Practice Based Commissioning PBC Urswick MC January 9th 2008

PBC defined “ the transfer of commissioning responsbilities along with the associated budget from the Primary Care Trust (PCT) to primary care clinicians, including nurses. They will determine the range of services to be provided for their population with the PCT acting as their agent to undertake any required procurements and to carry out the administrative taks to underpin these processes”

Seen by some as the ‘missing link’ Seen by others as the ‘weakest link’

Seen by others quite differently! PCTs Secondary Care BMA RCGP LMC

Practice Based Commissiong Nothing new in PBC as a concept “On 5th July, we start together, …………. It has not had an altogether troble free gestation. There have been understandable anxieties, inevitable in so great and novel under-taking. Nor will there be overnight any miraculous removal of our more serious shortages of nurses and others and of modern replanned buildings and equipment”

Practice Based Commissiong “…but the sooner we start, the sooner we can try together to see to these things and secure the improvement we all want. My job is to give you all the facilites, resources and help I can, and then to leave you alone as professional men and women to use your skill and judgement without hindrance. Let us try to develop that partnership from now on.”

Practice Based Commissiong Nothing new in PBC as a concept 1998 white paper, the New NHS stated that ‘over time, the Government expects that .. PCTs will extend indicative budgets to individual practices for the full range of services’

Why do PBC? 1: Eliminating waste ‘clinician to spend the money’ Budgement management Value for money Savings and investment

Eliminating Waste Ensure elective activity is needed Reduce avoidable non elective admissions Manage urgent care and reduce A&E attendances Manage outpatients, first and FU Improve efficiency and reduce costs of diagnostic tests and procedures Reduce consultant to consultant referrals

Why do PBC? 2: Re-design of provision ‘clinicians know what is best’ Preventing and tackling unschedule demand Patient pathways and community services Health & inequalities Partnerships, with NHS and LA

Payment by results ?? National Tariff for procedures / treatment A&E £101, £73, £55 Diabetic OP Orthopaedic OP £148 1st, £73 FU Vasectomy £491 MI Admission £4,640 Top up for children 11% Money flows with patient, cost per case Range of exclusions

Payment by results ?? National Tariff for procedures / treatment A&E £101, £73, £55 Dermatology OP £118 1st, £58 FU Orthopaedic OP £148 1st, £73 FU Gen Surgery OP £155 1st, £80 FU Diabetes OP £247 1st, £90 FU Paediatrics OP £217 1st, £114 FU Ophthalmology OP £93 1st, £87 FU ENT OP £116 1st, £62 FU Children top up 10-11%

Payment by results ?? National Tariff for procedures / treatment Vasectomy £491 Acute MI £4,640 Amputation £6,229 (N El, £10,313) Arthroscopy £1,063 Appendicectomy £1,943 Non El Top up for children 11%

Payment by results ?? Implements patient’s choice Level playing field for all NHS Private providers Allows PBC to be implemented Money flows with patient, cost per case

Getting Started PCTs will be responsible for ensuring that the following arrangements are in place to enable universal coverage by year end…

Getting Started - Information All practices to receive information that will allow them to understand their clinical and financial activity compared with local and national indicators Quarterly activity data Large amounts, cumbersome Often 1 or 2 quarters behind

Getting Started - Budget All practices have received an indicative budget covering an agreed scope of services Historic Fairshare Practice remains legal entity Cluster / collaborative working

Getting Started - Support All practices are receiving PCT support and incentive payments (LES) or locally agreed payment to support PBC £1.90 per capita for incentive scheme participation Dr Foster Validation (Software to validate activity) PBC business plan validation / DES payments Admin / clinical time / meetings / planning

Getting Started - Probity Governance and accountability arrangements for PBC are in place and these are agreed in partnership between the practice and the PCT PCT committee / Steering Group Direct lead into PCT PEC / Board membership Administrative support Cluster groups / practice level activity Meetings, meetings, meetings !!

Getting Started Clusters formed – no science behind this PCT driven, to ensure enough ‘patient power’ for negotiation Preventing ‘re-invention’ of wheels Corporate responsbility The practice remains the legal entity

Quality Issues Not evaluated Shift from secondary to primary care, always a good thing? POstcode lottery as inequalities exist and in some cases have been enhanced Perverse incentives for hospitals (A&E activity / admissions / 4 hr waits) Probity and governance as primary care practitioners are providers and commissioners

PBC Advantages Spend 10-15 minute discussing the ‘advantages’ of having PBC within a modern NHS service provision Advantages from the Pt perspective Advantages from the GP perspective Include good / positive possible outcomes from PBC initiatives

Practice Based Commissiong Importance of patient choice as a driver for quality and empowerment Practices able to secure wider range of services, commission alternative provision, plan service re-design Payment by results Increased importance of supporting people with Longterm conditions (LTC) Promote practice level budgets More efficient use of services / resources More front line Drs/nurses incolved in commissioning decisions

PBC Disadvantages Spend 10-15 minute discussing the ‘disadvantages’ of having PBC within the modern NHS service provision for Ptss Disadvantages from the Pt perspective Disadvantages from the GP perspective Include problems possibly encountered in implementing PBC nationally

PBC – the future Spend 10-15 minutes discussing the positive potential for PBC in the future NHS Where could PBC take ‘us’ What initiatives could be started, improved, exmaples of service re-design possible by implementing PBC Impact on other areas within the modern NHS, 18 wk waits, service re-design