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Making the most of practice-based commissioning

Dr Sohail Butt thinks PBC is key to the development of practices over the next few years – in the fifth in his series on the business of general practice he explains why

Dr Sohail Butt thinks PBC is key to the development of practices over the next few years – in the fifth in his series on the business of general practice he explains why

Many GPs have felt little inclination to get involved with practice-based commissioning (PBC). This reluctance stems from increasing clinical and management workload, disillusionment with change for change's sake, and lack of support for PBC from PCTs.

However, PBC may represent the only way for us to develop our practices during the next few years. Here are some points to think about.

Why bother with PBC this year?

It is an opportunity – perhaps the only one – to develop our practices as providers in the short and medium term and so improve services for our patients.

If we do not keep to budgets, redesign services and provide them effectively, we may leave the door open for private companies to move in on us. In time they may take away our core GP work.If there are any savings, you should be allowed to keep 70% to invest in local healthcare services. Your PCT should be offering you an incentive scheme which is equivalent to last year's DES of £1.90 a patient.

Why have a PBC group of practices?

It allows you more clout when it comes to negotiating better deals with the PCT and hospitals on support, budgets and contracts

You can fund clinicians for their essential input and a manager to do the essential management work.

Larger populations – that is 100,000 plus – allow you to provide many current hospital services in primary care in a more cost-effective way. Pooling where appropriate allows you to share risks for expensive care.You can share and reduce the essential clinical management and leadership work and so maintain maximum clinical sessions.

What could a strategic plan look like for a PBC consortium or company?

  • Year 1 – Set up group, employ management staff; cement agreements between group, practices and PCT; set up appropriate incentives, set up a limited company; agree ways of working; service redesign; generate savings
  • Year 2 – Implement the above
  • Years 3 and 4 – Consolidate and improve on year two performance and expand into other areas of patient need
  • Year 5 – Consider merger with another consortium or corporate provider

How big a PBC group should we be?

Up to 120,000 patients based around a hospital or geographical area seems to be viable for the following reasons:

1) Similar numbers are working well in various areas of England

2) Being able to travel and meet colleagues easily is very important

3) The possibility of using an old DGH is an advantage for siting GP-led outpatients work and community acute beds.

Which structure is right for our PBC group?

Informal groups and consortium arrangements are fine initially. These are easy to set up by local agreements, cheaper to run and have less administrative problems. You can use existing practice and PCT staff and structures to support you to keep costs down.

As the group develops and starts providing services, you may consider a more formal structure such as a community interest company or a company limited by shares.

Another option which is attractive and increasingly talked about is forming a company with each GP, practice manager, PBC managers and practice nurses being offered the opportunity to hold an equity stake. The advantages of this include:

  • Gets all staff to commit to the group
  • Wide involvement of all staff
  • Provides incentives to staff to make the company succeed
  • Generates capital for start-up costs
  • Allows you to employ and motivate people you need to do the job
  • Provides a formal structure for decision making
  • Allows you to limit your financial liability – so little risk

The disadvantages include:

  • Costs to set up company
  • Work associated with company
  • Liability for directors
  • Some people may not feel comfortable with it

What agreements do we need to get PBC going?

You need to develop or adapt three written agreements:

1) A business plan of how you will achieve the strategic plan, including clinician, management and admin support provision

2) An inter-practice agreement, setting out how the group is run and by whom

3) An agreement between the group and the PCT on how you will work together and finance/budget issues and payments.

What sort of things should we do initially?

It is always a good thing get some early wins under your belt to get everyone on side. Things you should address include outpatient referrals and relocating outpatients to primary care.

Outpatient referrals encourage GPs to look at each others' referrals in the major referral areas. They are a powerful tool for learning and reducing referral rates.

Relocating outpatients to primary care is also important and the following specialties are the top service design priorities for most GPs (it may be worth aiming for three to four in your first year): dermatology, diabetes, musculoskeletal, rheumatology, orthopaedics, opthalmology, cardiology, ENT.

Is there a problem with conflict of interest?

You should:

  • Declare interests
  • Have transparency of decision making, meetings, minutes and documents
  • Have clear governance rules
  • Have separate provider structures from commissioning structures

Where should we be now?

Much depends on your PCT. According to the Department of Health guidelines on PBC you should have received by now:

  • An indicative budget
  • Benchmarked activity data
  • An agreed local incentive scheme
  • Management support from the PCT

However, we are now three months into the financial year and many GPs have not received this information. This is due to the difficulties that many PCTs face through the reorganisation that occurred in October 2006.

If your PCT is not complying with the guidelines, you can discuss this with them and try to agree a timetable of action. If you are failing to progress, ask for help from your LMC or the strategic health authority.

PBC offers GPs an opportunity to lead on decisions on local health services, and provide new and better services for patients. In an uncertain primary care market, with reduced NHS income for most practices, it offers opportunities for practice development, improved patient care and additional income streams.

Dr Sohail Butt is a GP and managing partner in Ashford, Middlesex

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