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It’s time to step up and take the lead

Richard Alsop, NHS Northamptonshire’s director of strategy and system management, offers a PCT perspective on what commissioners should strive for

Richard Alsop, NHS Northamptonshire's director of strategy and system management, offers a PCT perspective on what commissioners should strive for

The need to support PBC development is obvious to me. To date, commissioners have failed to manage demand effectively, or reduce variation between referrers.

Yet it seems a major part of the solution to the reduced funding we will all face in 18 months lies in tackling variation and setting priorities that are collective, consistent and owned by primary care. Commissioning for quality and delivering productivity gains will require a really effective partnership between practice-based commissioners and their PCT, built on a shared vision and trust.

PCTs need to work hard to develop practice-based commissioning in their area, but commissioners need to meet them half way. They need to understand what PCT priorities are – better still, they can help shape the priorities and then lead that change and deliver on the big-ticket items. My sense is that most PCTs would welcome this approach and support it. Too often I still see a hobbyist approach to PBC – making small-scale changes in areas of personal interest. This may be a start, but it can't be the end point.

So what have we done here in Northamptonshire to promote and support PBC? First, we've tried to be true to our intent to involve. We nurtured and supported the development of our PBC consortiums – GPs stepped forward to lead and Nene Commissioning was formed. Nene has grown and now covers more than 90% of the PCT population, has a funded management structure and is credible both with practice constituents and PCT partners.

Having the right structures is important. Early on, we established a commissioning executive committee. This group comprises the executive directors of the PCT and the PBC clinical and managerial leads. Its key roles are to help develop strategy, develop the annual operating plan and consider all business cases for investment – whether from PBC or the PCT. Across the country, a common PBC complaint is that business cases don't get through. Here, the good business cases get approved and poor ones get knocked back, no matter who they come from. We have tried to oil the wheels of innovation by creating a £4m Invest to Save fund, which business cases can target for new services – for example, more than £1.5m is being invested in the largest PBC case, for proactive case management.

NHS Northamptonshire's priorities are delivered via programmes, with progress managed by a programme board. Practice-based commissioners are part of this board and are leading on two of our priority programmes – end-of-life care and long-term conditions – a signal of intent to lead from PBC, and a measure of trust to deliver from the PCT. We are currently developing our primary care strategy, and we are doing this with Nene Commissioning (and the LMC) to strengthen our partnership with primary care in preparation for tough times.

There are some difficulties to overcome as we move forward. Although the top of the PCT is signed up to empowering PBC, sometimes a combination of bureaucracy and management hierarchy slows progress. On the PBC side, there will be an increasing need to make and support hard decisions, and introduce peer challenge around unexplained variation. In a democratic, member-owned organisation such as a PBC group, that can be difficult. However this must be overcome if we are to establish the next level of partnership, which can deliver in a colder climate and benefit our patients.

Richard Alsop is NHS Northamptonshire's director of strategy and system management

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