Background Brief

Written before we had World Class Commisisoning: 2008

• Download “Creating a Patient Led NHS” Document from here  http://tinyurl.com/3now5 
  
• The NHS is moving towards Payment By Results. This is Cost Per Case payments based on Health Resource Groups.  An HRG is a mix of procedures (Read, ICD10, OCPS etc) and follow up that makes up an incidence of care.
  

•  Patients and G.P.s will have choice of providers, at first only five, but this will be opened up. (Now being closed down by PCTs as they deny local choice to cut costs)
  
•  The HRG price is a fixed National Tariff.
  

• Savings are not made by using different suppliers, unless they are private, primary care suppliers or the HRG is “unbundled” (e.g. a G.P. practice taking on the physio component of a hip operation HRG).  If a patient has many HRGs in one episode of care the most expensive is paid.
  

• Currently there is no mapping of HRGs to Read codes, and G.P.s are not informed of the HRG code involved on discharge letters, since HRGs are allocated later by clerks.   It is difficult to check HRG data within practices.  HRG data is collected by hospital trusts, and collated centrally under "NWCS". That process had not been linked to Choose and Book nor to the NPfIT programme, but now is being added as a "Secondary Use Service".  There is no fundholding type programme to be run at each practice.
  

• The PCT’s panic is due to huge local debt.  Also hospitals will earn on seeing and treating more patients, seemingly without limit.  Primary Care must somehow control the demand.   Hospitals will be tempted to “code-creep”, that is, increasing counted activity by diligent use of HRG coding. 
  

• G.P.s control of demand is difficult. G.P.s role as the gatekeepers, or even path finders, has been reduced over the years.  The way to control demand costs may be to act as providers of hospital type services at or below NHS HRG tariff, perhaps by employing secondary care staff and services. If G.P.s do it we need to “back-fill”…pay for a locum to do our primary care work.
  

• PCTs are being asked to divest themselves of the commissioning process, passing the responsibility closer to patients, that is to us G.P.s. 
  

• PCTs will hold the contracts. In effect G.P.s will advise the PCT with whom to place contracts.
  

• Dacorum and Watford’s focus has been on Practice Based Commissioning as a method to encourage G.P.s to be providers of secondary care….up to 800 operations to be undertaken in primary care and taken out of the Acute Trusts.
  

• PCTs are now to divest themselves of all provider services.  Of particular interest to G.P.s is the provision of Community Services, especially District Nursing Services.
  

• There is no management allowance as such.  G.P. would prefer to see an upfront price for doing the job, but PCTs think of it in terms of staff employed, especially their own staff, and the funding for this is mainly from “savings”. The PCT or their successor is expected to be the back office of the entire commissioning process. 
  

• G.P.s no longer have a monopoly in providing Primary Care.  Not only is there an Out of Hours service, but other activities, such as immunisation, can be contracted to other NHS or private providers.
  

• PCTs are merging.  We are down to one management team and two PCTs in Hertfordshire by 2006. The wheel turns again.

 
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