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Top tips on tackling the bigger picture

PBC needs to tackle change on a large scale if it is to deliver real reform. Emma Wilkinson asks the experts for their top tips

PBC needs to tackle change on a large scale if it is to deliver real reform. Emma Wilkinson asks the experts for their top tips

1 Go straight to the top

PCT chief executives can be in no doubt that PBC is a priority and will have the World-Class Commissioning (WCC) assurances firmly in mind. But do they know what your cluster can do, what you are capable of? Are they aware of the resource that is under their nose? And, just as important, is your cluster aware of the PCT's vision and what they see you being able to achieve?

Dr Donal Hynes, joint vice-chair of the NHS Alliance, agrees it would be a prudent step to meet and greet those at the top of the PCT. However, where the obvious choice may be to take the chief executive out to lunch, he feels a more workable approach may be to befriend the PEC chair or equivalent clinical lead in the organisation.

He says: ‘I agree with going to the top but you need to start with a clinician-to-clinician dialogue, which will invariably be more productive and a more practical way forward. You need to understand the game the PCT plays and you can't do that without having a conversation with the PCT.'

He adds it is worth finding out whether the director of finance is panicking about having to save money as well as doing PBC, or whether they genuinely believe PBC is the route to finding savings.

‘If you find these two things are aligned and the PCT understands the easiest way to achieve their goals is to bring in PBC, it is a great way forward. You need agreement on the strategic objectives.

‘The one thing PECs will have got very good at is how to engage with the chief executive and director of finance and that is a resource you need to tap into rather than having to wait months for an appointment.'

2 Be accountable

One of the biggest barriers to PBC groups working successfully on a larger scale is PCTs' lack of willingness to let go.

In order to take responsibility for their decisions, PBC groups need to take on board the associated risks should things go wrong.

Dr Johnny Marshall, chair of the NAPC, believes that ultimately legislation will be needed to ensure accountability is transferred to PBC groups when they are able to take that accountability on board in order to give PBC enough power to succeed. But he says in the meantime, there are still steps PBC clusters can take to instil confidence in them and lead to them having a greater slice of the pie.

‘In PBC we need to look at taking on accountability and responsibility for the wider spend rather than just making a contribution to the decision-making process around that spend. So we need to make clever decisions that we are accountable for.

‘There are PBC groups that are pushing for earned autonomy in order to persuade their PCT they deserve greater responsibility. That involves them demonstrating they are on board with local priorities, which may be things like performance management of referrals, and that they can deliver them better than the PCT. You need to convince your PCT managers they should be devolving more to you. The problem is, as finances get tight PCTs may be more reluctant to let go.'

He adds that when it comes to big projects, sharing risk between a cluster of PBC groups or even with the PCT is a good move. ‘If the barrier to what you're trying to do is the financial risk, you could share that with others. This was what happened under the total purchasing pilots.'

3 Get external help in

PCTs often do not have the skills you need to drive PBC forward in house, but what you need is out there. Dr Luke Twelves, a GP in Cambridgeshire and PBC director at UnitedHealth UK, says there is a wide range of tools available to aid commissioning.

‘This assistance is scalable in its delivery and therefore of direct interest to PBC commissioning groups looking to develop and innovate to drive better outcomes for the NHS and patients. For example, at UnitedHealth UK, we have the skills and tools to identify and develop data sources, to clean and improve the data and turn it into valuable information that can be used both strategically and on a day-to-day basis. Despite many high-quality tools and information sources such as NICE commissioning guidelines or Map of Medicine, the use of evidence-based medicine is variable within the NHS. We have comprehensive systems and processes and tools to allow evidence-based practice to underpin commissioning decisions in a robust and valuable way.'

He adds that PBC groups can use external help to execute projects as well as for performance management, identifying outcomes and training of staff. ‘We have the technology infrastructure and enablement supports that allow both PBC groups and PCTs to bring together disparate sources of information – for example SUS data, GP data and census information – and layer intelligence upon it, such as evidence-based medicine rules or population-risk based stratification tools, to deliver direct clinical and commissioning benefits.

4 Become well-versed in your PCT's big objectives

A PBC group will make great headway with their PCT if they can show they understand and are on board with the big priorities. Agreements will be reached faster and responsibility granted if everyone is singing from the same hymn sheet. The PBC cluster needs to find out what the PCT's biggest priority is, what the strategic vision is and what their WCC outcomes are, and use those as a starting point for their strategic plan.

Dr Shane Gordon, national co-lead for the NHS Alliance's PBC Federation, says his PBC cluster has had success with this approach. ‘This is information that is easily accessible. Find out what your PCT's health needs assessment – produced annually by the public health department – has highlighted. There will also be an assessment by the PCT and local authority laid out in a local area agreement which set out the priorities for investment. Practice-based commissioners also need to get hold of the PCT's operational plan for the year. If you can show how your plans support this strategy you are more likely to get help and agreement from the PCT on business cases. Make sure your strategic planning specifically references the PCT's plans because they are much more likely to get support. What the PCT picks are the big health needs and by going for those you will get more bang for your buck.'

Dr Gordon's cluster invested in an LES for the proactive GP management of chronic kidney disease before it was mentioned in QOF in order to meet the PCT's health priorities. ‘The PCT was keen to manage demand for kidney dialysis because we have an elderly population' he says.

5 Align with other PBC groups in your area

Dr Mike Dixon, chair of the NHS Alliance, says PBC groups should be thinking about working in collaboration with each other to boost their negotiating power.

‘It's a great idea because you will get different ideas but also there is safety in numbers, so if one consortium is able to overcome barriers that others haven't, it will strengthen the ability of the others to do so.

‘It also gives you an idea of the norms and what to expect. For example, one consortium might think it's usual for business proposals to take an age to go through but another might be getting them through really quickly.

‘PBC consortiums need to group together because as PBC becomes a bigger part of the landscape they will need to co-commission things they would be too small to commission on their own. PBC will increasingly be taking over the roles of the PCT and a few years from now commissioners will have much more responsibility. So sharing ideas will boost the strength of commissioners against, say, a hospital. If three PBC groups use the same hospital, by "ganging up" they should be in a far stronger position.'

He says there are lots of ways of formally collaborating with other groups but an informal process can work better.

‘One way is for PBC groups to have a parent organisation and use the same back office function – sort of a consortium of consortiums – but I'm not sure I'd go into something that formal at this stage because the political landscape is a bit uncertain. But it seems to me there needs to be at least a meeting between heads of local PBC consortiums to look at things that can be done together rather than separately.'

6 Get to grips with changes in community services

Dr James Kingsland, lead for the DH's national clinical PBC network, says PBC groups need to get their heads around the Transforming Community Services (TCS) Programme. First outlined in the Darzi Next Stage Review last year, the ambitious programme has not yet come to the attention of PBC, says Dr Kingsland, but general practice will play a vital part. The aims – unlocking quality and productivity gains, increasing focus on promoting health and developing services that reduce hospital admissions and support early discharge – are the goals PBC groups should already be working towards, he says.

‘Every SHA has a TCS board and one of the early goals is to try to make sure PCTs separate their provider and commissioner functions. Services historically provided by PCTs are going this year and that is where PBC needs to put a lot of effort. It also needs to focus on disease areas such as end-of-life care. I'm doing some work with the DH at the moment on delivering the TCS programme but it is something that is off the radar of front-line practice. Some PCTs have gone ahead and started divesting their provider functions but PBC needs to be the vehicle by which that happens.'

Emma Wilkinson is a freelance journalist

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