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A winning formula for practice-based commissioning

In this special report, Sir John Oldham, former head of the Improvement Foundation, examines what PBC trailblazers are doing right, and how the rest could learn from the best

In this special report, Sir John Oldham, former head of the Improvement Foundation, examines what PBC trailblazers are doing right, and how the rest could learn from the best

Introduction

Practice Based Commissioning commenced in 2006. Extensive support has been given to both practices and PCTs to assist the development of PBC.

A recent Audit Commission report indicated the policy appeared to have had only limited impact. PBC remains, however, an important and necessary plank of policy.

The task of this review was to examine those PCTs considered the best performers in PBC by their SHA, and seek to identify any commonalities in the approach that might be reproduced elsewhere.

The Process

Each SHA was contacted to nominate the PCT it considered the best performing for PBC. Structured interviews were carried out with the chief executive or director of commissioning, and lead GPs.

An analysis was undertaken of the interview responses to seek to identify common features that had been enacted in the best performing PCTs.

A second tranche of the analysis sought to identify any hygiene factors; that is factors that helped in the development of PBC but were not crucial.

A second round of unstructured interviews were carried out with known high performing practices around the country, to test the response to the eight identified features, but also to gain a sense of wider enthusiasm for PBC and activity within it.

Results

Of the identified ‘best performing PCTs' three were considered as no more than average.

The question asked of SHAs was to identify their best performing and that may have been the case. The alternative explanation is a misperception of what constitutes best performing.

This was not pursued. There was also a universal adoption of PBC operating through consortiums of practices, which other surveys indicate is the case for 64% of practices throughout the country. Therefore this was taken as the norm and not a separately identifiable success factor.

Differing organisational structures existed, with some consortiums operating as social enterprise companies or Provident Societies, while others did not.

Most who were less formal were in the process of considering moving towards a more formal organisational position by forming a company. It was clear there were commonalities in the approaches to developing PBC which were also key to successes.

And some of the successes were very tangible. For example, a PCT wide consortium had worked hard at establishing different pathways to move activity into primary care.

In just orthopaedics and rheumatology, they had seen a 60% reduction in referrals to the acute hospital. In total in the first year £675,000 of savings had been made, compared with a pre-PBC position of a £2 million deficit.

There were eight identifiable common features between the most successful PCTs. It was also instructive that at least two of the features were absent in the nominated PCTs who were considered of only average performance.

Visible supportive PCT leadership

In all the best cases the PCT leadership not only verbalised support for PBC but demonstrated their belief in actions.

All were committed to the principles, not simply as a concept, but in the belief that making a success of PBC was the means to engage those who were the main drivers for activity in their area, and the means to move services closer to patients and be more locally responsive.

The GPs interviewed were convinced by the PCT's actions that it wished to make a success of PBC. This provided the foundation for everything else. ‘Our PCT believes it is the right thing to do and believe in us.'

Clarity about roles

Substantial work had been put in between PCTs and consortiums to establish the ground rules early on. Crucially, this was a joint process, not handed by diktat from the PCT.

These arrangements covered how the operating framework was enacted, strategic alignment, individual responsibilities, joint responsibilities, communication mechanisms, handling of savings and deficits and process for business cases.

In some cases these were agreed documents, but in the most successful examples they formed formal accountability agreements between the PCT and consortium. ‘The PCT determines strategy, the PBC company delivers it.'

In the best performing there was also agreements between the practices within a consortium.

This amounted to a formal agreement as to what the consortia would do for a member practice, but also what the member practice's responsibilities were to the consortium (to keep in budget, deliver on use of agreed referral pathways, savings, prioritised activity and so on).

Timely, accurate comparative data

This was crucial. The secondary uses service was widely criticised: ‘How useful is having a budget if the data is so unreliable.'

One consortium had created its own parallel system to provide information to its practices and a PCT had developed an in-house programme that allowed activity and referral data to be collated from practices and presented online in an attractive fashion.

Practices could pre-programme reports for their own priorities. It would also enable practices to track their patients in hospitals which assisted early discharge and coding challenge – ‘creating budget consciousness'.

Locality structure within a PCT or within large consortium

This was important to facilitate more integrated working, make meetings easier and allow greater sensitisation to local need. They were built around obvious geographical communities. One PCT-wide consortium was in the process of devolving some budgetary responsibilities to localities.

Management support by the PCT

As with leadership commitment, management support was a high leverage factor to enable successful PBC development.

This was more than having identified PBC leads, but the active allocation of personnel days of activity to consortiums. The number of days depended on the size of the consortium.

These were usually AC8 grade or above in finance, informatics or public health and the best consortiums had frequent and direct access to assistant director level staff.

Management allowance for consortiums

Management allowances were identified as very important by both practices and PCTs, in addition to the PCT personnel support described above.

The amount was per capita based and the median was £2.50 per head of population. Use was agreed between consortium and PCT, but in general funded management personnel for the consortium and backfill for lead GPs.

This relatively modest amount gave practices the sense they were not going to be overwhelmed with additional work and could employ people to assist and locums to cover clinical work.

In some cases the employment of staff was with the PCT, but in the better developed consortiums employment was either through the company or one practice acting as an agent for others but indemnified by them.

Incentive schemes

Incentives usually took the form of a LES and provided an additional incentive for practices to focus on a particular prioritised area - for example, coding checks and data validation, adherence to a prescribing formulary, and identifying and managing frequently admitted patients.

Although a common feature, incentives may not be a critical factor.

Meaningful involvement in PCT commissioning decisions

This mattered. Sometimes the consortium leads were on the PEC, but in others the PBC consortium leads constituted part of the commissioning committee of the PCT.

Such committees had various names but were the key decision making bodies for commissioning outside the PCT board, and had senior management involvement and meetings with acute trust clinicians and managers.

In addition to these eight factors it was also possible to identify hygiene factors; not absolutely necessary but which seem to have facilitated the development of PBC.

• Consortiums arranged around identifiable geographies and communities

• A previous history of practices working together, sometimes within an old PCG (frequent) or as total purchasing pilots of old

• A continuity of senior personnel at the PCT

• PCTs giving active and early support to the keenest practices, not working to the lowest common denominator

• A formal structure in consortiums, with good governance

• A system for direct clinician to clinician contact between primary and secondary care to agree pathways, formularies and so on.

More than one of the consortium leads interviewed expressed concern that despite their progress they sensed the current level of engagement with practices had become more fragile.

They attributed this to misunderstanding about the Darzi practices, GP bashing in the media and a perceived lack of respect for and understanding of general practice in NHS management.

These were individual comments, but partly as a cross check on how widespread such views were, and to test out the eight identified features, a round of unstructured interviews was undertaken with known high-performing practices around the country.

These interviews supported the usefulness of the eight factors identified. The caveat was whether there was sufficient belief in PBC in senior and middle PCT management to ensure implementation.

The interviews also worryingly supported the contention that engagement was fragile, with an increasing amount of apathy, even in their own practices.

This was not about the concept of PBC for which there remained support, but the experience of trying to make it work locally against what was seen as unwillingness to devolve by PCTs.

Many cited that their PCT did not appear to be working under the operating framework and paid lip service to support for PBC, yet the data to the SHA would demonstrate full involvement from practices because of submission of a PBC plan ‘of sorts'.

In another consortiums, they told of how the budget was suddenly, and unilaterally, altered by their PCT in month 11, negating all the savings they were projected to make through hard work and discipline.

The lead GP predicts next year practices ‘won't bother'. This round of interviews, although anecdotal, supported both the opportunities and anxieties for PBC demonstrated in the structured interviews.

Conclusion

This review demonstrated PBC can achieve substantial gains for patients and the NHS, and that there are some common features in the best performers which could be reproduced in other PCTs.

Such implementation will not succeed unless two other issues are addressed - the lukewarm support of some PCTs to PBC, and the perceptions within the general practice community of attitudes towards them.

PBC is the best route by which the NHS can engage GPs in achieving a strategic shift in service provision and enable them to share responsibility for activity.

This engagement with the demand side of the equation is a necessity for the NHS as a whole, and ultimately for the patients we serve. PBC has not lost support as a concept – yet. But we do need to learn the lessons of how to best implement it.

Sir John Oldham is head of the consulting company Quest4quality and used to lead the Improvement Foundation. His review was commissioned by the Department of Health and reproduced with its kind permission.

Sir John Oldham

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