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How to choose which PBC projects to pursue

Sorting the wheat from the chaff can be difficult when it comes to prioritising PBC ideas – but help is at hand, as Dr Richard Jenkins explains.

Sorting the wheat from the chaff can be difficult when it comes to prioritising PBC ideas – but help is at hand, as Dr Richard Jenkins explains.

Practice-based commissioners play a key role in implementing the Care Closer to Home agenda. The potential pay-off is huge – million of pounds nationally will be saved if half of surgical follow-ups, rehabilitation stays and emergency admissions are shifted into community or primary care settings, or avoided in the first place.

The dilemma for PCTs and PBC consortiums is deciding which of the many ideas on transferring secondary care activity merit full-blown business proposals and implementation. In an effort to find a solution, the NHS Institute for Innovation and Improvement has worked with two healthcare communities to test out two new web-based tools that aim to sort the wheat from the chaff.

The Opportunity Locator allows users to analyse the local ‘shift potential' of services to be moved closer to the community. It uses national data to show how much care the PCT is commissioning predominantly in an acute setting that could be delivered in a community setting, in terms of both numbers of patients and financial cost.

The other tool, the Priority Selector, is a decision support process, which provides a means of forming a long list of initiatives into a locally agreed, prioritised list for taking forward as a commissioning proposal.

Each tool can be used separately but they are best used together as a strategic planning process. PCTs are now being actively encouraged to use this process and invite practice-based commissioners and clinical representatives to join them on this work. PBC groups can also use the tools themselves. A password is needed for some of the functionality on the tools, and should be available from your PCT's commissioning director.

Build a core local team

During testing, we found there is an ideal size and composition of the local core team who should be involved in using the tools: 18-24 members, split into roughly equal numbers of PCT executive, PBC and PEC representatives. Preferably there should be more clinicians than managers overall. However, resources and levels of commitment will vary so the composition can be adapted to your local requirements.

Whatever the make-up, it is important to have a co-ordinating administrator to look after the process, organise the meetings and workshops and provide the necessary material and data. PBC groups may already have this function in house or request their PCT to provide this.

Outside this core team, it is useful to have a supporting team of local stakeholders, such as patient representatives, the local authority and the acute trust, which can be called upon as needed for local input and knowledge to support broader engagement.

Put in the legwork

Between two and four days in total are needed over a six- to eight-week period to work through the tools. Although this seems a large commitment, if done well, this process need happen only once a year and will lead to a robust list of improvement initiatives for your locality. The process is broken down into four stages:

1 Gather insights

This stage involves using the Opportunity Locator and other relevant data sources to provide a basis for identifying opportunities. To reduce the commitment of PBC clinicians, the administrative co-ordinator should be able to source initial data within a day or two and distribute to the core team members.

2. Identify initiatives

This stage starts with a workshop for the core team to agree key areas of opportunity using the insights and data supplied from stage one. Over the next two weeks, the team members then develop a long list of initiatives, each of which includes a one- or two-sentence description to inform other members.

3 Prioritise projects

This stage also starts with a workshop, to validate the long list of initiatives developed from stage two. Over the following one or two weeks, the team members use the Priority Selector to individually score the initiatives by answering 20 questions

All the number crunching is automatically done by the tool and results are plotted onto a priority map. Another workshop closes this stage and here the scored list is reviewed and agreed.

4 Develop proposal

This stage starts with a workshop where the agreed list is developed into an agreed project portfolio. The final considerations of local capability and capacity to deliver the projects are incorporated, and over the following one or two weeks everything is written up as an agreed commissioning proposal.

Ingredients for success

The two sites involved in piloting this initiative successfully prioritised their projects to support Care Closer to Home. Oldham, for example, started with about 60 projects and ended with 15, which they further split into five projects over three waves (see case study above).

The main challenges both pilot sites experienced were around the core team. They both found that a mix of clinical, managerial and commissioning members was important for success and that the team needed to stick with the same members from the start of the process to the end for a successful outcome.

The tools are available free, along with other advice and products at the NHS Institute for Innovation and Improvement

Dr Richard Jenkins is a GP in Staffordshire and an associate (care outside hospital) at the NHS Institute for Innovation and Improvement

Dr Richard Jenkins the dilemma for commissioners is which of the many options merits a business proposal and implementation

The dilemma for commissioners is which of the many options merits a business proposal and implementation

one of the pilot sites started with a list of 60 projects and ended up with 15 by using the new tool one of the pilot sites started with a list of

one of the pilot sites started with a list of 60 projects and ended up with 15 by using the new tool

how projects are ranked how projects are ranked

The Priority Selector tool prompts users to score a potential initiative by answering 10 questions on its importance and 10 questions on its achievability, and giving a score on a 1-10 scale. Results are then number-crunched by the software.

Questions on importance include:
• To what extent would the initiative improve convenience and ease of access for users of the affected service?
• To what extent would the initiative contribute to reducing health inequalities in the area?
• To what extent would the initiative enhance the implementation of clinical practices designed to improve quality of life (such as admission avoidance or case management)?
• To what extent would the initiative
enable the achievement of evidence-based improvements in health outcomes?
• To what extent would the initiative address the key national priorities
set out in the Operating Framework and
in the Department of Health's reform agenda?

Questions on do-ability include:
• What is the likely reaction of local patient groups and politicians to the initiative?
• To what extent would the initiative require the current workforce to be redeployed?
• To what extent are any new or additional skills that are required for the initiative scarce or reliant on long-term training once staff have been appointed?
• Is there a provider capable of delivering the service required in this initiative?
• Would this initiative require additional financial investment?

Dr Hugh Sturgess Case Study: ‘Without it we would be drowning'

Dr Hugh Sturgess, a GP in Oldham, Lancashire, says the four half-day group sessions and the time individually spent scoring projects was time well spent.

As chair of Commissioning for Oldham, the area's single PBC group, he helped pilot and refine the Opportunity Locator and Priority Selector web-based tools developed by the NHS Institute for Innovation and Improvement. ‘Within the mire of all the things we'd like to do, if you don't use a prioritisation tool, you won't actually get onto doing any of the things you need to do. Without it we'd be drowning under 50 or 60 potential projects."

The process helped slim down his area's list into 15 projects, split into three tranches of five, to pursue by April 2009.

‘First, it gelled thinking among local commissioning GPs and the PCT into how we would get together all the information we required to then decide a way forward,' he says.

‘As we went through the process, one of the greatest benefits was that the partnership working between the PCT and commissioning GPs was hugely strengthened through our shared understanding of issues and needs. The PCT came to understand what data requirements we had and we similarly developed an understanding of the pressures the PCT was under. We not only gained insights into our local practices and localities but also how we fitted into the bigger picture across the PCT and borough.'

The top priorities agreed as a result of the process include plans to:
• attach a primary care assessment unit to A&E
• create a fully integrated community diabetes service that will handle all outpatient activity currently undertaken in hospitals
• set up a COPD service offering pulmonary rehabilitation in the community instead of hospital, as well as interventions aimed at preventing patients with acute exacerbations being admitted to hospital.

Dr Sturgess notes that a group ‘moderation exercise' was held to slightly tinker with the results, to ensure a human understanding of local needs could be applied where the prioritisation tool seemed to be too mechanistic.

Oldham PCT has decided to use the process generally for all commissioning priorities, not just Care Closer to Home projects. ‘A significant proportion of commissioning projects are Care Closer to Home, but some will be health promotion and disease prevention activities and they have all got to link together.'

Santhi Rajagopal, lead service improvement partner at Oldham PCT, says: ‘It's been a fantastic opportunity to work in a structured manner to redesign the way services are delivered in the NHS. Patients will benefit from this approach because it will be clearly linked to their health needs and the way they want their care delivered.

I'm looking forward to using these products while commissioning new services – not just for one or two projects – so we can fully reap the rewards of these commissioning tools.'

Dr Richard Jenkins

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