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How to... write a winning PBC business plan

Writing a successful practice-based commissioning business plan requires GPs to do their homework on proposals, set out costings and negotiate targets with PCTs, says Dr Mark Spencer

Writing a successful practice-based commissioning business plan requires GPs to do their homework on proposals, set out costings and negotiate targets with PCTs, says Dr Mark Spencer

The first task of any commissioning practice is to produce a business plan. Below are our tips on ensuring you get this document right.

1 Do your homework

The PBC business plan needs to include the PCT's priority areas. These can be found in the PCT's local development plan and public health report. Cross-referencing these documents from your plan is essential.

2 Engage all practice staff, clinical and administrative

We set aside protected time, holding two full away days and several Wednesday afternoon sessions. Several members of the practice had been involved with commissioning at a PCT level, so we were fortunate enough not to have to bring in external ‘experts' or facilitators for our meetings. All staff were initially updated as to the ethos and process of PBC and we then sought their ideas as to how to proceed.

3 Brainstorm which services to target

We drew up a list of possible services we felt were high priority both in terms of improving access to secondary care, such as dermatology, and the provision of new services.

We recognised, for example, that our local provider of mental health services had restricted its services only to patients with severe mental health problems, so there was an opportunity to provide mental health services ourselves.

We also drew up a list of our ‘specialist' skills, both clinical and administrative, that could be deployed under PBC.

4 Identify where possible financial savings can be made

It was clear from our assessment that savings could be made in two areas: prescribing, with expertise from a pharmacist, and reducing secondary care activity in emergency admissions and outpatients.

PCT data for 2004/5 showed that the practice was already 10 per cent below the PCT average for outpatient referrals and indeed had the lowest referral rates in the PCT. However we were confident this could be reduced further and focused on dermatology, general medicine and orthopaedics.

The PCT data also showed the practice had the lowest emergency admission rates of any practice, 12 per cent below the PCT average. Again, we were confident this could be reduced further.

From the practice, the two specialities with the highest emergency admission rates (excluding mental health) were general medicine and orthopaedics.

It was evident that within general medicine the majority of patients being admitted had a pre-existing long-term condition, particularly cardiac obstructive pulmonary disease and/or vascular disease (diabetes, ischaemic heart disease or heart failure). Most patients also had a concomitant mental illness, especially depression.

For emergency orthopaedic admissions, it was clear that a significant number of patients were being admitted with osteoporotic fractures.

We estimated we could reduce out-patient activity by about 10 per cent and unscheduled admissions by about 5 per cent, which would give an overall saving on secondary care spend in the region of £170,000.

5 Draw up service development plans and costings

We decided to develop and provide the following services:

• GPSI dermatology clinic. We were fortunate to have the skills within the practice of a GP with previous staff grade experience in dermatology. He was successful in becoming a PCT accredited GPSI so we could pursue an in-house dermatology clinic.

• Primary care chronic pain clinic (aimed at reducing orthopaedic referrals). We believed alternative therapies to medication, such as acupuncture, in-house physiotherapy and TENS machines, could improve pain management.

• Primary care mental health service. Plans included using mental health nurses as an alternative to antidepressants.

• Case management of complex patients. Targeting the 30 patients with the highest emergency admission rates.

• Osteoporosis and falls management strategy (aimed at reducing fractures).

We felt that by implementing NICE guidelines for osteoporosis and linking this to a falls assessment we could reduce fracture rates.

• Enhanced service for patients with diabetes, heart disease and COPD. We wanted to optimise the management of patients with these conditions within nurse-led clinics, attending to both their physical and mental health, as well as improving medicines management through drug-specific protocols to ensure evidence-based and cost-effective medicines and rationalising the prescribing for patients on multiple medicines.

Each service was fully costed (see right) and service delivery plans were discussed and agreed with the PCT.

6 Compile the right data to support your case

Ensure IT systems are in place to record secondary care activity in order to validate hospital-generated activity.

7 Build start-up and continuing management costs into the plan

Be realistic about the time commitment of management staff and clinicians. Include educational activity and attendance at recognised PBC courses. Set aside protected time for regular practice PBC meetings and update sessions for staff.

8 Agree targets

Agree with the PCT what targets should be set and how money will be released once savings have been generated and confirmed.

Our targets included making financial savings against the prescribing budget. These were easy to identify on an ongoing basis throughout the financial year from PPA data. This allowed savings to be reinvested by about November-December within the financial year.

We also agreed targets for a reduction in secondary care activity. This was much more problematic as we had to wait until the end of the financial year before any reductions could be confirmed. The savings have been added on to this year's PBC budget.

The targets were all agreed via protracted negotiations with PCT managers.

9 Write the business plan in the type of language that is understood by PCT managers

The PCT may well have a set format or template for production of the plan and I would encourage GPs to stick to it.

10 Communicate the plan

Ensure that you maintain communication about the business plan across all members of the practice team. Also ensure regular communication with other practice managers and with PCT managers.

Dr Mark Spencer is a full-time GP and practice lead for service development and finance at the Mount View Practice in Fleetwood, Lancashire. For further details, contact

Mount View Practice: our background and successes so far

• In 2005/6, the Mount View Practice embarked on practice-based commissioning (PBC) as an individual practice with the full support of Wyre PCT.

• Mount View is a PMS practice in Fleetwood, Lancashire with a list of 13,000 patients, seven GPs and an assortment of healthcare professionals including nurses, a pharmacist and a mental health team.

• Fleetwood is an area of high deprivation with a life expectancy in males of only 67 years. There is a high prevalence of long-term conditions such as vascular disease, chronic respiratory disease, substance misuse and mental illness.

• As soon as the initial Department of Health guidance on PBC was published in the autumn of 2004, we realised the opportunities it had to offer and submitted an expression of interest to the PCT.

• Since then all members of the practice have been involved in the drawing up and implementation of our PBC strategy. The PCT nominated Mount View – the only commissioning practice in the PCT – as a pathfinder practice.

• This means we are used as a pilot site to explore various strategies and the effect they have on the utilisation of secondary care. This allows the PCT to make predictions of activity and spend across its whole area.

• We have worked jointly to ensure that a common sense approach has been adopted to data collection, service developments and financial flows.

• We had a very successful first year as a PBC practice. We reduced outpatient referrals in dermatology and general medicine by more than 30 per cent and in orthopaedics by 15 per cent. We have reduced fracture admissions by 11 per cent and acute medical admissions by 3 per cent.

We also reduced our prescribing spend by 8 per cent, thanks to the work of our pharmacist. Our overall savings would have been greater if we had not made a conscious decision to reinvest about £190,000 into the increased use of medicines for heart failure, COPD and osteoporosis, in order to implement local and NICE guidelines. Our net prescribing savings totalled £185,000.

• Overall we reduced our spend in 2005/6 by more than £500,000, compared with 2004/5. The PCT has allowed investment in the region of £250,000 in the services highlighted in section 5.

• We are very proud of Mount View's achievements, especially with being recognised nationally as winners of the 2006 NHS Alliance Acorn Award for Practice-Based Commissioning.

Mount View Practice's business case

1 0.6 whole-time equivalent (WTE) pharmacist £30,000 a year

To allow more pharmacist input into the management of patients with long-term conditions as well as managing the prescribing spend.

2 One WTE G-grade mental health nurse £35,000 a year

Part of the continuing development of a practice-based primary care mental health team.

3 One WTE mental health worker (counsellor) £22,000 a year

As above. Not only improves the quality of care for patients with anxiety and depression but also improves access to routine GP appointments.

4 Practice medical adviser £9,000 a year

The appointment of an independent medical adviser to the GPs and other healthcare professionals within the practice will assist with implementation of referral and prescribing protocols as well as analysis of emergency admission data.

5 GPSI dermatology clinic

£25,000 per year

An in-house service, with a proposed roll-out to other practices.

6 Enhanced service for patients with chronic pain £45,000 a year

A multidisciplinary in-house service with the aim of reducing prescribing spend and orthopaedic referrals.

7 One WTE G grade community nurse £35,000 per year

To work with the primary healthcare team and the PCT-employed community matron and focus upon the provision of care for housebound patients with long-term conditions, with the aim of improving quality of life of patients as well as reducing unnecessary emergency admissions.

8 Admin/IT costs £30,000 a year

Ongoing funding for GP time, practice manager time and admin/data analysis time (PCT previously provided initial start-up costs of £15,000).

9 Practice PBC education and training

£4,500 To allow continuing education and training specifically focused on PBC.

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