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How to win approval for your PBC business case

A range of experts share their lessons from experience on what makes a PBC proposal more likely to gain approval and funding

A range of experts share their lessons from experience on what makes a PBC proposal more likely to gain approval and funding

1. ‘ADDRESS QUALITY AND CLINICAL GOVERNANCE ISSUES'

Dr Peter Reader, GP and medical director of Islington PCT

My main priority is to ensure business plans duly take account of clinical governance and quality issues.

I think it's easy for GPs, because of the nature of how we just deal with what walks in the door, to take the approach of ‘I'm pretty good at hypertension, I think I could manage a few more patients who are difficult for other practitioners to manage'.

Instead we should stand back and take a more robust look at the qualifications, mentoring and education required to support the person delivering the new service, and the impact and risks within the practice of developing that service.

So GPs need to consider a few key points. Are the rooms in their practice really up to spec? Is the waiting room going to be big enough?

How will they manage patients who are not going to be seen because Dr Smith is now doing the new clinic? Does the practice location suit neighbouring practices that will refer to the new service?

GPs should read the new national GPSI guidance, which is very helpful, but also be aware of the challenges in putting it into practice, such as acute trusts becoming increasingly reluctant to be putting time into validating GPSIs who're going to be stealing their work.

Another challenge for GPs is to look beyond quick wins such as becoming a dermatology or ENT GPSI, and consider other patient pathways and larger sections of care, perhaps involving transfer of staff.

However, the challenge is that hospitals are very well set up around clinical governance and audit procedures whereas primary care is just not as well served, so some specialists may be reluctant to move out into the community because of concerns about isolation compared with support they've had in secondary care.

The quality of business plans is variable. Some people who have had experience of fundholding are often better at it, but not exclusively.

Overall, there's a big skills, time and management gap. Most PCTs have commissioning staff who are now supporting practices in doing PBC but that's very different to actually having PBC-employed managers working full-time in practices, who could provide expertise.

2 ‘USE PRO-FORMA BUSINESS PLANS TO COVER ALL THE BASES'

Dr Ranjit Gill, GP and chair of Stockport Managed Care Commissioning Company, which approves some business cases on behalf of Stockport PCT

We supply GPs with pro-forma business plans, and the content depends on the amount of money being bid for – if it's less than £50,000, the requirements are less onerous; if it's between £50,000 and £250,000, slightly more onerous; beyond £250,000 requires a full business case.

The fundamental tenets are as follows:

• Describe what the need is that the business case is trying to address, and ensure that need is within the PCT's overall business plan. PCTs use different language for their own business plans – some call them a financial plan, a strategic plan or an LDP – but whatever the terminology your PCT uses, you should ensure at the outset you say that this is the need, and that it is consistent with the PCT's need.

• Describe exactly what it is you're proposing to do in as fine a detail as you can, with associated costs attached.

You might want to refer to national pay rates and bandings for nurses, healthcare assistants and other staff who will help deliver the service, and define the skills required to deliver that service.

You also need to work out how much you pay the average GP (to provide a new service), which may be locally determined, then work out what equipment costs you need, looking at whether there's any national standard or guidance on equipment that should be used.

• Set out the alternatives – are there other ways of skinning the same cat?

• Carry out a risk assessment – what are the risks of the project going wrong? What are you going to do to mitigate that risk?

• Describe how your idea fits with the wider picture and its consequences on associated or linked services, such as social services, and how you're going to liaise with them – this is more formally known as an ‘impact assessment'.

• Say what evaluation criteria you will use to prove how you will know that what you're doing is going to deliver on what you say it's going to deliver on. So you might say: ‘We'll know we've succeeded because fewer patients will go to hospital, more patients will be seen at the surgery or more will be seen faster, cheaper or quicker.'

3 ‘PRESS YOUR PCT TO RESPOND TO YOUR PLAN QUICKLY'

Dr James Kingsland, GP and chair of the National Association of Primary Care

Any service redesign you aspire to do through PBC has absolutely got to have clear clinical and corporate governance arrangements within it, to show there's evidence behind why you want to do the work, you've assessed where it is at the moment and what it costs, and that the redesign is consistent with modern, authoritative opinion – rather than a process that just says ‘trust me, I'm a doctor' or ‘I don't like this service' or ‘this doesn't seem to be working very well'.

You also need to assess the risks of that redesign, how they compare with current risks and what will happen if things don't go wrong, in terms of health outcomes or cost efficiency.

That's what any PCT would want to see and having seen it, should find it very difficult to turn down.

However, what we are finding is that too many or most PCTs do not assess business cases in a reasonable amount of time.

Original DH guidance made it clear it should be in eight weeks, and we know that work in 2006 by the prime minister's delivery unit on why PBC was faltering found that PCTs should be able to assess and reply to a business case within four weeks.

There's no excuse for any world-class commissioning or aspiring PCT not to have systems in place to receive, assess and report back to the applicant in four weeks.

That's a vital part of PBC development. GPs should send their business cases by registered post with a note saying: ‘We respectfully remind the PCT that we expect a reply to this business case, posted on (date), within 28 days. If you are unable to meet that, please let us know within a week.'
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4 ‘FIND OUT IF THE PCT IS FUNDING A BARGAIN BASEMENT OR ROLLS ROYCE SERVICE'

Dr Michael Dixon, GP and chair of the NHS Alliance

My first suggestion would be to make sure it looks professional, rather than something that has been written on the back of an envelope.

It's also very important to find out the level of funding available from your PCT. Are they looking to fund a bargain basement, cheap and cheerful service, or a Rolls Royce service? If your PCT has a fairly tight budget, you should show that the scheme can finance itself within a given time-frame.

You need to show buy-in, both from your peer group, and patients. If you are setting up a new practice-based GPSI service, will neighbouring practices be likely to refer to it, and will patients want to use it?

You must be aware of your PCT's local plans – there's no point bidding for service X if the PCT's priorities are service Y.

5 ‘KEEP YOUR SUMMARY TO JUST ONE SIDE OF A4'

Dr Peter Weaving, GP and locality lead for Cumbria PCT

In our area, which is fortunate to have seed funding for projects available, there are very basic requirements for business plans.

GPs need to target plans to where there's an area of need – so for example, at the moment our PCT is big on sexual health services.

They also need to consider things that are simple, and that are going to be sustainable in the long term.

The boxes we want GPs to tick are that it provides better and more convenient care, literally closer to home for the patient, and is cheaper than what's currently provided.

It's also good to provide a succinct summary, backed up by supporting information in more detail that can be looked into when needed. Personally, what holds my attention is a half-A4 summary – but what we normally say within the PCT is ‘I want to see that on one side of A4'.

DH GUIDANCE ON PBC BUSINESS CASES

PBC business cases should cover:
• service to be provided
• benefits for patients
• expected improvements in efficiency and effectiveness
• management resources required
• costs of the proposals and their recovery period

PCT criteria for assessing business cases should include:
• evidence-based clinical effectiveness
• clinical safety, quality and governance
• a contribution to offering care closer to home and delivery of the national 18-week referral-to-treatment target
• whether the specific needs of population groups such as disabled people (including those with learning difficulties or mental health needs), people in black and minority ethnic communities, the differing needs of men and women and of the diverse age groups, different faiths and sexual orientation of individuals and groups accessing services have been taken into account
• patient and stakeholder support
• justification/evidence that resources can be released through the substitution of care
• affordability within the current and projected indicative budgets
• consideration of whether formal tendering is required, which it is envisaged will be infrequent
• assessment of the risks of the development
• the procurement route
• value for money, including using benchmarked costs to determine a reasonable price range for services

The approvals process
• PCTs should take a more proportionate attitude to risk when deciding to approve business cases, according to Mark Britnell, DH director general of commissioning and system management
• Business plans should be approved by a PCT committee or subcommittee chaired by a non-executive director, although small plans may be approved more informally under local arrangements sanctioned by an executive director
• GPs must exclude themselves from decision-making on any PBC business cases in which they have an interest or with which they are associated
• PCTs should aim to approve PBC business cases within four weeks and no later than eight weeks

For more details see Practice-based commissioning: practical implementation at The Department of Health's website - www.dh.gov.uk

DH guidance on PCTs own business plans How to win the stamp of approval

GPs need to consider things that are simple and that are going to be sustainable in the long-term.

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