are not getting very excited about Practice Based Commissioning. There
does not seem to be anything in it for their patients or for their
practices apart from creating more work at practice level. The
desire to ensure
that PBC is nothing like GP Fundholding of the 1990s, whilst having the
same purpose, has created a model that has the consistency of rice
Technical Guidance was "neither technical nor
guidance". Fundholding had many flaws, but it was simple in
that it counted that which could be counted, things that moved or
happened; a patient attended outpatients, or had an
PBC and Payments by Results are by grouped procedures and by patient
defined as Health Resource Groups using National Tariffs. This solves
some of the
problems of fundholding but the proposed system will create new
put together commissioning and contracting for Primary Care, and
Care Based Commissioning on one site GP
Other pages on this subject are here:
much more adventurous than anyone dared be 1987-1997 on the provider
encouraging the use of private providers, despite protestations that
this is leading to "privatisation" of the NHS. The majority of G.P.s
practices have always been in the private
sector, so always "privatised" with contracts with the NHS.
profits depend on G.P.s keeping their costs down. There is a logic in
extending this principle to secondary care (hospital type)
is not clear how
private providers, especially new ones and enterprising G.P.s to get
into the new market for services. There is no bidding
Each PCT will still have the political imperative to protect its
own NHS hospital. The purchaser side it too week and too
removed from patients. Many PCTs have themselves
providers and purchasers, weakening their purchasing
PCTs see G.P.s are their employees who need monitoring and auditing,
whilst those very G.P.s are supposed to lead on
PCTs are going to find it difficult to really let
is an example of how it has been done elsewhere.
Commissioning was introduced into North
secondary care has been
included in the scheme, outpatients, elective care, locality services
development of extensive
locality services for a wide range of care.
patients attending casualty from the PCT has not been rising.The understanding of
patterns between GPs has allowed the widespread development of
pathways of care across primary and secondary care with consultants
specialities now working in primary care with GPwSI.Waiting times have now fallen well below 6/12
and for the majority of patients are at 3/12.
commissioning has generated maximum practice and clinical engagement
essential ingredients in this process.Practices
have been in the driving seat.Practices
have taken ownership of the problems and
have achieved more
than the PCT could have achieved.The
PCT’s role has been to facilitate and coordinate this process.
opinion on Primary Care Based Commissioning
Dacorum and Watford PCTs visited North Bradford PCT 17th
December 2004.There was an
excellent presentation. There were lots of interesting
diversions and questions and good answers.
as a PCG,
must have kept its head down and ignored most of the policy statements
that was around in The Dobson Era, 1997-1999, allowing many of the
had been developed in the Fundholding era to remain in place, and even
to continue to develop.
PCT has 12
“good” practices in North Bradford PCT area,
all partnerships. One of which was an anti-fundholder, the rest were
Fundholding, and there was a group of Fundholding Total Purchasers. All the practices are now
wonder if any of the practices had gone PMS
plus, coming out of Fundholding early, as that move would have
of their fundholding purchasing funds for in-house services. The phrase PMS plus was not used at
meeting. But in effect all these practices are PMS plus.
The PCT has the
that the PCT is a back office working on behalf of the practices.The PCT’s role
is to support and commission,
must be at
practice level, including planning.We
gathered that the current fashion for locality
based district nurses
was not supported by the PCT.No
staff are employed by the PCT.The
still provides the community staff.We got
the impression that the PCT would like to be rid of that as well, ahead
of its time.
District Nursing budgets have been put back into the
pots, ring fenced, as per Fundholding days: Practices can vire money
District Nursing but not out of it.
planning” is a North
Bradford PCT motto.Only 20% of PCT
time and resources can be spent
for change are from
practice level up.
such as specialist services within surgeries, and in-house work were
on equity grounds. The more adventurous practices and all
to have been encouraged.
At the end of fundholding
PCG wide commissioning model was quickly established and
this brought in the anti-fundholder.
Although there is no management allowance for Practice Based
Commissioning, North Bradford does provide funds and incentives other
than the possibility of retaining any savings.This is the performance
fund, and is made up
of elements that would be in most PCTs development pool. It is
the infrastructure of primary care and to support continuous
There is £2.00 per head to collect their own referral data,
attend key meetings and professional development, the practices must
annual revised business plan, practices must have summarised medical
work with investors in people and use the local electronic booking
fund gives a
possible income £50k for 10k list size – recurrent.
are additional to the QOF and QMAS.
There is an
scheme as well which can give a further £42,500 per
patients. Amongst are
targets for the use
and E, use
of proformas for orthopaedic referral, and that GPsWIshould be the first port of call for most
referrals in the specialities provided by the practices.They
have brought together various payments and put it under this single
including a simple prescribing incentive scheme; come in below budget.
can also use any
savings in-house, from the
secondary care budget. The amount they keep ranges from 25% if
windfall, up to
80% if planned.Excluding
income, and QOF income, all the incentives, including drug prescribing
incentives, seems to give an extra £80,000 for 10,000
patients. QOF is on
top of that, and is paid monthly at
100%; there is no risk to the PCT as the practices were expected to hit
points with ease, since
they had been
running to similar incentives for some time under PMS and Total
The Practices have opted
in, and kept
out of hours, keeping
their on call co-op going. They pay a commercial service for the night
holding onto the out of hours contract,
G.P.s can continue keep a handle on the use of A&E.The practices’
commissioning contracts gives
extra incentives for them to do so.
G.P.s themselves have
themselves to be GPwSI in
various subjects of their choosing.Accreditation
is local, and is run though the hospital trust consultants (mainly by
sessions in consultant clinics) some may need diplomas.The GPwSI are funded as part of the practices
GPwSIs are employed by the
As the practices are
close to each
other it is reasonable
that GPwSIs work is for all patients in the PCT area. That
is one way equity of provision is
achieved. I am not
sure how far this
goes in real life. It may do, as practices are very close to each other.
The PCT runs monthly
together days for all the
practices and the practices hand over to an on-call service.Ideas are spread from
practice to practice.
PCT PEC has a
representative from every practice.Practices
nominate any member of their team, which
may be their District
Nurse, their practice manager or a doctor. The fact that one practice
their district nurse, a PCT employee, shows how much ownership the
feel they have of the whole process, and of the community team. There
is also a
PCT member of staff
goes round to help at the practices once a week.
We were shown impressive
with all practices coming down to very low levels from different
points. Now patients are referred to go to an assessment and intensive
me wonders some of the current success is
due to an introduced time lag before the referral to the consultant is
eventually made. Perhaps
will creep back up in a year or two. A delay will save money, and then
patients will never need the op as die or move away. At least the
should get patients stronger for theatre and rehabilitation.
the seminar were
sceptical about GPwSI, wondering if it will be cheaper in the end, and
we had concerns
about the clinical governance of GPwSI sessions and G.P.s indications
referral (would referral rates go up?).I
prefer to see the G.P. keep the role as the one
generalist doctor in the NHS. Use of GPwSIs may allow the
rest of us to
Government is pushing GPwSI.The
Bradford GP PEC chair pointed out to us the therapeutic effect of the
for a few G.P.s who were just about to burn out, GPWSI has brought them
life and given them enthusiasm for the job, albeit a different job.
interested in taking on Practice Based Commissioning?
Because the health service needs G.P.s to keep a lid on hospital
expenditure, as it did in 1991.
By Results (PbR) is the contracting system
that is being set up between PCTs and Hospital
Resource Groups. These were to be cost and volume. I now
contracts are to be COST PER CASE, and
was to generate 70% of hospital income from April 1st 2005
Although this is not
we must stop using
that F word, the language and problems are the same.We are in a time warp.G.P.s
circa 1994, the NHS Trusts realised that they could code
that were done in outpatients
as a day case event, and charge for that as well as the outpatient cost?Well, a famous Trust in Yorkshire
has just twigged to that wheeze, and attempting it in
The Government has just realised this problem, and has postponed 50% of
the Payment By Results scheme, according to
The Financial Times of 11th January 2005. Emergency
admissions will not be included in the first year because it is
destabilising and risks too high. Funny that this conclusion was made
in fundholding era, when for the most part A&E was excluded
is from the hospitals and is held by a National System, not part of
something called NWCS I think. Trusts have to upload their
system and PCTs get it back. Some PCTs collect data directly from their
as that is quicker. These are now treatment episodes, not
Consultant Episodes. Payment is on the most expensive HRG
single episode. Some Trusts still show FCEs and a fudge factor is used
a finished episode- somehow. Choose
and Book has no accounting element to it at
need to validate the
data and collect their own referral data.Bradford’s
PCT IT guru
produced spreadsheets that
looked exactly like those Fund reports 1,2,3,4. They
included A/E and other inpatient stays
that were only in a very few Total Purchasing Budgets of that other era.
are now in a
state of terror that PbR will result in Trusts upping the ante by "code
creep" and by pulling patients in (via casualty).
PCTs are getting very keen on Practice Based Commissioning to reduce,
least and keep a lid on the hospitals. They
need G.P.s once again. Stopping A/E use
and admissions going up is one aim. I
suspect that changes in junior doctors’ hours changes may be
a cause of
the increase in admissions. However as from 11/02/2005 it
that the pressure is off, as Accident and emergency is out of the
incentivised once again to control hospital costs.
management allowance but we will not be allowed to call it that; it
called a contract for practice performance management, that groups
other incentives and payments, as per Bradford
is no national scale, nor extra funding ring fenced to administer the
can we take it on
Our base is different.
geographical separation of
practices in most PCTs is much larger. Dacorum’s
attempt at total Purchasing failed
before it started in 1994/5.
In Dacorum, on the
grounds of equity,
a lot has been lost
practices that took on
Fundholding, and those who took on PMS early, and developed in house
have had their hard won gains stripped. GPwSIs
have had their contracts taken away. Most
In-house clinics were lost very early on.
In our patch, G.P.s were
allowed to develop ideas
just because they are interested in a subject. That does not fit with
planning role of the PCT.Enhanced
services have been stripped down to the lowest common denominator and
all practices. Incentives and encouragement are disparaged on the
it creates inequality of provision.The Bradford
approach is that the weaker get pulled up by the innovative and
practices to run with their own ideas, North Bradford
has now achieved equity in provision by contracting to practices that
thing” for the whole population.
against the North
Dame Janet Smith
complained in her Shipman
Enquiry 5th report,
that one of the “problems” in
developing clinical governance systems, is that G.P. are self employed.
Many PCTs already believe
wished to be providers and
employ G.P.s directly. That
has been squashed recently as PCTs must now divest themselves of
provider functions. See
Many PCTs believe that
the PCT needs
to be the provider,
planner auditor, inspector, regulator and assessor of G.P. practices,
preferably directly employing as many of the practice staff as
with Practice Managers and Practice Nurses, and some doctors as well.
The Ayling Enquiry
should not be employed in
practices (as per 1960’s contracts) and that Practice
independent of the doctors to allow whistle blowing.
PCT seems to have
had opposing views, but is
achieving the aim of equity of provision using bottom up, practice-led
approach passes much of
the planning functions back down to practices.
example of how differing
PCTs tackle issues can be seen
around the care plan models being developed across the UK
following ideas developed by Kaiser-Permanente and other USA HMOs. The
being addressed is for those patients who go into hospital multiple
year. It implies weak or poor community teams. Those admissions are
and account for a fair proportion of all hospital admissions. PCTs will be setting up
groups, audit systems, appointing specialist nurses directly, and
on hospital at home schemes; bringing G.P.s in on it later, as they are
part of the problem, not the solution.
The simpler approach is
to point out
the issue, and fund the
G.P.s to sort it.
Commissioning in Hertfordshire
Dacorum G.P.s are hitting
targets and beyond. That
shows yet again, that when G.P.s are given incentives, and providing
proposed work has some clinical basis to it, G.Ps,
will invent, go out and do, and then hit
any target given.I
know that G.P. can
play games with targets, as occurred with advanced access, but in that
did not see the clinical benefit, and had evidence to support that view.