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Five things that will change PBC in 2009

What does next year hold for PBC? Sue McNulty, editor of Practical Commissioning, takes a look

What does next year hold for PBC? Sue McNulty, editor of Practical Commissioning, takes a look

1 Unveiling of integrated Care Organisations – March

The final 20 successful integrated care organisations pilots will be announced at the end of March.

Although only a fraction of GPs will be involved in these pilots, the models will be a blueprint for how PBC develops long term.

Dr Johnny Marshall, chair of the National Association of Primary Care, says: ‘What I'm looking to see when the ICO pilots are announced is whether they are really testing out new things that we couldn't just be doing anyway. How far is the DH going to push the integrated care model?'

Of particular interest, says Dr Marshall, will be how the DH deals with the crossover between providing and commissioning roles in such integrated models.

He adds: ‘With ICOs, it's not really clear how that commissioning and providing model is going to pan out and it's going to be interesting to see what they look like.

‘I want to know how you overcome the conflict of interest issue without ending up with an organisation that's not responsive enough. The purchaser-provider split brings about creative tension. That's quite an issue that needs to be worked out.'

2 SHA innovation fund value announced – before April

The creation of a new SHA innovation fund was announced when Lord Darzi's Next Stage Review was published in July 2008 and the exact value of the fund will be made known in the next four months.

Some £550m has been given as an overall figure to fund the commitments set out in the Next Stage Review and a substantial amount of this is expected to go into the SHA innovation fund. Lord Darzi and DH officials are said to be keen to see PBC gets a generous slice of the eventual fund.

Dr Mike Dixon, chair of the NHS Alliance, says: ‘This has the potential to pump-prime redesign projects, especially where money is tight. This will be extra money to begin a project when cost-effectiveness is crucial but not proven and you have to run a double service to begin with.

‘I'm determined – and am having lots of discussions at the moment – to ensure plenty of that money will be available for commissioners to spend in this way.'

3 Introduction of HRG4 tariff codes – April

Due to start on 1 April, Healthcare Resource Group version 4 is seen as a double-edged sword.

HRG is the set of codes hospitals use to label an episode of patient care and a tariff is applied to each code to allow a cost to be worked out for each hospital visit or stay.

Hospitals currently use HRG version 3.5, which has 650 codes – the new version 4 will have 2,500 codes.

Its introduction will be key to unbundling tariffs for the following nine services – radiology, rehabilitation, chemotherapy, radiotherapy, renal dialysis, critical care, high-cost drugs, specific palliative care and interventional radiology – and so more care will be delivered in community settings for these.

However HRG4 is not without its critics. There were rumours at the end of 2007 that the DH was getting cold feet about the switch, when finance directors raised concerns over its robustness.

Graham Poulter, managing director of iQ Medical, says: ‘The Audit Commission has said the error rate in terms of coding is 9.4% [for version 3.5]. Our experience is that it's much higher, and if you speak to any PBC group or practice manager they will say the same thing. If you translate that figure as the percentages of the £22bn spent on inpatient episodes then that works out as £13.6m per PCT.'

He predicts that the error rate is likely to rise in correlation with the number of codes.

4 Government PBC survey to be published – April

The DH publishes a PBC survey every quarter but Dr Mike Dixon predicts the April one will be a real test for PBC.

Two years will have passed since the NHS Alliance and the King's Fund's joint report in April 2007, when a straw poll of 257 GPs and practice managers showed 70% rated their PCT's support for PBC as poor.

Dr Dixon says: ‘We were reassured the issues raised were being listened to by Patricia Hewitt. And at the NHS Alliance conference in October we had Alan Johnson effectively saying PBC had been in the slow lane but he was going to get it moving.

‘By April people's patience will have run out. There ought to be a riot if things haven't moved on and that should concentrate hearts and minds over the next month or so.'

But Dr Johnny Marshall says the April survey will be too soon to judge whether there has been a change, and the December 2009 survey will be more telling.

‘If they're serious about involving clinicians in commissioning and don't act on it by December, many of my colleagues will feel disengaged for years, and it will take a long time to get them back on board.'

5 World-class commissioning assurance system – from September

The first formal assessments of whether PCTs are meeting world-class commissioning competencies will begin in September.

PCTs are already a third of the way through a first-year ‘dry run', whereby they will receive feedback on their performance but the results will not be made public.

Scott McKenzie, a PBC consultant, says September 2009 will be ‘showtime' for PCTs as their results will be in the public domain the following year, with 2009 assessments due for publication in March 2010.

He says: ‘Some PCTs are already being told they're not particularly great leaders of the NHS and they need to be doing something about engaging stakeholders. Two-thirds of PCTs have yet to decommission anything. The culture of PCTs around PBC has got to change.

‘PBC groups will find they are pushing at more of an open door in 2009 and they will get a fairer hearing for their PBC plans and find there is proper data in place for PBC.'

5 things that will change PBC in 2009

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