| Primary Care Based
Practice Based Commissioning
other chapters relating to this are here
Practice Based Commissioning is a third-way and tree-hugging concoction of vague concepts that are both confusing and irritating to most G.P.s.
World Class Commissioning is an edifice constructed entirely out of NHS managment speak and NHS buzzwords designed to measure to death or simply neuter local commissioning groups.
Hospitals charge their Primary Care Trusts (health authorities) on a cost per case basis. The decisions on how such contracts run are to be made made by Practice Based Commissioning Groups, which could be a single G.P. surgery, or clusters of G.P.s. In Dacorum, West Hertfordshire, General Practitioners have banded together to form a single Practice Based Commissioning Group: DacCom PbC Ltd. In theory this group takes on the commissioning role of the merging Primary Care Trusts as Dacorum and Watford Primary Care Trusts will not exist later this year (2006)
The costs of hospital care runs to a national tariff, fixed by the Department of Health. The tariff menu is defined by a series of Health Resource Groups. Each HRG is made up of a complete episode of care. An HRG for a hip operation may include the rehabilitation and follow up, and a fixed number of hospital bed day stays. Costs can be saved by un-bundling the HRG so that, for example, the post operation physiotherapy element is run in the community. There are many HRGs. Getting the HRG prices right is a most complex task. The HRG tarrif had to be revised in at the last minute in March 2006.
Practice Based Commissioning is supposed to bring the decisions of commissioning back to the G.P.s in Primary Care. It may have come too late. If G.P.s had access to the Health Service's extra funding through Practice Based Commissioning, or the if government had not abolished fundholding in the first place, G.P.s would have spent the increased NHS funding on new ideas and pathways, and would not have continued to feed the current system. The NHS has swallowed up a doubling of its funding, and now has little to show for it. Cuts (i.e. failure to grow at such a fast pace) are coming. G.P.s are invited to take up the poisoned chalice; controlling costs which were not theirs in the making.
Contracts between hospitals and commissioners will held by the new Primary Care Trusts. PBC surgeries or groups will be little more than subcommittees of the Primary Care Trust.
Issues of PBC
These are indicative budgets, and will be set for each commissioning group, down to each G.P. Practice on a capitation, patient list size, basis. That is lovely for the nicer parts of the county, where the demand on the NHS is less, and the use of private medicine is greater. Berkhamsted PBC budgets would be flush with funds, and Hemel Hempstead would be broke. That is one reason Dacorum G.P.s opted to run PBC as a single unit. Commissioning groups would select areas of healthcare services to manage in their patch. The groups also take on the debts.
Management Allowance for G.P.s to run local commissioning of services:
There is none, but a so called "DES" at 95p a patient, paid to participating practices. It would make more sense to share that funding between practices by allocating most of it to DacCom, the commissioning group, but there is discouragement from GPC and LMC in doing that. That policy weakens area wide commissioning groups. Further management funds are supposed come later out of "savings" made by new commissioning policies.
Unlike G.P. Fundholding there is no practice based software to count activity, waiting times and exception reporting, nor is there any locally based accounting software. Without G.P.s being actively involved in data validation and collection, the quality and timing of data will be suspect. Most of the data activity is expected to be run at PCT level, using current staff a long way from the patients.
What can G.P.s do about hospital expenditure as commissioners?
1. G.P.s cannot shop around between hospitals since the price is the same: that's the National Tariff.
2. G.P.s could "change pathways" and redirect patient care back to Primary Care. This means "unbundling" HRGs. Hospitals have no incentives to do so. G.P.s would also have difficulty as the numbers of patients at each practice that could be helped in this way will be too small to offer viable, stable and secure alternative services.
3. G.P.s must stop sending patients to hospital.
There is a large variation in referral rates to hospitals. Outpatient activities vary according to G.P. practitioner, whilst operation rates vary according to the consultant or hospital. Changing G.P. variations is very difficult.
A "poor" G.P. who refers lots to the hospital has difficulty in changing his ways. The incentives to change are minimal. The option to move a G.P. sideways, or buy him out, does not exist. At the moment a G.P.'s practice is only of value to a G.P. while he continues to work there. There are NHS rules which forbid a G.P. from being bought out; the sale of goodwill is forbidden amongst G.P.s (but not amongst private companies taking on GP services).
Three common ideas to keep patients away from hospital:
1. Referral management centres. One idea to deal with G.P. "inappropriate" referrals is to have all referrals "vetted" in some way by a committee, or board before being sent on again. The process delays the referral (a cost saving in itself). The medico-legal liability of the decision to refer on, or not to, would seem to pass to this committee. A paradoxical effect would be to encourage G.P.s to refer everything to the committee for vetting, to reduce their own risk.
2. Clinical Assessment Services (CAS) Here the patients are seen by G.P.s with special interest, perhaps in a hospital setting, with access to a larger team, before patients are referred on. Again savings could be made by delaying referral to the hospital consultant team. These services would be useful in rheumatological or mild osteoarthitis conditions and "rheumatic" aches and pains. All that may happen with this new service, is that more patients would be referred. G.P.s, when faced with patients with patients with chronic conditions that they struggled with managing on their own for years, will now have a nice new service to use. Before, the G.P.s would have been too embarrassed to pass some problems onto a consultant, knowing that the consultant would have little new to offer.
3 Integrated Pathways and New Pathways of Care This is a very trendy concept. Developing better ways to manage patients in and out of hospital. How we mange conditions should be based on best evidence and to National guidelines and standards. The idea that each commissioning group sits down and creates pathways is time wasting madness, and perpetuates the post-code lottery that NICE and judicial reviews rule against time and time again. Already in West Herts we have at PCT level, Clinical Effectiveness Programmes that have produced much paper, not read (let alone seen) by most G.P.s. These papers are said to promote a learning culture, identifying, sharing and implementing best practice, applying evidence based practice and providing a strategic framework, jointly integrated governance informing a programme of work, quadrant-wide and so on and so on. Each area must re-invent the wheel.
4. G.P.s in casualty. Experienced G.P.s could help reduce admissions. What seems to happen when this is tried is that such G.P.s become G.P. with special interest in Accident and Emergency Medicine, and very useful experienced pair of hands for the hospital and end up working under the hospital's risk avoidance culture. Unless there was a G.P. run surgery in front of casualty, offering the walk-in service, and actually blocking the path to A&E, it is difficult to see how G.P.s can be of use in preventing admissions to hospital.
The Snag of Choose and Book
The Government has put huge investments in a clumsy, and not properly working, on-line outpatient booking system. The idea is that G.P. book patients into hospital clinics directly. Neat if the system were slick and fast. But it takes ages and cannot be run during a consultation. The key element of the programme is of patient CHOICE. Patients should be able to choose one of five hospitals, including a private one, for their NHS treatment. That does not fit in with new Integrated Care Pathways, nor does it fit with Referral Management systems nor Clinical Assessment Services. Those services are to ensure that there is NO choice.
Dacorum PBC Group and its Commissioning Budget
What budget would we be given? Practice Based budgets would be allocated to practices on a capitation basis,
Minus £5.1 Million "deficit".
The PBC budget would also be lumbered with the following
1 Deficit £5.1Million (The local hospital's huge deficits are another matter and much larger sum)
2 Pre-determined recovery plan.
3 Clinicenta block contract.
4 NHS Integrated Service Improvement Programme.
5 Investing in Your Health: The Plan for NHS Services in Beds and Herts is here.
6 Weak contracting: short term non-binding contracts thwarting investment by G.P.s for the long term.
7 Random Government Edicts, such as the the recent enforcement on PCT to use an unlicensed medicine when under political pressure from a single disease lobby group.
The recovery plan for Dacorum and Watford PCTs is HERE. In that document there are lots of things G.P.s must do, including denying their patients the right to have minor surgery performed by a consultant. There has been little consultation on these ideas. The PBC groups must get on and enact these changes; but there is no capacity to do these things in primary care without encouragement to invest.
We suspect that sums will have to be allocated towards Hemel Hempstead's surgicentre, to be run by Clinicenta. We have not seen the details of the contract, but we assume that there is a large guaranteed block element; guaranteeing income for many years to come. Since the private operators take on investment costs, a guaranteed level of activity is to be expected, indeed it is essential. However that block contract limits what a commissioning group can actually do, since a large element of our patients' care will be subject to the block contract to this centre. The block contract will be a commercial and binding contract, unlike the contracts between G.P.s, PCTs and NHS Hospitals; those cannot be legally enforced except by way of judicial review of any decisions made. We understand that this protection of funding, the block contract element is in fact centrally funded by the department, and at present would not form part of the local budget, but usually this sort of central funding is repatriated to the PCTs or health authorities after a year or two.
On top of this the Commissioning groups are encumbered with NHS Integrated Service Improvement Programme
and for Dacorum and Watford there is a 62 page "Benefits Realisation Plan"
G.P.s as providers of more care:
G.P.s are expected to have to be prepared to take on on more hospital type activity and minor procedures. To do this requires investment in training, building and equipment and it also requires funding of the "back-fill" costs; that is when a G.P. specialist is doing operations or cardiac scanning, or a dermatology clinic, someone else has to do his G.P. work which has to be paid for. The result is that the cost of a G.P. doing "hospital" type work can be as great as hospital costs....and the patient many not have had the benefit of a hospital Consultant opinion. G.P.s would need to invest to run such services. But the NHS rules are always changing, and the PBC framework is far too vague. The contracts between G.P.s and PCTs are not legally binding. The risk for a G.P. practice taking on this work are huge. So when the wind changes, removing funding to a G.P. "extra" service would be easy and rapid, as it would be less politically sensitive than "cutting beds". There was no political fuss when G.P.s lost the extra services they provided during the fundholding era (1992-1999).
Practice Based Commissioning is very fragile. It could be pointless.
Solution? Part one is here!
NOT the Solution is HERE