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At the heart of general practice since 1960

A beginner’s guide to practice-based commissioning

Dr Stefan Cembrowicz gives a quick overview of PBC, a subject that may well come up in an interview for your first GP job

Dr Stefan Cembrowicz gives a quick overview of PBC, a subject that may well come up in an interview for your first GP job

Practice-based commissioning may not have been high on your must-know list during your training. But PBC is a concept set to dominate general practice finance so it is worth getting your head around it.

What is it?

The central idea behind PBC is that money follows the patient and that more care moves from secondary to primary settings.

The theory goes that if GPs are given control of their own budgets for commissioning secondary care and community health services, hospital referrals will fall and hospitals' running costs will be reduced. This is because GPs will be more aware of costs and what the needs of the patients are. The intended result is that patients will receive the right level of care quickly, cheaply and closer to home.

The difference between fundholding and PBC is that the savings (known as Freed Up Resources – FUR) cannot be pocketed. However, 70% can be recycled to improve patient care in the practice.

How does it work?

Practices initially receive information on their use of health services, including scheduled care, unscheduled care and diagnostics.

The PCT then sets an indicative budget for each practice initially based on historic practice spending .

For now, practices can choose which services they wish to do PBC for, but in the long term the plan is that practices will use PBC to provide all health care, with the exception of a few highly specialised services.

Practices, with support from their PCT, then identify the health needs of the local population and, in conjunction with local stakeholders, identify the appropriate services to be provided. Practices must offer patients a choice – there should be no coercion to use a practice-based service.

Groups other than practices will be able to hold indicative commissioning budgets, for instance community-based nursing teams.

Legal responsibility for the budget remains with the PCT.

When is it happening?

PBC went live in 2005. There is no contractual obligation to take part in it, though PCTs can challenge a practice's use of resources, for example prescribing and referral behaviours, if it thinks them excessive under clauses in the GMS and PMS contracts.

The factfile at the end of this article details the type of schemes that are already up and running.

The current phase, which began in April, means every PCT and GP practice can receive support to deliver the Government's targets to reduce emergency admissions and ensure patients receive planned care within 18 weeks to meet the Government's central waiting time target.

What's wrong with PBC?

Some practices report that implementation is slow and commissioning plans are hampered by bureaucracy and lack of support from PCTs. Newly formed PCTs may not be ready to provide the essential management support that GPs will need, including access to referral data, HR, support, and help with business plans. GPs are, however, able to take the budget for management support elsewhere if they are not adequately supported.

There is also the question of how much individual practices can change service provision in secondary care because of the small scale of their purchasing. Achieving major changes in secondary care will need considerable co-ordination between practices. However, examples are starting to come through of this. For example, in Epsom, Surrrey, 16 practices have joined together to form one provider contracting organisation. With this scale of critical mass of resources and patients, GP commissioners will have the scope for major reform.

And if we don't join in?

If we want to stay in charge of our patients' healthcare, now is our chance. It is crucially important for us to get involved because if we don't, we could end up with others doing the commissioning – PCTs, or worse.

Dr Stefan Cembrowicz is a GP in Bristol

Useful websites

The Improvement Foundation runs the PBC development programme

NHS Alliance

The National Association of Primary Care

BMA

NHS Networks contains 400 examples of projects

Department of Health

Xytal is a GP-led company offering consultancy on PBC

Examples of PBC projects

• Educating A&E users to reduce admissions: A practice in Enfield, north London, uses community matrons to educate heavy users of A&E how better to use GP services. There has been a reduction in emergency admissions by 18%.
• Identifying older people at high risk of admission: Another north London practice has identified older people at high risk of hospital admission. A community matron and social worker manage these high-risk patients, and also provide hospital in-reach and packages of care geared towards early discharge. The cost of emergency admissions has fallen by 44% (giving a predicted annual FUR of £0.25m for the practice). There have been fewer admissions, fewer crisis situations as well as a reduction in GP home visits and better job satisfaction.
• Setting up a pulmonary rehabilitation clinic: This clinic has been set up by GPs and has been shown to reduce admissions and length of stay for COPD patients, as well as improving their quality of life and exercise tolerance.

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