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Where does the Government truly stand on PBC?

GP concerns over PBC were put directly to Mark Britnell, the Department of Health’s director general of commissioning and system management, when Rebecca Norris met him this month

GP concerns over PBC were put directly to Mark Britnell, the Department of Health's director general of commissioning and system management, when Rebecca Norris met him this month

Many GPs warn that risk-averse attitudes held by PCTs that demand failsafe business cases or lengthy approval processes are stifling commissioning creativity. How is the DH going to instigate a culture among PCTs to allow consortiums to innovate without unnecessary restraint?

Mr Britnell candidly acknowledges the problem. ‘Certainly I've been alarmed to see that some PCTs want tomes of War and Peace for what I would consider to be relatively straightforward redesign ideas.'

He points out that among the 11 new competencies set for PCTs by the World Class Commissioning (WCC) programme announced by the DH in December, PCTs must work with clinicians as well as have a ‘relentless focus on innovation and improvement'.

‘PCTs need to be better at assessing proportionate risk. By that I mean if you've got a small business case that is a good idea and doesn't need a lot of money, then I think the level of scrutiny surrounding that bid needs to be proportionate. Unhappily at the moment there are examples I've heard of where that's been disproportionate.'

41190031He says trust and relationship-building between practice-based commissioners and PCTs has been hampered by PCT reorganisations and a year of financial instability in the NHS. ‘But I think we've put that behind us. PBC is very much here to stay and certainly we expect its development to accelerate, not decelerate, over the next period.'

He adds: ‘What's important is that we get better at developing a governance framework. It's not that business cases or planning are wrong – it is a normal part of any business process. If it's suffocating and disproportionate that's where it becomes bureaucratic and drives away innovation.

‘Overall, I think we'd expect to see PCTs being more proportionate, more innovative and more supportive. But the quid pro quo, especially for the larger PBC consortiums, is they would be much more mature and sensitised to governance issues.'

So would he approve of more consortiums operating like Stockport Managed Care Company (see page 26 of this issue), which has been delegated powers to approve business cases worth up to £500,000?

He says a number of tests should first apply:

• What is the organisation's track record for turning investment into action? If there is no track record, do you believe your investors will use money wisely?

• Are relationships between the PCT and practices and governance arrangements suitably and sufficiently well developed?

• How much health gain and patient benefit will the business case produce?

He adds PCTs should accept the risk of some business cases failing. ‘It's almost like venture investment. I would support seeding investments where we thought there was a good case for patient benefit.'

The World Class Commissioning programme is now taking up a large part of PCTs' energy – but some GPs feel the WCC literature makes little mention of PBC. How will the DH performance-manage PCTs to ensure that PBC is seen as essential to WCC?

Mr Britnell says just because PBC is not mentioned within all the new competencies for PCTs set out in WCC, this does not mean that every competency cannot and should not be applied to PBC.

Practices, just like PCTs, could be local NHS leaders, who manage medical information more proactively and make sound financial investments – as various competency requirements call for, he says.

Mr Britnell reveals that practice-based commissioners, ‘for the first time ever', will be invited to assess PCTs on how well they are developing PBC against some of those competencies.

This will occur through an extension of the current quarterly practice survey of 2,000 practices across England on PBC progress, as well as a new 360° review process on PCT performance being introduced. National benchmarking, peer review and self-review will also make up the new compliance and assurance framework for PCTs.

A PCT that persistently fails to back PBC will be rated red under the framework's traffic light system and be subject to action plans and close regional or national scrutiny. The framework starts this summer, with first ratings to be issued in 2009/10.

For some practice-based commissioners, having direct control of budgets, rather than managing indicative sums, remains the ‘holy grail' of PBC. What is the DH doing to make this possible?

GPs may get some firm answers on this, hints Mr Britnell, when Lord Darzi's Next Stage Review is published by July.

He says: ‘It's something we are considering as part of the Next Stage Review. Obviously that's a matter that ministers need to consider further.

It would be premature to give any commitment now – however, we do understand the concerns of some practice-based commissioners and we are also aware of examples that exist internationally about integrated care or managed care organisations, which we're carefully inspecting. It's too early to say whether we'll deliver the holy grail for some of your readers, but it's something we're looking at quite carefully.'

Mr Britnell confirms there's an appetite for direct budget holding among the primary care and community services advisory board that reports to health minister Ben Bradshaw, and the DH is also aware of the National Association of Primary Care and the NHS Alliance's hopes for piloting of direct budgets.

Many GPs feel PBC will fail without proper reimbursement of staff time spent on its development and management. How will the DH ensure practices are supported?

Mr Britnell says he is convinced the decision to have PBC management costs determined locally was ‘the right course of action'.

However he says: ‘I can't personally see how PBC can develop unless there's formal support, both managerial and fiscal, to PBC consortiums.' He cites Hampshire as a good example of where the PCTs have made payments via local enhanced service allocations to develop consortium capability, capacity and infrastructure.

Over time, consortiums will need to start making their own investments in capability and capacity, he adds.

Mr Britnell also reveals that the forthcoming primary care and community strategy being drawn up under the Next Stage Review will acknowledge the different levels of PBC that exist – from large consortiums through to practices that are happy providing but not commissioning new services.

‘In the strategy we're not going to try to dictate that one size fits all – but it will encourage those that do want to go further, faster, to do just that.'

Some GPs believe investment in equipping clinicians to take on a commissioning role remains very poor. What is the DH doing to ensure that sufficient resources are committed to developing more skilled practice-based commissioners?

Mr Britnell highlights two recent initiatives and two forthcoming developments.

‘I sent out a letter on 10 March that confirms that commissioners will now also be able to directly avail themselves of FESC, with the agreement of their PCT.' He says this shows the DH listened to the NHS Alliance, which had urged the move.

FESC is the nationally negotiated framework between the DH and a list of pre-approved private firms such as BUPA and UnitedHealth Europe. It was set up to allow the companies to bid to provide – initially to PCTs – commissioning expertise and functions such as data-crunching and carrying out contract talks with acute providers. It has drawn criticism from some quarters as evidence of further privatisation of the NHS.

As well as opening up FESC to practices, Mr Britnell says the DH has jointly funded the new Advanced Commissioning postgrad programme at Teesside University, with the Improvement Foundation, NHS Alliance and NAPC. ‘That's a small but significant step in the right direction.'

He also reveals: ‘We will expect in the summer to issue one or two tenders from the DH to encourage those who believe in PBC, to help develop PBC at grassroots level even further.

I would hope that the NAPC, NHS Alliance, Improvement Foundation and others may decide to respond to that tender, so that instead of having a number of people commentating on national policy, they can help deliver and execute its implementation more effectively by working with us.'

The tender specification has not yet been written but it will be ‘absolutely focused on re-energising and extending PBC further'.

Mr Britnell adds that two clinicians, who will focus on PBC, will be appointed in the next two or three months to work with national director of primary care Dr David Colin-Thome.

Does the tender exercise show the DH feels more dramatic action is needed to ensure PBC doesn't wither on the vine?

‘Not dramatic – I'd say more focused work. The policy is clear: the NHS needs to be getting on with it. Like any new policy, I think we're listening hard, learning and adjusting.'

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