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How will your PCT measure up as a world-class commissioner?

PCTs face new checks on their commissioning abilities – including their support for PBC – under an assurance system launched last month. Practical Commissioning quizzed Dr David Jenner on what it all means for GPs. See how PCT performance will be measured in the factfile at the bottom of the article.

PCTs face new checks on their commissioning abilities – including their support for PBC – under an assurance system launched last month. Practical Commissioning quizzed Dr David Jenner on what it all means for GPs. See how PCT performance will be measured in the factfile at the bottom of the article.

Last month the Department of Health unveiled details of exactly how PCTs will be assessed as ‘world-class commissioners'.

Starting from this autumn, the SHA-led assurance system will measure performance in three areas – health outcomes, competencies and governance. Assessments will be undertaken through a mixture of PCT self-assessment feedback from local partners such as practice-based commissioners, and ultimately, an annual interrogation of PCTs by a review panel.

This will lead to a scorecard, giving regional and national rankings, although league tables will not be made public until the second year of the system, in 2009/10.

Why should practice-based commissioners and other GPs be aware of the new world-class commissioning (WCC) assurance system?

WCC is basically a huge fitness-for-purpose exercise for commissioning and it places clinical leadership right at the heart of that.

Shortly after the original WCC document was published in December, I did wonder whether WCC was designed to replace PBC. But now we've had the message about PBC reinforced by the final Darzi report (High Quality Care For All, published on 30 June) we can see that WCC is in fact a way of holding PCTs to account for enabling PBC to happen.

If you look at paragraph 27, page 53 of the Darzi report, it states that the assurance system will draw on evidence ‘including a feedback survey from clinicians, the quarterly PBC survey and PBC governance arrangements'.

Paragraph 29, on page 65, also says:

‘We will ensure that PCTs are held fully to account for the quality of their support for PBC, including the management support given to PBC groups and the quality and timeliness of data (for example on budgets, referrals and hospital activity).'

Will practice-based commissioners have any role in assessing PCTs?

They are named, in the WCC assurance handbook, as one of the potential partners, along with other local organisations and people in the commissioning game, who should give 360° appraisal of PCTs.

The NHS Alliance has proposed to the Department of Health that PBC consortium leads should be a mandatory partner because at present their involvement is only optional.

I think there would have to be very good reasons why consortium leads were not named as partners, and if they're not involved, it should prompt the SHA to ask why.

There is a huge danger that PCTs will choose to do their self-assessments without involving PBC consortiums because of the time pressures on implementing this system in the first year.

So I believe PBC consortiums need to be on the front foot and start approaching their PCT and asking how they are going to involve GPs in their self-assessment process.

Is the assurance framework measuring the right things?

It's nice to see the emphasis on quality and outcomes in WCC. Health outcomes are definitely what we want to measure, and the mixture of some national, and some locally chosen, makes very good sense.

Is it right that the first year's results won't be made public?

That information would probably be available under the Freedom of Information Act anyway. But maybe it's right to get people to be honest in year one so they're not asked to write their own death certificate.

How do you think most PCTs will be ranked in the first year?

I know of no PCTs that are world class – these are challenging targets. I think it is expected that the vast majority of PCTs will be at levels one or two [four being the highest level].

Wouldn't it have been better to get a watchdog-style body – in the same way as foundation trusts answer to the regulator Monitor – to run the assurance system?

I think there are dangers in moving too fast to that. The Healthcare Commission is in its sunset era, the Care Quality Commission is just coming in. The danger with external regulation is that organisations spend their time ticking boxes, not doing the work.

We know there will be an independent organisation on the panel assessing PCTs – probably someone from McKinsey or Humana [which is part of a consortium of private firms that have won a Department of Health contract to provide consultancy for the implementation of the assurance system].

Ultimately, do you think this assurance system will improve support for PBC?

Yes, I think there is a very good chance.

However I think there is a danger, given that SHAs are the key assurance bodies for WCC, that there are still some SHAs who are complicit with PCTs in not believing in PBC and who display a whole central command and control culture, by setting, for example, a range of ‘local' targets that go beyond national ones and are not fully owned by the front line.

There has been a lot of talk about reforms being locally led and clinically driven – yet it often seems that locally led means ‘at SHA level' and clinically driven means ‘hand-picked members of PECs and medical directors'.

So I think it will need strong leadership from the DH and ministers, and I don't doubt the ministerial commitment to PBC.

Are practice-based commissioners strong enough to influence the WCC agenda?

There's still an each-way bet on whether practices will rise to the challenge of PBC.

If GPs don't the FESC contractors [the private companies pre-approved by the DH to advise PCTs on commissioning] introduced under WCC are waiting in the wings.

I think practices have to choose between being primary care providers or wanting to influence commissioning. If they want to be only providers, they will have to influence through third-sector organisations.

FESC contractors will commission for profit whereas practice-based commissioners cannot. So GPs will have to decide whether this is the best use of local resources.

What's encouraging is that we know from latest surveys that nearly 70% of practices still support the concept of PBC.

Dr David Jenner is NHS Alliance lead for PBC and a GP in Cullompton, Devon

How the world-class commissioning assurance system will work

PCT performance will be measured in three areas:



Each PCT's ability to improve the health and wellbeing of the local population will be measured through:
• two nationally set indicators – life expectancy and health inequalities
• up to eight locally set indicators, which must be agreed with patients, doctors and other community partners.

Scoring will recognise that improvements take time, so the focus will be on why the local priorities were chosen and how results will be produced. Scorecards will show current performance and improvements against SHA and national averages based on Office of National Statistics data. PCTs will also receive performance figures adjusted for local health deprivation.



PCTs were set 11 organisational world-class commissioning competencies in December 2007:

1 locally lead the NHS
2 work with community partners
3 engage with public and patients
4 collaborate with clinicians
5 manage knowledge and assess needs
6 prioritise investment
7 stimulate the market
8 promote improvement and innovation
9 secure procurement skills
10 manage the local health system
11 make sound financial investments.

Performance on the first 10 will be measured under the competencies section of the assurance system; the 11th will be measured under the governance section. Three indicators apply to each competency, so on number four, a PCT would be measured on ‘clinical engagement', dissemination of information to support clinical decision-making' and ‘reputation as leader of clinical engagement'.

PCTs will self-assess from level one to four (with four being best) whether they meet the criteria. They must meet all three criteria at one level before moving up the competency ranking a level. The final ranking for each competency will be determined by the review panel, taking into account other evidence (such as a new PCT feedback survey).

Respondents must come from three groups: partners (such as practice-based commissioners, the SHA, local government, or patient groups), providers and opinion formers (such as the local press).



PCT governance will be measured by assessing three areas: strategy, finance and board. This will cover the PCT's five-year vision and objectives, long- and short-term financial planning and management, and organisational culture, structures and risk management.

PCTs will receive a green, amber or red (the worst) rating for each of the three areas. PCTs will be asked to self-certify their ‘board' ratings but final decisions will be made by the review panel. Governance ratings will be informed by scores PCTs receive separately from the Audit Commission and the Healthcare Commission.



As well as ratings on the outcomes, competencies and governance, the final scorecard will include a ‘potential for improvement' commentary.



• End of October: final deadline for PCT submission of self-assessments, documents and survey results.
• An SHA analyst prepares a briefing document in advance for the review panel, based on the PCT's submission and SHA insight. It should give the PCT's benchmarked position and suggested questions for the panel review days.
• November/December: panel review days take place where PCT board members are quizzed on their performance.
• PCT receives final scorecard and a final meeting takes place between the SHA and PCT to agree actions, and any incentives or sanctions against the PCT.
• February (from 2009/10): national ratings published.



The review panels that will assess performance must be made up of:
• SHA (a director from local SHA)
• clinician (a PEC chair or medical director, from another PCT)
• local government (a director of adult or children's services from another PCT area)
• independent expert (executive director from an international organisation or another industry)
• PCT (a PCT chief executive from another SHA area).



Top-performing PCTs will achieve ‘world-class PCT' status and get ‘a package of complementary incentives'.

Top-performing means:
• at least half of the outcomes showing above-average rates of improvement compared to the national average; and
• level three in all competencies, with at least half of them also rated at level four; and
• green in all three areas of governance; and
• an overall positive commentary on potential for improvement.

PCTs that cause concern will be required to take remedial action set by the SHA. If they persistently fail, the NHS chief executive will deem the PCT ‘challenged' and can sack the PCT board, bring in new staff and initiate a turnaround plan.


How will your PCT measure up as a world class commissioner? Dr David Jenner - clinical leadership is at the heart of WCC

PBC consortiums need to be on the front foot and ask PCTs how they will involve GPs in the process of self-assessment

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