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NHS Guidance pdf Commissioning Web Site Payment By Results Delay Primary Care Contracting
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Practice
Based
Commissioning
Practice
Based
Commissioning was introduced into The
numbers of
patients attending casualty from the PCT has not been rising. The understanding of
elective referral
patterns between GPs has allowed the widespread development of
alternative
pathways of care across primary and secondary care with consultants
from many
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. Practice based 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. An
opinion on Primary Care Based Commissioning The 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 PMS. I wonder if any of the practices had gone PMS plus, coming out of Fundholding early, as that move would have protected most of their fundholding purchasing funds for in-house services. The phrase PMS plus was not used at the meeting. But in effect all these practices are PMS plus. Fundholding
era gains,
such as specialist services within surgeries, and in-house work were
not withdrawn
on equity grounds. The more adventurous practices and all
endeavours seem
to have been encouraged.
There is an incentive scheme as well which can give a further £42,500 per 10,000 patients. Amongst are targets for the use of A and E, use of proformas for orthopaedic referral, and that GPsWI should 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 title including a simple prescribing incentive scheme; come in below budget. The Practices have opted
in, and kept
out of hours, keeping
their on call co-op going. They pay a commercial service for the G.P.s themselves have volunteered themselves to be GPwSI in various subjects of their choosing. Accreditation is local, and is run though the hospital trust consultants (mainly by doing sessions in consultant clinics) some may need diplomas. The GPwSI are funded as part of the practices contracts. No GPwSIs are employed by the PCT. 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 training/get together days for all the practices and the practices hand over to an on-call service. Ideas are spread from practice to practice. The 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 sends their district nurse, a PCT employee, shows how much ownership the practices feel they have of the whole process, and of the community team. There is also a locality forum. A PCT member of staff goes round to help at the practices once a week. We were shown impressive figures for Orthopaedic referrals, with all practices coming down to very low levels from different starting points. Now patients are referred to go to an assessment and intensive physiotherapy service first. Nasty me wonders some of the current success is due to an introduced time lag before the referral to the consultant is eventually made. Perhaps referral rates will creep back up in a year or two. A delay will save money, and then some patients will never need the op as die or move away. At least the physiotherapy should get patients stronger for theatre and rehabilitation. Both Watford/Dacorum G.P.s attending 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 for referral (would referral rates go up?). I prefer to see the G.P. keep the role as the one remaining holistic generalist doctor in the NHS. Use of GPwSIs may allow the rest of us to become de-skilled. However the Government is pushing GPwSI. The North Bradford GP PEC chair pointed out to us the therapeutic effect of the GPwSI programme for a few G.P.s who were just about to burn out, GPWSI has brought them back to life and given them enthusiasm for the job, albeit a different job. Why
are PCTS
interested in taking on Practice Based Commissioning? Payment By Results (PbR) is the contracting system that is being set up between PCTs and Hospital trusts, using Health Resource Groups. These were to be cost and volume. I now learn the contracts are to be COST PER CASE, and was to generate 70% of hospital income from April 1st 2005 Although this is not
Fundholding, and
we must stop using
that F word, the language and problems are the same.
We are in a time warp.
G.P.s
will remember,
circa 1994, the NHS Trusts realised that they could code
sigmoidoscopies
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 The
referral data
is from the hospitals and is held by a National System, not part of
NPfIT,
something called NWCS I think. Trusts have to upload their
data
to this
system and PCTs get it back. Some PCTs collect data directly from their
trusts
as that is quicker. These are now treatment episodes, not
Finished
Consultant Episodes. Payment is on the most expensive HRG
used
during a
single episode. Some Trusts still show FCEs and a fudge factor is used
to give
a finished episode- somehow. Choose
and Book has no accounting element to it at
all. G.P.s still
need to validate the
data and collect their own referral data.
PCTs 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). So suddenly PCTs are getting very keen on Practice Based Commissioning to reduce, or at 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 some of the increase in admissions. However as from 11/02/2005 it seems that the pressure is off, as Accident and emergency is out of the scheme. G.P.
will be
incentivised once again to control hospital costs.
There will
be a
management allowance but we will not be allowed to call it that; it
will be
called a contract for practice performance management, that groups
together
other incentives and payments, as per How can we take it on in Hertfordshire? Our base is different. The 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 since 1999. Those practices that took on Fundholding, and those who took on PMS early, and developed in house services, 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
not been
allowed to develop ideas
just because they are interested in a subject. That does not fit with
the perceived
planning role of the PCT. Enhanced
services have been stripped down to the lowest common denominator and
fed to
all practices. Incentives and encouragement are disparaged on the
grounds that
it creates inequality of provision.
The Other
forces working
against the 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
that, and
wished to be providers and
employ G.P.s directly. That
policy
has been squashed recently as PCTs must now divest themselves of
provider functions. See
Patient Led
NHS Many PCTs believe that the PCT needs to be the provider, planner auditor, inspector, regulator and assessor of G.P. practices, and preferably directly employing as many of the practice staff as possible, starting with Practice Managers and Practice Nurses, and some doctors as well. The Ayling Enquiry suggests wives should not be employed in practices (as per 1960’s contracts) and that Practice managers should be independent of the doctors to allow whistle blowing. The simpler approach is to point out the issue, and fund the G.P.s to sort it. Dacorum G.P.s are hitting the QOF targets and beyond. That shows yet again, that when G.P.s are given incentives, and providing the 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 case G.P.s did not see the clinical benefit, and had evidence to support that view. Gerry
Bulger Updated 14th
April 2006 |
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