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   NHS Guidance pdf     Commissioning Web Site     Payment By Results Delay  Primary Care Contracting

Primary Care Based Commissioning

Practice Based Commissioning and Payment By Results.
General Practitioners 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 Government's 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 pudding. 

The PBC 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 operation.  PBC and Payments by Results are by grouped procedures and by patient pathways, as defined as Health Resource Groups using National Tariffs. This solves some of the problems of fundholding but the proposed system will create new tensions and distortions.

The Government has put together commissioning and contracting for Primary Care, and Primary Care Based Commissioning on one site GP contracts and Practice Based Commissioning
Other pages on this subject are here:

The Government is much more adventurous than anyone dared be 1987-1997 on the provider side by 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.  G.P.s' profits depend on G.P.s keeping their costs down. There is a logic in extending this principle to secondary care (hospital type) provision. The Kings Fund has a paper on the private NHS contracts here

Linking Choose and Book to Practice Based Commissioning makes sense, but a mistake was made at the start. Choose and Book was separated from the invoicing and data collection. Now it needs to come back together. Choose and Book has got off to a bad start as it transfers the clerical work of booking appointments to G.P. practices without transferring any funds to do so. Funding for this is now being spend on hardware, not as revenue for practices.

A view on Practice Based Commissioning and  Outpatients is HERE

It 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 process. 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 become providers and purchasers, weakening their purchasing functions.  PCTs see G.P.s are their employees who need monitoring and auditing, whilst those very G.P.s are supposed to lead on commissioning.  PCTs are going to find it difficult to really let go.   Below is an example of how it has been done elsewhere.

 An introduction From NatPact Web Site North Bradford PCT

Practice Based Commissioning was introduced into North Bradford 4 years ago.  All secondary care has been included in the scheme, outpatients, elective care, locality services and acute care.  This has allowed North Bradford to accelerate the development of extensive locality services for a wide range of care. 

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
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.

North Bradford, as a PCG, must have kept its head down and ignored most of the policy statements and sentiment that was around in The Dobson Era, 1997-1999, allowing many of the systems that had been developed in the Fundholding era to remain in place, and even allowed to continue to develop.

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.

The PCT has the view that the PCT is a back office working on behalf of the practices.  The PCT’s role is to support and commission, not provision.  Everything 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 G.P. staff are employed by the PCT.  The PCT 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. Already District Nursing budgets have been put back into the Practices’ commissioning pots, ring fenced, as per Fundholding days: Practices can vire money into District Nursing but not out of it.

“Doing rather than planning” is a North Bradford PCT motto.  Only 20% of PCT time and resources can be spent on planning.  Ideas for change are from practice level up. 

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.  At the end of fundholding a 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 “investing in the infrastructure of primary care and to support continuous improvement”. There is £2.00 per head to collect their own referral data, an incentive to attend key meetings and professional development, the practices must provide an annual revised business plan, practices must have summarised medical records, work with investors in people and use the local electronic booking system / booked admissions.  This fund gives a possible income £50k for 10k list size – recurrent. These are additional to the QOF and QMAS.

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.

Practices 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 savings 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 the 1049 points with ease,  since they had been running to similar incentives for some time under PMS and Total Purchasing.

The Practices have opted in, and kept out of hours, keeping their on call co-op going. They pay a commercial service for the 11pm-8am night shift.  By 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 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?
Because the health service needs G.P.s to keep a lid on hospital expenditure, as it did in 1991.

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 Yorkshire has just twigged to that wheeze, and attempting it in 2004.   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 from that scheme.  

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.  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.

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 Bradford PCT. There is no national scale, nor extra funding ring fenced to administer the scheme.

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 Bradford approach is that the weaker get pulled up by the innovative and impatient practices.   Having allowed leading practices to run with their own ideas, North Bradford has now achieved equity in provision by contracting to practices that do “their thing” for the whole population.

Other forces working against the North Bradford Model.

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.

Bradford PCT seems to have had opposing views, but is achieving the aim of equity of provision using bottom up, practice-led approach.  That approach passes much of the planning functions back down to practices.

An 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 problem being addressed is for those patients who go into hospital multiple times a year. It implies weak or poor community teams. Those admissions are expensive and account for a fair proportion of all hospital admissions.  PCTs will be setting up teams, planning groups, audit systems, appointing specialist nurses directly, and spending more on hospital at home schemes; bringing G.P.s in on it later, as they are seen 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.  

Practice Based Commissioning in Hertfordshire

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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