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GPs buried under trusts' workload dump

Get ready to decommission

With NHS budgets being squeezed, is it time to start decommissioning services? Emma Wilkinson asked four experts to share their thoughts

With NHS budgets being squeezed, is it time to start decommissioning services? Emma Wilkinson asked four experts to share their thoughts

Our experts

Dr Nick Goodwin (NG) senior fellow, King's Fund

Dr Johnny Marshall (JM) chair of the NAPC

Dr James Kingsland (JK) president of the NAPC and lead for the National Clinical PBC Network

Dr David Jenner (DJ) practice-based commissioning lead, NHS Alliance

The recession is set to hit the health service hard – and PBC groups will be at the sharp end. After years of relative plenty, commissioners will face a ‘very grim' picture from 2011, according to the NHS Confederation. It predicts that PCTs will face budget cuts of at least 2.5% to 3% – a total reduction of £15bn over five years.

So what does commissioning in a cold climate mean for PBC? Could these dire financial warnings actually provide an opportunity to take charge? Experts say the need for clinicians to lead true service redesign, withdrawing poor or unnecessary services as well as creating new ones, has never been greater.

What are the key challenges facing PBC groups as resources shrink?

JK ‘In one sense I'm quite excited about a budget that's going to be challenging to manage. PBC was developed because we have lots of waste and inefficiency in the NHS and it was the vehicle to challenge primary care to scale up what they offered.

‘The concept of having an NHS that didn't have all the services or providers it currently has was there at the inception of PBC in 2004 – it is about service redesign, not just recommissioning existing services.'

NG ‘We're already entering a financial regime where top of everyone's agenda is how they'll cope when allocations to PCTs are not as high as they have been.

‘If we're going to keep quality in a cold climate then we'll have to commission our way out of it – if we don't, we'll end up with what has happened in the past with parts of care closing and hospitals laying off staff.'

DJ ‘You have a situation where people at the top are saying we're fine and financial predictions are saying we're not. I would encourage PBC groups to go and have discussions with the PCT about the financial health of the local services. Major system failure in public services is unacceptable.

‘In the NHS, we cannot let ourselves get into a situation where care and essential services are compromised. PBC has got to be involved by the PCT in tackling the scale of the problem, but for most people the problem hasn't materialised this year. Nobody is being honest. We need open discussions locally about what will happen.'

What is the strategic role of PBC in this climate of decommissioning?

JM ‘We need what I call world-class decommissioning. The important thing about removing a service is to ensure there is an alternative to meet patient need. The biggest danger in a cold climate is people just take a ‘slash and burn' approach but then that demand or cost pops up in another part of the system.

‘For example, you take away an outpatient service and those patients end up going to A&E instead. So you need another way of managing that demand. Or you decide that something is a low priority and you're not going to provide it, for procedures that we have all agreed do not need to be done.

‘In terms of PBC, we need to make sure we are providing that clinical voice that understands there is still a need and to make sure the patient doesn't fall through the gaps. You don't want waiting lists getting longer or staff training being cut. But we do need to do things differently and that is what PBC can bring to the table. Some PCTs have started to get that but I don't think everyone does.'

DJ ‘Fundamentally PBC should be used to stimulate whole-system discussions and to achieve a co-ordinated approach. In a cold climate you need extensive collaboration between providers and commissioners to make sure the whole-system change is considered – piecemeal change is going to fragment care.

‘The future might even include providing services outside tariffs or with activity caps, which is going to be controversial.'

NG ‘One of the problems faced by PBC is that primary care professionals are only interested in providing hospital services in a different setting – they're not really interested in service redesign.

‘And we can't do service redesign without doing it on a large geographical basis. PBC hasn't really got off the ground and people aren't thinking strategically.'

JK ‘The decommissioning word can cause angst so we have to explain what we mean by our language – it's about rethinking where services are delivered. There is a lot done in hospitals that shouldn't be done. But this is not about just taking £5m out of hospitals – if that's your approach then the acute trust will put the barriers up.

‘PCTs who say to hospitals "we are doing this to you" come up against hostility and the scheme often collapses at a very early stage. That is where we need clinicians to come in – to say "we have a programme that can improve efficiency by £5m".

‘Hospitals need to be focusing on the things they do well instead of the things that can be better provided in primary care, such as care of long-term conditions and some diagnostics.'

Where should we be looking for services that can be decommissioned without compromising patient care in any way?

JM ‘Everyone has obvious places to start looking. One would be reducing length of stay and providing things like virtual wards in the community where people can be safely looked after at home rather than taking up expensive hospital beds. Then you have recommissioned rather than just removed a service and that is what I mean by world-class decommissioning.

‘You couldn't just say "let's close those beds" without looking at the needs of those patients, and expect primary care to pick up the pieces.'

JK ‘Hospitals need to be focusing on the things they do well instead of the things that can be better provided in primary care, such as care of long-term conditions or some diagnostics.

‘We still do things like tonsillectomies and hysterectomies and other things where there's very little evidence behind them.'

DJ ‘One side is services that are not necessary and add little in terms of health outcome. But we have to be careful, we don't want to create an artefact of closing down one thing and increasing costs somewhere else. This means agreeing a "what not to fund" list.

‘Far more common will be trying to adjust thresholds for referral of treatment – a mixture of overt and covert rationing. Often the threshold at which a patient is referred from primary to secondary care can be inappropriate, and the role of the clinician is to call foul.

‘Then there is the much more difficult issue of treatments which are clinically effective but not terribly cost-effective and you have to say we can have that one or this one and that is far more complicated.'

NG ‘We need a tiered approach – there are certain services that PBC can provide differently to their patients, such as diagnostics, certain outpatient services and minor injuries. But when you're thinking about service redesign and decommissioning, practices need to work within a larger group, a PBC federation, to do that effectively.

Can PBC-led decommissioning achieve the necessary savings?

DJ ‘It is crucial that commissioners are involved in discussions with providers. Instead of closing just a few beds here and there, which doesn't really lead to any cost saving, we might need to talk to providers so they can shut whole units or wards to release the full costs. ‘But at the same time we need to think about redeploying that resource into the community. That is what can be done with whole system collaboration – redeploying the skilled workforce – and you're not going to do that by commissioners sitting down and looking at a series of tenders.'

JK ‘I feel like a broken record but we still need to sort out the issues of changing the mindset and culture around PBC. We need to change the process of how we rethink and reinvest in services.

‘When people sit down and do it they say, we had no idea we were just peeing money away in the breeze. Then they realise that a 15% reduction in spending is achievable. If we finally empower the referrer to make decisions on the best interests of their patients we will achieve it, no problem.

‘PBC needs budgetary control, the responsibility to challenge how that budget is being spent, and to have accountability.'

NG ‘PBC groups can innovate locally for certain things but when it comes to those big discussions you have to do that at a higher level. You can't have 30 practices in an area trying to decommission services – the trust would wipe the floor with them.

‘The longer-term, three-to-five-year issue is moving care into the community and service redesign. Even before the current economic crisis, it was clear that we needed to transform services for the rising numbers of people with long-term conditions.'

What should be top of the to-do list for PBC groups?

JK ‘PBC groups need to be holding their PCT to account for the guidance and starting to draw up accountability agreements to put roles and responsibilities in place.

Don't wait to be asked to drive things forward.'

NG ‘The number one priority is getting the right business mechanism in place to negotiate and performance manage contracts and really enforce assessment of payment. We're going to have to do that immediately.

‘Commissioners have a very inequitable relationship with large acute providers and the first thing we need to do is rebalance that. There are three key issues:

• The need to understand fully what the business of the hospital provider is

• Having really senior leaders at their side at the negotiating table

• Getting the information and data systems in place to disprove the information provided by the NHS trust, so PBC can question and validate the quality of returns from the hospitals.

‘We also need more stringent contracts. That will save somewhere around 5-10%.'

DJ ‘The role of PBC is first of all to see what the bottom line is. It is the job of PBC to find clinical quality and look at effectiveness of outcomes.

‘The second thing is to see if the service is providing value for money. After

ensuring patient experience, access and convenience there are trade-offs to be had.'

JK ‘You need to start with an assessment of how resources are currently being used, get the evidence and work out how it needs to be changed. If you find a problem in urgent care you can then analyse that service.

‘You need to have very early conversations with the hospital. If there is inefficiency, wastage or duplication, or something could be better done outside hospital, that needs to be worked out at clinician-to-clinician level, talking about the reasons why and the evidence for change. Also early in the debate you need to work out how you're going to involve the patient groups.'

JM ‘You need to develop a relationship with the acute trust. It's about saying the future of this trust is providing the right services for the local population and that means we need to develop and change as we deal with that in a cold climate. If they don't do that then commissioners will have to find a different acute provider who will provide them with what they want.'

Emma Wilkinson is a freelance journalist

What the Government must do What the Government must do

Chris Ham, professor of Health Policy and Management, Birmingham University, wrote in Health in a Cold Climate, 2009:'The NHS in England is faced with the prospect of finding savings of £15-20bn over the period 2011 to 2014.The Department of Health and NHS organisations need to adopt an intelligent approach to finding these savings that avoids both ‘salami slicing' and ‘slash and burn'The Department of Health should review current policies with the aim of deciding what changes are needed as the NHS moves from expansion to contraction.'

Decommissioning – some suggestions for PCTs Decommissioning – some suggestions for PCTs

• Ensure all existing referral and treatment thresholds are adhered to by implementing referral and utilisation management initiatives (such as referral incentive schemes)
• Consider raising referral and treatment thresholds or tightening eligibility criteria for certain interventions
• Increase patient involvement in decision-making and care delivery, and support a fundamental shift towards self-management of long-term conditions
• Ensure that where new services are introduced to manage demand in a different way, the existing services are actively and explicitly decommissioned
• Identify opportunities to decommission infrastructure (buildings and staff) as part of an agreed strategy to cease or shift service provision
Source: Discussion paper Commissioning in a Cold Climate, NHS Confederation, June 2009

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