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Darzi special: what the Next Stage Review means for PBC

PBC promised more freedom and support; Darzi rules out direct budgets; GPs to bid for integrated care organisations; new innovation fund; best practice tariff; personal health budgets; business case approvals

PBC promised more freedom and support; Darzi rules out direct budgets; GPs to bid for integrated care organisations; new innovation fund; best practice tariff; personal health budgets; business case approvals

PBC promised more freedom and support

Practice-based commissioners have been promised greater freedoms and support from PCTs in two key documents published under the NHS Next Stage Review.

The final report from health minister Lord Darzi, High Quality for All, which came out on 30 June, and the associated paper Our vision for primary and community care, published a few days later, both pledge to ‘reinvigorate PBC'.

Both also state that PCTs will be ‘held to account for the quality of their support, including the management support given to PBC groups and the quality and timeliness of data (e.g. on budgets, referrals and hospital activity)'.

The primary care document adds that the DH ‘expects all PCTs to provide a management allowance for PBC groups to support innovative practice'.

It also acknowledges that PBC has developed at a variable pace across the country but says there should be ‘earned autonomy' for leading-edge groups who succeed in improving health outcomes. ‘They should be entitled to increased freedoms in managing resources and designing services,' it urges.

Dr James Kingsland, chair of the National Association of Primary Care, said he would have preferred stronger wording to give practices a ‘right', rather than an ‘entitlement' to greater freedoms, but that overall ‘it's

a much stronger and more consistent message than we've had in the past couple of years'.

Greater PCT management support shouldn't ‘just mean a few people from your PCT helping out – it should be real cash to do business case development and service transformation'.

Dr Kingsland believed some messages had been ‘softened' due to a last minute change by the DH to make the Darzi report ‘more public-facing' instead of written specifically for a health service audience.

‘But I still believe we can argue that PCTs who don't liberate practice-based commissioners are being deliberately obstructive and do not aspire to be world-class commissioners. There can be no misunderstanding that this document signals that PBC is a vital part of NHS reform.'

Dr Michael Dixon, chair of the NHS Alliance, added: ‘There's some very strong rhetoric about getting data and support right, and about having more autonomy the more you can prove you can do.

But it's largely aspirational – it will mean nothing unless practices see a very transparent and robust system for making PBC go into a different gear. The real onus will be on the DH and ministers to show they're creating a system that will really change things.'

Darzi rules out direct budgets

Direct budget-holding by practice-based commissioners has been ruled out for the moment by the Department of Health.

Practice-based commissioning leaders had hoped to persuade Lord Darzi to agree to pilots of direct budget holding but the minister's final report only refers to some PBC groups possibly gaining increased freedoms to ‘manage' budgets.

At the moment PBC groups manage indicative budgets, relying on PCT-supplied figures and rules on use of budget savings.

Dr James Kingsland, chair of the NAPC, said he believed the NHS Confederation – which represents acute and primary care trusts – had put pressure on Lord Darzi to reject the proposal.

‘There were some concerns from PCTs about what signal it would send to PCT management about their futures and how their culture would have to change quite rapidly. They also cite the PCT's ultimate [legal] accountability for finances, and whether GPs given cash would have that same accountability. I think these are all weakening arguments.

‘However we acknowledge that there are still issues about whether, as PBC consortiums, we are sophisticated enough at the moment.'

Dr Michael Dixon, chair of the NHS Alliance, added: ‘There is the fundamental issue that if PCTs give money entirely to a PBC group and that group overspends, what happens?'

However GPs might gain more budget-holding opportunities if they lead integrated care organisations.

GPs to bid for integrated care organisations

GPs will be invited to bid to run integrated care organisation (ICO) pilots under plans confirmed in the final Darzi report.

The report says evidence shows that ICOs – where GPs, secondary care doctors, community health staff and local authorities work more closely – can improve the prevention and treatment of long-term conditions and deliver seamless care.

The pilots will test a range of ICO models but all will be based around a GP's registered patient population. It is believed 10 to 15 pilots will be run.

Some practice-based commissioners are already pioneering ICOs – such as Dr Tim Richardson, a GP in Epsom, Surrey, who has consultants working alongside him in the community to deliver day surgery and other services.

NAPC chair Dr James Kingsland said ICOs were the natural end game for PBC: ‘The natural progression of PBC consortiums is to merge health and social care to keep patients out of hospital, as well as provide diagnostics for vertically integrated care, so that becomes an ICO.'

The Department of Health plans to hold an ICO discussion event for interested GPs on 12 August in London. Delegates will receive a draft ‘prospectus' on the ICO pilot programme and have an opportunity to discuss and contribute towards the content before a finalised version is published. Register your interest in attending via the ICO policy mailbox:

In brief

New innovation fund

An Innovation Fund announced by the final Darzi report could give PBC groups a new source of funding for pioneering projects. SHAs will have a new legal duty to ‘promote innovation' from the regionally held cash, the national value of which has yet to be announced.

In a separate announcement, health minister Ben Bradshaw said there would shortly be a tendering process for a PBC support, governance and organisation framework that would mean access to PBC expertise at every level in every locality.
He said: 'Hampshire PCT has invested several million pounds in support of PBC and such examples need to become the norm.'

Best practice tariffs

Commissioners will get more clout to force hospitals to raise their game under a new Best Practice Tariffs programme announced by the final Darzi report.
The move will allow PCTs to reward acute trusts for high quality care by paying best practice prices, rather than the nationally set average price under Payment by Results.
The programme will start in 2010/11 in four clinical areas where there is ‘significant unexplained variation in practice': cataracts, fractured neck of femur, cholecystectomy and stroke care.
NAPC chair Dr James Kingsland said: ‘I applaud this change. If you're good and you attract more patients, you get more money and incentives to continue. Those who don't shouldn't moan – they should look to improve their service, and if they still lose work and become unviable, then so be it.'

NAPC roadshows

The NAPC is planning roadshows to ensure a consistent message goes out about what the primary and community care strategy will mean in practice.
Each roadshow will include an SHA chief executive, Department of Health officials, primary care tsar Dr David Colin-Thome and members of the primary and community care strategy board.
It hopes the seminars, starting in September, will reach about 600 people.
NAPC chair Dr James Kingsland said the aim of the roadshows was to avoid misunderstandings developing, as had been the case with polyclinics.
Dates and venues will be announced on the NAPC website

Personal health budgets

Personal health budgets are to be piloted for 5,000 people with long-term conditions, the Darzi report announced.
The concept comes from social care, where service users with disabilities receive direct payments to hire their own care staff or purchase more flexible services. The Department of Health had previously been resistant the idea.

Commissioning priority areas set

Canny PBC groups may find their business cases are more likely to win approval if they cover one of the commissioning priority areas set for PCTs by the final Darzi report.
‘Our efforts must be focused on six key goals: tackling obesity, reducing alcohol harm, treating drug addiction, reducing smoking rates, improving sexual health and improving mental health,' the report states.
Every PCT is expected to commission ‘comprehensive wellbeing and prevention services, in partnership with local authorities, with the services that are offered personalised to meet the specific needs of their local populations', it adds.

Lord Darzi (right) at the launch of the NHS Next Stage Review

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