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Developing an escalator to reach new PBC heights

Dr Stephen Shortt explains how a new ‘escalator’ model will ensure a give-and-take relationship between the PCT and commissioners

Dr Stephen Shortt explains how a new ‘escalator' model will ensure a give-and-take relationship between the PCT and commissioners

PBC in Nottinghamshire County has made good progress, but the level of engagement is not what it needs to be. To invigorate the process and provide greater incentives to make a success of PBC, we have developed an escalator model in which high performance is rewarded with increased independence and more freedom to innovate. As clusters move up the escalator, they will be rewarded by greater autonomy and harder budgets.

The background

Nottinghamshire County has strong PBC cluster structures, good cluster leadership, dedicated managerial resources at PBC cluster level and – very unusually among PCTs – we have already moved to a fair-share resource allocation.

Most GPs support PBC and we have seen increased levels of collaborative working between GPs and the PCT, as well as hospital staff, community matrons and so on. Every single commissioning decision in our PCT has PBC oversight and PBC is at the heart of the planning and business decisions.

If practices' year-end financial out-turn shows they have made savings they are allowed to spend all of this on services for patients. But although we've made significant progress overall, a lack of progress in improving services for patients at scale means we risk enthusiasm waning.

Most PBC-led initiatives here are small-scale local pilots focusing on the provision of hospital services in community settings. They are having little impact on patient care nor are they improving use of resources.

There appears to be little PBC interest in the wider commissioning activities – there is very little overlap between what PBC and the PCT are doing. There is no sense of PBC becoming the mechanism of achieving widespread change and helping the PCT deal with the big strategic issues of health inequalities, the development of a model for long-term conditions and, in particular, looking at lifestyle behaviours that ultimately predict long-term conditions and that form the biggest burden on the NHS both nationally and locally.

To invigorate the process and get PBC operating at the level it needed to be we had to identify the barriers to progress and remove them (see box, below).

The idea behind the escalator

During a two-year secondment at the DH I was involved in developing the primary care strategy, in which it was felt very important that GPs were empowered and PBC was given more force and momentum.

The incentives to make a success of PBC are fundamentally quite weak. Essentially it is a voluntary activity, there are few sanctions and the incentives available to motivate clinicians are inadequate.

Transforming the system to enable it to manage current pressures and future risk requires leadership that has to come to a large extent from GPs. They not only make the front-line decisions that determine the quality and efficiency of care but also have the technical knowledge to help make sound strategic decisions and choices about long-term patterns of service delivery.

This led me to the idea of a PBC escalator model based on a ‘give and get' agreement between PBC and the PCT. For example, practice-based commissioners might ‘give':

• contractual accountability for national local objectives

• a greater strategic contribution

• a shift to a population health focus in their locality.

They will ‘get':

• greater responsibility over budgets

• the possibility of hard budgets

• greater autonomy over local operational commissioning

• embedded managerial support from the PCT within the cluster, to have cluster-level responsibility and accountability with a PCT role and function as well

• flexibility in planning cycles and financial accounting periods

• flexibility in use of resources, fast-tracking business cases and the possibility of accessing innovations funds.

In essence we have developed a multilayered matrix model of successful PBC with a continuum of earned autonomy.

The escalator model has been developed together by PCT officers and PBC clinical leads. The escalator concept was approved by the PCT board earlier this year, the idea has universal support from all the clusters and we have been working on the detail on governance, performance arrangements and accountability, which will be put to the PEC this month. The escalator should be in place within the next couple of months.

How the escalator works

In each of the four levels of the PBC escalator are four different domains. PBC clusters start off at the platform level (level one). They move up when they reach the required level of competency as set out in the framework and ratified by a group at the PCT consisting of director of commissioning, director of finance and director of public health. At the lower levels the focus is mainly on hospital contracts, budgets, prescribing and management costs but as the cluster gains competence they take on things such as community services and psychological therapies, moving on up through, say, GP contracts and ambulance services and culminating with things like joint commissioning. At level 3 GMS and PMS arrangements will come into the scope of PBC which will require new governance arrangements.

The level of PCT support changes as the cluster moves up the escalator; from being able to call on PCT resources, to having PCT staff embedded in the PBC organisation, to working part of the time for the PBC cluster and the rest of the time for the PCT. This removes one of the barriers to PBC – the PCT's lack of ability to give substantial support. As clusters become more successful and extend the scope of their PBC, the support becomes embedded under their local managerial influence. PBC and PCTs are mutually dependent – a successful PCT can grant more autonomy to PBC.

Greater freedom in terms of budgets, business cases and so on is earned as the cluster moves up the escalator.

The aim is to give clinicians the incentive to widen their sphere of influence and see how they can help support World-Class Commissioning. In terms of governance this model aims to move towards a multi-professional platform, so GPs work with community staff, secondary care and so on.

The cluster governance arrangements have been developed further to include an accountability to local populations, and to help towards World-Class Commissioning with partnership-working between general practice and community services and social care, sharing financial risk and taking responsibility for clinical quality.

The process will provide reliable and timely data so clusters can identify risks and opportunities and manage their performance.

Although the escalator is not live yet, many clusters are orientating their business planning so they will move through the stages when it starts, and secure their autonomy, freedom and flexibility.

PBC is currently quite infantilising – the commissioner identifies a problem, considers the solution and then has to take it to the PCT and ask it to procure the service. This model puts the relationship on a much more mature footing.

Dr Stephen Shortt is a GP in East Leake, Nottinghamshire, and chair of NHS Nottinghamshire County PEC

The PCT's view

Matt Youdale, director of communications and engagement, on how Nottinghamshire County PCT perceives the escalator

'The escalator is a tool that will allow the PCT and GPs involved in PBC to quantify where they are currently at and what they need to do to get to the next level. I hope it will help us align the development of PBC with the development of the PCT, which is one of our aims for developing as an organisation and achieving World-Class Commissioning.

It will help GPs see what World Class Commissioning means for them, and allow us to work out whether PBC is world class by saying ‘if you are performing certain activities and achieving certain objectives, this is where you are likely to appear on the score chart'. It is also a way for the PCT to test itself, to see whether we are helping GPs to develop.

PBC is the best mechanism we have for giving GPs the power they want to spend money locally for the benefit of their patients, along with managerial and logistical support from us, and the escalator will help us give them the space to develop. Some GPs will be more enthusiastic than others but that's the same in PBC generally, and the incremental approach that is fundamental to the escalator should help make the process of developing PBC less daunting for GPs not at the cutting edge.

The NHS is being encouraged to be innovative and that's what we're doing here. The escalator is an answer to GPs who feel PBC gives them little real power. If the escalator does its job and makes us better at PBC, then I hope every GP in the county will be happier as they will see that we are committed to PBC and want to make it work. The proof of the pudding will be in the eating – they will see PBC making a difference.'

The GP's view

Local GP Dr Tony Marsh gives his view on the escalator

'My view of the PBC escalator is one of cautious optimism. The positives are that it is purported to allow GPs greater freedom in decisions about what we do and the speed with which we do it. There will also be less scrutiny from the PCT if we want to introduce services and more PCT staff allocated within the PBC cluster areas.

The downside is the increase in responsibilities. One of the things clusters find hardest is to convince GP constituents of the need to follow PCT priorities and targets. The further you go up the escalator, the more you will be responsible for those and that may lead to a degree of conflict.

It also presupposes a situation where some clusters are further advanced than others and, although it may seem right that the further advanced clusters are given more responsibility and freedoms, it could mean you have different abilities to introduce services in different areas so there's a risk of widening inequalities in the PCT area.

I don't think you can assume immediate agreement from GPs – it will be a question of people weighing one thing against another. Do the freedoms and rights we are going to get outweigh the difficulties we might face from increased responsibilities?

It will require a significant shift of manpower from the PCT into the clusters.

I hope it will increase the locality basis of the way we work – I think it would be worthwhile taking on the extra responsibilities if it gave us more of an ability to do things within our own locality.'

Barriers to overcomeBarriers to overcome Barriers to overcome

Several barriers to PBC progress were identified, both locally through feedback from GPs and also, more generally, by organisations such as the King's Fund.
These barriers include:
• issues over roles and responsibilities – no common vision for PBC at a local level
• capacity and capability problems – limitations on GPs' time, lack of some core skills in management, the PCT's inability to deliver the substantial amount of support needed
• lack of reliable data to develop ideas and manage budgets
• issues concerning relationships, including communication, information, prioritisation and trust – in Nottinghamshire six PCTs had been merged into one and this made it difficult to have proximity in relationships across the geographical territory
• governance and accountability problems

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