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Go back to basics to revive PBC

GPs left demoralised over the past year can take heart from the latest developments and start to revitalise PBC. Dr Shane Gordon advises on how to pep up commissioning in your area

GPs left demoralised over the past year can take heart from the latest developments and start to revitalise PBC. Dr Shane Gordon advises on how to pep up commissioning in your area

Last year was a difficult time for practice-based commissioners with budget deficits affecting many PCTs. This meant there was little investment for new ideas and little intellectual energy left to expend on PBC. This left many PBC clusters feeling frustrated and demoralised.

Fortunately, there are signs this year will be different. In December the Department of Health unveiled its plans for ‘world-class commissioning', including 11 competencies which commissioners need to develop. This places an emphasis on PCTs working with clinicians and community partners and developing the competence and capabilities of practice-based commissioners.

The National Audit Office published a report in the same month, A Prescription for Partnership, encouraging entrepreneurial clinicians to get involved in the financial management of health services. Finally, the NHS Operating Framework 2008/9, setting out the strategic direction of the NHS from April, defined commissioners as ‘PCTs working with practice-based commissioners'.

So it seems clear that PBC is here to stay and that the department sees the process as a partnership between practice-based commissioners and PCTs. But fine words do not make getting an idea from drawing board to commissioned service any easier.

The past two years have taught us that commissioning is less like a quick trip to the supermarket to select the best service, and more like farming, where you must plan your crops months in advance, tending them carefully to fruition. Here are six top tips to help you re-energise PBC and take advantage of the more positive climate.

1 Mobilise your workforce

The challenge of PBC can be daunting for any clinician as the steep learning curve and large amount of information both put pressures on our time. The key to coping with this is to share the burden.

Remember that it is practice-based, not GP-based, commissioning. There are many members of the primary care team who might be able to contribute to your efforts if given the opportunity. Several successful clusters have engaged practice managers, nurses, pharmacists and even patients in their work.

This not only increases your potential workforce, but gives a wider range of ideas and presents a more inclusive face when dealing with external partners such as the PCT and local authorities.

It can be easy to get sucked into the detail of developing new services before you have a chance to take stock of the overall picture. Make sure that your cluster spends time on internal development activity so that you get the best out of your team – understand the different roles required for successful PBC, who is currently filling each role and where the gaps are.

Pharmaceutical companies can be helpful partners in providing workshop facilitators to work through this exercise.

2 Motivate your workforce

Remember that engagement in PBC can be helpful at many levels. Encouraging practices to contribute ideas and input into the development of new services can be very productive.

Our commissioning group has found that visits to practices to explain PBC, our current plans, practice budgets and activity data have been highly successful in engaging and motivating clinicians and practice managers alike. Simple communication strategies such as one-page newsletters containing tips to help practices manage their budgets can be very effective.

Getting practices involved in PBC is not all about financial incentive. Rewarding their innovation by allowing them to use the resources tied up in indicative budgets more creatively will encourage further innovation. One of our local practices recently chose to spend some of its prescribing budget on a new 24-hour blood pressure monitor after working out that it was cost-effective to detect white coat hypertension.

Nevertheless, a good incentive scheme will deliver a degree of commitment from your practices for their hard work. Ensuring that the incentive scheme is well structured and addresses PCT priority areas such as reducing referral rates, emergency admissions and specific prescribing incentives will help to persuade the PCT to invest money in it.

We have also rewarded practices for controlling their overall budgets, which was highly successful in turning around an overspent position and paid for itself at a ratio of 20:1.

3 Understand the landscape

It is essential to remember that PBC does not happen in a vacuum. Success in PBC is tightly bound up with co-operation from your PCT. It is therefore helpful to try to understand the ever-changing political and policy landscape in which trusts operate. Ensuring that your PBC plans address the PCT's current priorities will help to secure approval through various decision-making stages and project support in implementing them.

Some of the key policy drivers at present include your local health needs assessment, carried out by the public health team to identify specific geographical and demographic challenges within your population. This piece of work will become part of the more sophisticated joint strategic needs assessment that PCTs and local authorities are required to jointly produce.

It will inform the commissioning of both organisations towards shared goals.

Understanding the main messages from these public health priorities will enable you to tailor your PBC plans to satisfy the needs of your strategic partners. Of particular interest are likely to be identified health inequalities linked to obesity, smoking and mental health issues.

4 Plant your ideas early

At present most PCTs are frantically working on their local development plan (LDP). This will decide what resources are allocated for projects in the following financial year. Clearly, for PBC to be successful it needs to be fully engaged in this process.

Over the past two years in our area we have been successful in negotiating a joint commissioning plan between the PCT and its PBC clusters. This means that practice-based commissioners have the opportunity to have their plans included in the PCT's commissioning agenda, to have an overview of all the other commissioning priorities within the PCT and to have some influence over those plans which they feel strongly about.

Indeed, in the past year, we have been successful in applying the axiom that there is ‘no commissioning except that which includes PBC'.

Regular discussion with your PCT commissioners is essential as priorities can change quickly in response to external pressures such as the media and DH. We now have a weekly one-hour meeting between the PCT's PBC lead and the clinical leads of our PBC clusters.

5 Nurture your allies

As with any enterprise, PBC is easier if you develop relationships with key strategic partners. From our perspective these include the PCT, the local authority (particularly social services), local acute trusts, the SHA, the voluntary sector and patients.

The DH's world-class commissioning initiative gives PCTs fresh challenges in terms of meeting standards, to be scrutinised by SHAs. Cultivate good relationships with PCT colleagues and help them to demonstrate their achievement of the standards in partnership with you.

Become an ally of your PCT in contacts with external organisations and position your PBC cluster as a strong partner in meeting shared challenges. A close and supportive relationship with the PCT makes it more likely that they will be responsive to your ideas and suggestions.

The non-executive directors of the PCT are a powerful influence within the board. They often come from industry, education and political backgrounds and are usually not afraid to ask awkward questions.

Time spent getting to know them and understand their particular perspectives is usually well spent. Engaging them in your thinking about PBC and your plans at an early stage will help to avoid unnecessary derailment of those plans by the PCT board.

Your local authority may be a willing partner in changing models of care provision – remember local government has a 15-year headstart in how to commission services. They may have access to resources such as project management and funding for projects that deliver shared benefit, such as telemedicine.

They may also hold information to help residents access resources directly, which could equally be accessed through your surgery. This could even include sophisticated tools such as self-assessment for home equipment, traditionally provided through occupational therapy services. This in turn can provide more rapid access to equipment, prevent unnecessary admissions to hospital and maintain the patient's independence.

6 Cultivate patient support

Of all the partners who can feed into your plans, patients rightly remain the most influential. Your local patient and public involvement forum will shortly be disbanded to be replaced, under new legislation, by the new local involvement networks. Many experienced patient representatives may feel displaced and poorly represented by this new type of organisation, and could become powerful allies for your PBC clusters, if properly involved in your commissioning plans.

Single interest groups can also be powerful champions. Age Concern, the Red Cross, MIND, the MS Society and the Parkinson's Disease Society are all examples of bodies keen to be engaged in providing new services. In some cases they may also have access to funding for initiatives that address their particular concerns.

In summary: work hard on developing a broad outlook for your PBC cluster, share the workload where possible and foster alliances to help you achieve your goals.

Dr Shane Gordon is a GP in Essex, chief executive of the Colchester PBC Group, East of England lead for the NHS Alliance's PBC Federation and chair of the NHS Next Steps Review planned care workstream

Dr Shane Gordon PBC is less like a quick trip to the supermarket and more like farming – you must plan months ahead

PBC is less like a quick trip to the supermarket and more like farming – you must plan months ahead

PBC plans with

PBC plans with a link to obesity, smoking or mental health will probably be of particular interest to PCTs

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