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Five things one document can do for PBC

Hailed as a definitive document, Clinical Commissioning: Our Vision for Practice-Based Commissioning states exactly what PBC groups are entitled to and when it must be delivered. Dr James Kingsland, NAPC president and national PBC clinical network lead, takes us through it

Hailed as a definitive document, Clinical Commissioning: Our Vision for Practice-Based Commissioning states exactly what PBC groups are entitled to and when it must be delivered. Dr James Kingsland, NAPC president and national PBC clinical network lead, takes us through it


1 Indicative budgets to be delivered by 1 May

What the document says: ‘Every practice should receive its indicative budget and have agreed its management and financial support with the PCT by 1 May each year – with ultimate recourse to the SHA if this is not delivered.'

What it means: Exactly what it says on the tin. This is unambiguous, in response to feedback from practice-based commissioners frustrated that despite PCT claims that every practice had a budget, that wasn't actually the case.

In some instances, PCTs had failed to understand what a budget actually was. It's not just about historic spend but should detail exactly the total resources available for the registered population at practice level – everything (and that does mean everything) the PCT manages except for primary care contractor contracts.

Although PBC groups may want to, and should, block back some areas such as tertiary care, the primary care clinical commissioner (the referrer) should still be aware of total spend and be entitled to question this or come up with new ideas for deployment, and thus become jointly accountable with the PCT.

It also sets a clear deadline of 1 May each year, giving PBC groups the right to the information they need, when they need it. If there are genuine reasons for any delay, the PCT must have a dialogue with PBC groups ahead of the deadline.

What's happening on the ground: The definition of ‘budget' varies enormously between PCTs. Although some are living up to the spirit of PBC, other PCTs may claim success but practices have nothing but a complex list of mind-numbing detail reflecting only a tiny proportion of the overall spend. A budget must be straightforward. Both the practice and PCT need to understand exactly what resource is available, what pressures are on this, and how it is currently deployed.

What you need to do about it: Start an open dialogue with your PCT chief executive or finance director, reminding them of the deadline and setting out what you expect in terms of information and budgets. Pick up the phone and explain which issues you need to discuss. Ensure you have a clear compact between practices, the PBC group and PCT, setting out what each side must do and how to handle any disputes.

If relationships are tricky, you may need to step up a level and exchange formal letters. Ultimately if there is no way to reach agreement, the dispute can be escalated to the SHA.

2 Business plans to be turned around within eight weeks

What the document says: ‘PCTs should make decisions on PBC plans and business cases within a maximum of eight weeks.'

What it means: There is no reason why a clear business case – that identifies a need, the evidence for change, the impact on resources and patient experience and measures outcomes – should not be assessed within four weeks.

PCTs do not have the power to independently veto plans. However where business cases are underdeveloped, lack vital information or do not reflect priority areas for investment identified in the PCT's strategic plans, then they may be returned with requests for further information.

Managers may question some of the financial arrangements or other aspects, but these investigations must take place within the eight-week deadline, not once it has passed. If there are genuine reasons why the process might take longer, the PCT should explain this to the PBC group, rather than create unnecessary delay.

What's happening on the ground: Delays are not unusual. This is often related to the bureaucracy applied by PCTs to PBC business case approval. Previous guidance outlines how this can be streamlined, but too often PCTs put a complicated process in place. No PBC groups have yet contacted me to complain about a lack of response within the deadline but that is possibly because not many business cases are being submitted.

What you need to do about it: First, make sure you have all the foundations – a compact between your group and the PCT and a strong business case. Then stay in touch throughout the process, discussing any questions that arise, rather than waiting until the end.

Ultimately, if deadlines are missed despite attempts at dialogue, then you can ask the SHA to arbitrate.

3 PCTs cannot reach Level 2 on their World-Class Commissioning assessment without delivering your entitlements

What the document says: ‘A PCT will not be able to reach level 2 of World Class Commissioning without strong clinical involvement and support for PBC.'

What it means: One of the 11 World-Class Commissioning (WCC) competencies is about engagement of clinicians in the commissioning process. The WCC assurance process includes an assessment of the strength of PCT support for PBC. The document also says the PBC ‘entitlements' – which include timely, accurate data, indicative budgets and swift decision-making – must be delivered or else level 2 will not be reached.

It is not envisaged that all 152 PCTs will achieve world-class status as commissioners– WCC is aspirational, a vision to work towards. But within that there is a clear signal. If PCTs or PBC groups fail to make progress or aspire to the vision, or if they ignore the policy, a question arises about the PCT's fitness for purpose and its place within the NHS. The trust may be seen as failing patients and become subject to performance management to assess whether the management structure is right.

What's happening on the ground: The PBC reinvigoration programme has had some positive impact. PCTs and clinicians have put PBC way up their agenda as a major player in the programme of NHS reform.

I am hearing and seeing more progress from our regional PBC visits over the past nine months, increasing clinical leadership provoking change and people getting their sleeves rolled up.

But there should be no complacency. While all PCTs may report that PBC is flourishing, that is just not the evidence on the ground. The quarterly MORI poll that assesses PBC progress is to be relaunched, providing an even more accurate picture .

What you need to do about it: If your PCT is failing to deliver your ‘entitlements', you need to refer back to your accountability agreement and this guidance. You should attempt to have an amicable discussion at local level, with each side striving to understand the other.

If this doesn't work, bringing in external consultants to get PCT and PBC groups talking the same language and working together may help. The five PBC Capability Framework providers, as well as other consultancies in the field, can support local PBC development and implementation. Having an outsider to hold the ring can be very helpful in breaking down some of the barriers.

If attempts to have a reasonable dialogue fail, then as before you need to move to more formal correspondence and, ultimately, the SHA. But the SHA will expect you to have made every effort to resolve matters locally first.

4 Any Willing Provider model to be increasingly used

What the document says: ‘World-class commissioners will… increasingly use ‘‘any willing provider'' arrangements to stimulate a range of providers for more specialist services and extend patient choice into community settings. Where new services are best delivered as an integral part of general practice or other primary care provision, PCTs may commission them through local enhanced services.'

What it means: PCTs will increasingly be responsible for assessing the quality of providers, operating a quality assurance system that enables new providers to enter the healthcare market, breaking up existing monopolies and block contracts.

New providers should not be guaranteed any cost or volume of work – instead they must compete for patients by offering a service that better meets patients' needs.

What's happening on the ground: The NHS is still largely a provider-driven service, with too much money tied up in block contracts. PCTs should be looking to expand the Any Willing Provider (AWP) model when new service specifications are identified by PBC groups.

At the moment this policy is not well developed. There are new services coming on stream but often the providers are given a guarantee of a flow of work. There seem to be few AWPs entering the market at their own risk, depending on GPs to refer to them and patients to choose their service.

What you need to do about it: PCTs should be looking to use the AWP model more and more and rely less on tendering for provider services, identifying where there is a need for competition and plurality. PBC groups should be developing commissioning plans and service specifications that challenge new market entrants to meet those requirements.

5 PCTs can delegate hard budgets for a specific condition or pathway

What the document says: ‘For some areas of care (eg for a specific condition or pathway), PCTs may discuss with PBCs and agree to delegate direct responsibility for managing ‘‘hard'' budgets and taking these investment decisions.'

What it means: Literally cash in the bank. PCTs may not be too keen to go down this route if confidence is low in PBC – after all it is still the chief executive who is the accountable officer. PBC groups will also have to show they are complying with the Principles and Rules for Co-operation and Competition. But hard budgets are about recognising there is a shared responsibility between PCT and PBC groups.

Responsibility for hard budgets means that the PBC group takes on more of the risk of any overspend, not the PCT.

What's happening on the ground: My own group, Wallasey Health Alliance, has a cash budget to commission new social care interventions – adult social services bills the PBC consortium directly for new services that demonstrate an efficiency gain in health service spend. The consortium is held to account by the PCT on how it manages the budget. To read more about Wallasey, go to www.practicalcommissioning.net and search for Wallasey.

Although this kind of model is not yet widespread, it is likely to become more common. Aligning clinical responsibilities with financial ones makes sense.

There may be a big bang after the next general election, with a new administration wanting PBC accelerated so every group is expected to hold a hard budget.

What you need to do about it: You need a functional consortium that is able to interrogate data and budgets and understands the local health economy, before considering taking on full financial responsibility. You must be able to demonstrate your value to the PCT and local health community.

Interview by Kaye McIntosh

Further information www.dh.gov.uk –

click on Managing your organisation, Commissioning, and Practice-based commissioning

‘Clinical commissioning: Our Vision for Practice-Based Commissioning', Department of Health, March 2009

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