HA support, IM & T (Smith et al 2000)

7. 7 Overall messages from history Little research evidence demonstrating that any commissioning impacts on secondary care Little research evidence demonstrating that any commissioning impacts on secondary care Primary care commissioning can secure more responsiveness Primary care commissioning can secure more responsiveness Greatest impact of pclc in primary and intermediate care, new forms of quality assessment, new forms of specialist primary care, new alternative community-based services, prescribing practice Greatest impact of pclc in primary and intermediate care, new forms of quality assessment, new forms of specialist primary care, new alternative community-based services, prescribing practice Can change longstanding working practices Can change longstanding working practices Will increase transaction costs Will increase transaction costs Smith et al 2004

8. 8 There is a new policy context that is important May expect fewer problems regarding equity and transaction costs May expect fewer problems regarding equity and transaction costs –PBR/national tariff reducing ability to secure preferential rates and lower transaction costs –NSF, national standards, NICE guidelines leading to greater standardisation –Existence of PECs to balance strategy with clinical engagement –Capitation budgeting to ease equity fears

9. 9 Implementing practice-based commissioning Key dimensions of pbc Collectivity Collectivity –Individual practices –Semi-corporate associations –Multi-practice corporations Scope of services Scope of services Spectrum of incentives Spectrum of incentives –Peer pressure to hard budgets

10. 10 Implementing practice-based commissioning (2) Important trade-offs between ‘autonomous dynamic’ practice level commissioning and ‘strategic collective’ commissioning Important trade-offs between ‘autonomous dynamic’ practice level commissioning and ‘strategic collective’ commissioning

11. 11 Implementing practice-based commissioning (3) ‘Autonomous dynamic’ practice level may be welcome when: ‘Autonomous dynamic’ practice level may be welcome when: –Complex re-design not required or sustainability of major local providers not in doubt –Is a range of alternative providers available –Services in question are ‘referral sensitive’ –Trade-offs exist in medium/long term between primary care prevention and treatment (e.g. chronic care)

12. 12 Implementing practice-based commissioning (4) ‘Strategic collective’ commissioning welcome when: ‘Strategic collective’ commissioning welcome when: –Service in question is highly specialist –Complex service redesign required (especially requiring multi-institutional co-operation and new care pathways)

13. 13 Managing the tensions Incremental decisions may not always aggregate to coherent strategy - role of the Local Development Plan vital. Incremental decisions may not always aggregate to coherent strategy - role of the Local Development Plan vital. Issues of scale – how big is big enough, how big is too big? Issues of scale – how big is big enough, how big is too big? Protecting patient choice and value for money/propriety Protecting patient choice and value for money/propriety Revisiting public accountability Revisiting public accountability –Engaging the public –What PCT targets can be devolved? Ensuring clinical quality and safety within a competitive market Ensuring clinical quality and safety within a competitive market Neither PCT nor practices have a monopoly of power, will need to negotiate local approach Neither PCT nor practices have a monopoly of power, will need to negotiate local approach