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Make a success of practice-based commissioning

Practices are entitled to hold an indicative budget which represents the costs of their patients' usage of secondary care services. If this is not being provided routinely, practices should ask for it. Under Payment by Results, secondary care is paid for every patient referred or admitted under a national tariff.

Payment for engagement in PBC can be obtained by signing up for a directed enhanced service (DES) for which two payments per head of patient are available – 95p for agreeing a plan and 95p on delivery of the plan.

More enterprising PCTs and practices have agreed local enhanced schemes (LES) where practices receive a percentage of savings made on their budgets. Innovative practices and PCTs have introduced alternatives to traditional referrals to secondary care which can reduce spending on referrals to hospital and on emergency admissions.

Emergency admissions to hospital are very expensive and are likely to be the most productive source of potential savings.

Steps to success

1 Ask for your budget and for a meeting with the PCT to help you understand it.

2 Find out the tariff prices for conditions where a change in your management might be possible. This will enable you to project potential savings.

3 Draw up an agreement with the PCT as to the share of any saving you will receive and ensure that this is guaranteed regardless of other PCT priorities.

4 Ask your PCT whether it can highlight areas for which you are admitting or referring more patients than peer practices locally.

5 Ask the PCT and other practices whether there have been successful schemes locally that have reduced admissions or referrals and how they work.

6 Look for easy wins. Protocol-driven nurse-led DVT clinics have saved substantial amounts in some PCT areas. Specialist physiotherapists triaging hip, knee or back referrals to secondary care can significantly reduce referrals to orthopaedics at a much lower cost than outpatient referrals.

7 Ask yourself whether, given extra resources, some patients who are currently admitted to hospital could be looked after at home. Would your PCT be willing to invest in enhanced district nursing hours and skills to facilitate this?

8 Try to identify patients who are at increased risk of admission and make plans to reduce the risk. For example, COPD patients can be taught to ask for antibiotics and steroids as soon as they develop warning signs of infection. Refer older patients for a multidisciplinary falls assessment after any fall or if you become aware of gait or balance problems.

9 Consider meeting your partners to review referrals/admissions in a non-threatening way. Learn from ways in which your partners might have behaved differently.

In summary: open discussions with your PCT and agree a guaranteed share of savings. In addition, learn from other successful schemes, compare yourselves with peers and look for easy wins.Dr Phil Taylor is a GP in Axminster, Devon

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