1. Practice Based Commissioning PBC Urswick MC January 9th 2008

3. 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”

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

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

6. 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”

7. 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.”

9. 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’

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

11. 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

12. 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

13. 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

14. 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%

15. 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%

16. 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

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

18. 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

19. 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

20. 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

21. 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 !!

22. 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

23. 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

26. PBC Advantages
Spend 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

27. 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

28. PBC Disadvantages
Spend 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

29. PBC – the future
Spend 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