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GPs buried under trusts' workload dump

Top tips for PBC in the credit crunch

As the pressure grows for PBC to help the NHS cope with increasing financial constraints, we asked experts for their advice.

As the pressure grows for PBC to help the NHS cope with increasing financial constraints, we asked experts for their advice.

1 Think big to prove outcomes

The volatility of health budgets means you have to have a large enough population to demonstrate outcomes, according to Dr Rodney Jones, a statistical adviser at Healthcare Analysis and Forecasting who has had several papers on PBC published in peer-reviewed journals.

‘GPs know that with a drug trial you have to have a certain size to demonstrate the positive – too small a sample and the randomness of the patients overwhelms your ability to ascertain anything. And it's the same with money; you have to have a large sample size to show you've saved anything and that it isn't the result of chance.'

In a recent study, Dr Jones showed how volatility increases exponentially as you go below a population of 100,000.

‘A practice might achieve savings by doing nothing and a practice down the road might be doing great stuff but by chance makes a horrendous loss. To buffer that volatility I really think you need PBC groups that have more than 100,000 patients.'

Dr Johnny Marshall, chair of the National Association for Primary Care, agrees size does matter. ‘With a population of 100,000 you can manage pretty much anything, short of a busload of pensioners falling down a mountain and ending up in ICU.'

But smaller groups can offset the drawbacks, he adds. While the 100,000 statistic is ‘a useful piece of information', the key is to look for support from other clusters, your PCT or even external organisations.

‘I can't say what the exact figure should be – bigger is better to some extent. But you have to trade that against the benefits of a smaller cluster in terms of relationships and local knowledge.'

2 Get your head round risk

There are already reports that PCTs are becoming risk-averse as the financial crisis bites. Dr Jones advises becoming familiar with risk strategy – something that even some PCT managers have not got their heads round – and making it part of your consortium's language.

‘Healthcare is a very risky industry. You have budgets but that's different to the amount of money that needs to be spent – the latter is very volatile as there are some things you simply can't control, for example the number of patients who are going to have appendicitis.

‘The credit squeeze makes a good case for PBC as you have to redouble your efforts to save money to offset the effects of volatility.'

Dr Jones argues you need a population of at least one million to manage risk, which some PCTs already have risk pools to tackle, though this could be as much as 10 million.

Dr Shane Gordon, chief executive of Colchester PBC Group and co-lead of the NHS Alliance PBC Federation, says smaller PBC groups can overcome the problems of scale by working with their neighbours to share risk. This could include:

• high-cost hospital stays, say above £10,000

• high-cost drugs

• changes in list size.

He says: ‘What matters is the size of the risk-sharing pool, which could be between many clusters. We only have two clusters in our PCT and we share across both.'

3 Consider dropping procedures

Dr Gordon says the scope for making serious savings is in hospital activity. ‘We need to stop doing things that don't need doing. If you look across the country, the variation is enormous and that is down to local culture. Surgeons will operate if you give them wards full of surgical patients.'

Interventions of questionable benefit, such as tonsillectomy, should be prime targets for savings, he adds. Commissioners should look at the Better Care, Better Value indicators, from the NHS Institute for Innovation and Improvement at

The 15 top-level indicators are intended to help commissioners and acute trusts see where to improve their efficiency – you can look up your local acute trust or PCT and compare performance nationally and within a region.

The indicator for Managing Surgical Thresholds, for instance, shows whether the rate of operations for a basket of five procedures, including myringotomy and dilation and curretage, is higher or lower than would be expected given the PCT population.

Dr Gordon suggests commissioners should also look at the indicator for Managing Variation in Emergency Admissions. It gives a list of 19 ambulatory care conditions (see box below) where admissions could be avoided through better management in primary care – from hypertension to dental conditions and iron-deficiency anaemia.

Dr Marshall agrees: ‘We must stop doing things where the evidence shows there is no benefit.' But this doesn't mean 100% of the money spent on ineffective procedures will be saved, he adds, as you will need to manage those patients in primary care.

4 Review referrals and outcomes

Dr Gordon says PBC groups should be looking carefully at conversion rates. ‘Our ENT rate locally is 10% – out of every 10 patients referred only one requires an operation. That's not an efficient use of a surgical specialty.

‘My feeling is GPs refer when they come to the end of their ability to manage the problem, through lack of knowledge, lack of confidence, lack of alternatives.'

This is exactly what PBC is for, he adds – improving the standard of primary care. For ENT, his own surgery offers the Siemens HearCheck screening tool, which can effectively exclude significant hearing loss, as well as aural toilets.

It's about identifying any weak areas and then getting the training, skills and equipment needed to handle them in-house, says Dr Gordon.

‘If we don't do it, when PCTs have got to make savings, they will start cancelling the contracts they have some control over – LES, DES and PMS. We have to give them alternatives to that course of action.'

5 Focus on counting and coding

Dr Jones says commissioners should keep a close eye on the fine detail of costs claimed by hospitals: ‘It's fairly well known that when trusts get into difficulty they change the way they count and they therefore extract money out of the system.'

Dr Gordon agrees there is often a problem here. ‘We found more than 20% of the discharge summaries we were sent locally were inaccurate.' But, he warns, ‘you can point out a lot of glaring errors but getting any money back is another matter'.

Dr Marshall says acute trusts may well claim there are other activities that are not being charged. ‘We do need to validate the data but it does not always translate into immediate freed-up resources.'

6 Examine particular HRGs

Dr Jones argues investing some time in interrogating the highest volume HRGs locally may pay dividends. He suggests there may be some dubious counting going on here. ‘If trusts want to bend the rules, they may take aspects of outpatient activity and call it day cases.'

Many of the top procedures show very high local variation in the apparent intervention rate due to counting issues at different acute hospitals, he explains.

‘When you look at the performance of different PCTs, and the relative ranking of HRGs, you can have totally different ranking and you wonder, is this the same country?'

This could be down to confusion rather than deliberate attempts to mislead, he says. ‘I wouldn't call it miscounting, I would call it confused counting – data definitions have never been audited. It has been left to subjective interpretation as to what is the line between a day case and an outpatient.'

7 Don't give up

‘PBC is about life and death for the NHS,' says Dr Marshall. Although the coming financial crisis might make people wonder why they should bother, he thinks it is more important than ever. ‘It's the only way we are going to deliver the transformational change the NHS needs to survive. ‘There are 18 months to save the NHS before the credit crunch kicks in. If we want to transform local services we need clinicians on board and that is what PBC is designed to do. For PCTs, this is about achieving financial balance but for practices it is far more important, it's about delivering services to patients.'

Even Dr Jones, who argues PBC could be more statistically robust, says it's a worthwhile policy. ‘Efforts to save money are never wasted. You need to make savings in lots of places to buffer this volatility.

It's everybody's job to do that and it's much better to have the clinicians in the room making these decisions with managers.

‘The aim is to avoid getting to a point where the PCT makes slash-and-burn cuts.'

Interviews by editor Sue McNulty and freelance journalist Kaye McIntosh

Ambulatory care sensitive conditions Ambulatory care sensitive conditions

Better Care, Better Value suggests many admissions in these areas could be avoided through better management in primary care.
angina (without major procedure)
ENT infections
convulsions and epilepsy
congestive heart failure
flu and pneumonia (in patients more than two months old)
dehydration and gastroenteritis
cellulitis (without major procedure)
diabetes with complications
iron-deficiency anaemia
perforated/bleeding ulcer
dental conditions
pelvic inflammatory disease
vaccine-preventable conditions
nutritional deficiencies
Source: Better Care, Better Value

PBC Masterclass

PBC Masterclass: Regional events

What: These regional PBC events are designed to equip you with the sophisticated skills needed to overcome barriers and push on towards PBC success.

When: 10 individual events running from October 2009 to January 2010

Where: 10 different regions throughout England. Each event has been tailored to address the learning priorities highlighted by practice-based commissioners in that area.

Next steps: Find out more and book

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