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Gold, incentives and meh

How can we drive PBC to integrate with local authorities?

Practical Commissioning editor Susan McNulty asked Robin Lorimer of the Integrated Care Network about how PBC consortiums can work with local authorities

Practical Commissioning editor Susan McNulty asked Robin Lorimer of the Integrated Care Network about how PBC consortiums can work with local authorities

Where are we at with joint commissioning and pooled budgets?

Some £3.5bn has been spent in this way, be it commissioning or providing services between PCTs and local authorities (LAs), since the necessary legislation was introduced in 2000. This is according to the national register of pooled budgets (see the Department of Health and Care Services Improvement Partnership websites).

So the money involved is not small beer – and the true figure could be even higher as the register itself has not been as up to date as it could be. This was because of a problem in registering information, which has now been addressed.

41213222Such partnerships, though, have usually been between PCTs and local authorities rather than with or driven by PBC consortiums. That's because there are strategic arrangements in place for PCTs and LAs to work together – through, for example, joint strategic needs assessment (JSNA) and local joint planning such as Children and Young People Partnership Boards.

The white paper Our Health, Our Care, Our Say raised the prospect of more use of pooled budgets by PBC groups working with their PCT and LAs. This built upon the notion that GPs are on the ground and in touch with patient needs – so who better to work with the LA in developing new services?

Increasingly, with the help of PBC indicative budgets, PCTs are engaging their PBC groups to inform decisions about LA partnerships so the PCT has access to a general practice view. However, this is not a uniform approach.

So why hasn't PBC made real inroads into joint commissioning yet?

The real issue for PBC is that a lot of the models that have got off the ground haven't ventured far beyond traditional health services, management of long-term conditions and appropriate use of secondary care. Not many have focused on the commissioning of services outside hospital such as in mental health, learning disabilities, physical disabilities, substance misuse or older people's services.

It's these areas of shared care and shared clients that will be of interest to LAs. LAs won't be looking for engagement on, say, an osteoporosis pathway but they will be interested in services that help to manage patients out of hospital in the community, offer safe alternatives to hospital or nursing homes and support people and their choices for care.

What will change things?

PCTs and LAs now have a statutory requirement to produce a JSNA, which will lay out the needs of their population, as well as a local area agreement (LAA). The latter is essentially a delivery agreement between central and local government with the NHS to deliver a set of agreed local outcomes. LAAs will often cover aspirations in such areas as healthier communities, children and older people.

As JSNAs and LAAs develop, they should highlight the needs of the population and hopefully shift the focus onto the development of services in the community.

When you think about it, the NHS wants to stop people being admitted to hospital or attending A&E unnecessarily, and LAs are trying to stop people being admitted to institutions when they could be cared for in their own homes or a more homely setting.

To support people in the community requires a mixture of partnerships, not only with the PCT but also PBC groups and the third sector.

GP practices have to want to work with the local authority and move beyond their comfort zone of focusing on NHS services.

And local authorities need to understand how to engage with practices when they are used to working with the PCT or local NHS trust but not with PBC groups.

There is a huge opportunity for LAs to work with PBC clusters as the latter have a very detailed and thorough view of the local community in the same way perhaps as the LA may have thorough community profiles and breakdown on the use of its services.

At any given time, GP surgeries and LA services may be responding at the same time to the same patients – there are many opportunities where PBC clusters working with LA partners would be able to commission or provide more appropriate services for those people.

Lord Darzi's Next Stage Review talks about the need to develop metrics – pricing and payment systems – for out-of-hospital services. This will make it easier to commission such services through PBC.

Ironically LAs as commissioners are much further ahead in some areas than the NHS in knowing how to cost and measure performance of their services in the community because arranging services to care for people in the community is their core business.

And LAs have had time to develop this approach since the introduction of care management and the new role of the LA as arranger rather than simply provider of care. This began in 1993 with the introduction of the NHS & Community Care Act (which also introduced the NHS purchaser-provider split) when the LAs also took over responsibility for nursing home costs from the department of social security.

This has meant LAs have skills and experience in understanding and developing markets based on forecasting, and meeting choice based on assessment of need. They are experts in working with local costs – and now the NHS is moving in a similar direction for community-based services, especially as PCTs understand the nature of their own provider services much better. This is a prelude to many PCTs putting these services under the management of new organisations such as community foundation trusts and social enterprise organisations.

What does a PBC cluster bring to the table that a PCT doesn't?

The advantage of PBC is that one cluster might see changes could be made for patients in their area that might not apply to the group of practices in the next cluster.

Look at any community and each has its own pockets of need – it's about getting down to local decisions on how to design local services to respond to those needs.

PCTs already have LA involvement in their governance arrangements and what PCTs can do is identify areas where it would be beneficial for their LA to work with a certain cluster around shared approaches to design, commissioning and delivery of care.

What advice would you have for commissioners wanting to move down an integrated care route with their LA?

Even if a PBC group is not making overt moves to work more closely with its local authority, as PBC grows and develops more services in the community PBC groups will have to seek the views of the local authority when submitting business plans. PBC is already meant to take account of other services and involve those such as the LA in their proposals where these might impact upon their own duties.

Without this there could be a presumption that the local authority budget and model of delivery is ready, willing and able to cope and respond to more services being delivered differently outside the hospital by the NHS.

My second piece of advice would be that social services are organised around defined communities or neighbourhoods, so the PBC group should find out if it is clustered in a similar locality. Are they coterminous, or close to being so?

Local authorities are probably uncertain how to engage with clusters because they've not necessarily been encouraged to do so and might even be unsure whether they should or shouldn't.

GPs might not be used to sitting in a cluster talking about the commissioning strategy for mental health or shared older people services, even though they are often used to feeling frustrated about the lack of cohesion between health and social care.

The question is, do they want to take on some of the responsibility for improving that partnership? There's nothing to say they can't. But practice-based commissioners also have the right to opt

out of certain commissioning and pass it back to the PCT. Where this happens, clearly the PCT has to take a lead but that doesn't mean they can't still foster relationships between the PBC group and the LA.

A timely piece of advice, too, is that PCTs are now working towards deciding the location of their internal ‘provider arms'. These may separate out the provision in the community from the PCT in order to leave trusts free to concentrate on the commissioning of services. This means treating their community provider like any other provider of health services.

In this case, a decision needs to be made about the future managing organisation for community health service teams, which include health visitors and district nurses, therapies, clinics and community hospitals. LAs and PBC consortiums should think about the kinds of relationships they have with these teams and services.

Smaller provider arms may not have the critical mass to be viable on their own as separate entities. If they are subsumed into a larger organisation that cannot accommodate a diversity of geographic models or is not sufficiently locally influenced, there could be some loss to local sensitivity.

Practice-based commissioners and LAs might see that some of these services, along with social care, could be better jointly commissioned or in some instances jointly provided within an integrated care approach.

Robin Lorimer is an independent management consultant with a background in commissioning for health and social care design. He is also an associate for the Integrated Care Network at the Care Services Improvement Partnership.

How can we drive PBC to integrate with local authorities? Interview at a glance Further resources

Our town-hall jargon buster
• A 17-minute podcast of a debate on PBC is on the
CSIP website
. The discussion is between: Rod Craig, head of services for older people and adults with disabilities at Southwark Health and Social Care; Dr Nav Chana, GP and member of the National Association of Primary Care executive; and Brian Skinner, chief executive of Southampton City PCT. The discussion is facilitated by Robin Lorimer.
• Practice-based commissioning – an introduction for a local authority audience, Department of Health, October 2006

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