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Top tips: Setting up a PBC consortium

Practices can maximise their opportunities under practice-based commissioning if they form a consortium. Dr Luke Twelves, chair of consortium HuntsComm, shares 10 top tips

Practices can maximise their opportunities under practice-based commissioning if they form a consortium. Dr Luke Twelves, chair of consortium HuntsComm, shares 10 top tips

1 Understand the pros of setting up a consortium

A consortium will allow you to share or delegate a significant amount of the effort involved in practice-based commissioning (PBC) while maximising the opportunities.

Major service redesign, which will gain the biggest benefits for patients and practices under PBC, is nigh-on impossible at a practice level.

Working together will allow you to pool budgets to cover high risks. For example, the impact of a long-stay patient on intensive care could be massive at practice-only level.

Presenting a united front and working co-operatively allows primary care as a whole to become stronger.

A consortium can also centralise the burden of reading relevant documents and communicating with PCTs and secondary care, saving time that most clinicians do not have.

The HuntsComm committee includes four GPs, one practice manager, one lay member and one nurse, who spend four to eight sessions per month on consortium work. They also receive administrative and data support from the PCT.

2 set out your strategic plan

You need to have a vision of what PBC means for your area – this will guide everything from the size of your consortium to forming the foundation of agreements with your PCT.

Write it down so that everyone knows what they are signing up to. There can be a temptation to put the plan to one side and focus on structures. It can be a difficult task, but once written, it makes life a lot easier.

Set it down early in the process.

3 Choose the right size

Your consortium needs to be big enough to be heard and small enough to be responsive to its members and the community it represents. It must work practically in terms of communication, service redesign and effective group working.

Questions to ask include:

• Should we focus around one hospital or several?

• The local geography – can people get to meetings?

• Is there a history of group working – for example, through out-of-hours co-ops?

• Should we work around old PCT areas?

• Should we focus on working with like-minded GPs?

• What is the PCT trying to set up?

• What motivation exists in primary care – is there a natural leader?

• Most importantly, can we work together?

HuntsComm decided to base its consortium around the old [pre-October reconfigurations] PCT area, comprising 22 practices serving 150,000 patients. But don't discount the ‘like-minded GPs' ideas. As fair share budgets are introduced in the future, this model of grouping together motivated GPs may become increasingly popular.

4 Choose the right structure

There are lots of options, broadly fitting into two groups: formal, such as companies or partnerships; and informal, such as loose locality associations or a sub-group of the PCT.

An informal structure is easy to set up, will have less administration and may be cheaper to run. A formal structure could give you more freedom to develop services, but could also involve more administration and legal obligations.

HuntsComm acts as a subcommittee of the PCT. It was quick to set up and means there is no need for audited accounts from the consortium. Administration is reduced and there are simple employment structures for PCT staff who are supporting the consortium.

As such a consortium develops, separating from the PCT may bring advantages that outweigh the additional work involved. If the support and structures are there from the start, you may wish to go straight into forming a company or some form of partnership.

The subject is complex, and it's worth exploring all your options. PBC consortium working guidance published by the GPC in April last year is a useful starter (www.lmc. org.uk).

5 get your consortium's agreements right

Irrespective of the legal set-up of your consortium, it is essential not to scrimp on agreements. These vary from letters of agreement to formal contracts.

You will have to write or amend your own documentation, or pay someone to do it for you. The more formal the consortium's structure (such as a limited company), the more likely the need to factor in the cost of legal advice.

So what agreements are needed?

• A proposal document (see tip 2)

• A consortium constitution, setting how the consortium is run and by whom

• Consortium agreements with the PCT – don't forget these agreements are two-way documents

• Consortiums agreements with practices (see tip 6)

Where do you start? Standing orders and clinical governance documentation for your PCT provide a useful basis if you are writing your own agreements.

6 Incentivise practices

It doesn't matter how good a consortium you have, it will not succeed if you try to carry out PBC only at committee or board level. The constituent practices need to be engaged. Larger consortiums in particular will have to concentrate on engagement.

Consider an incentive plan to ensure that the practices work towards the common aims of the consortium, and receive funding to back-fill time for PBC work within practices. This could be funded on a ‘spend to save' plan agreed with your PCT.

Your consortium's agreement with practices should include the consortium's overall plans, incentive arrangements and practice obligations.

In our consortium, the Towards PBC directed enhanced service (DES) money was pooled by the practices, and the PCT added some ‘spend to save' money. The incentive scheme divides money between acute care, elective care and global markers, with each of these subdivided into effort and results. The incentive scheme also contains sections for prescribing and Choose and Book.

7 Communicate with practices

Ensure communication with practices is two-way. It may sound obvious, but getting everyone together on a regular basis in invaluable. We baulked at the cost of doing this early on, and then regretted it.

We have now moved to monthly ‘all practice' meetings, attended by a representative of each practice. In addition to this we have bi-monthly cluster meetings, each attended by a quarter of the consortium, as well as consortium visits to each practice every two to three months.

8 Minimise conflict of interest

This is not a new problem. PECs and PCT provider arms have had to grapple with the potential conflict of interest that can arise where those making commissioning decisions may also be potential providers of services.

The higher the level of innovation proposed, the more likely the potential for conflicts, as successful PBC requires willing providers.

How do you deal with such conflicts?

• Declare all interests

• Be transparent at all times. Ensure minutes are taken at meetings, and public meetings held when required

• Have clear corporate governance rules (see tip 5)

• Separate any provider structures from commissioning structures. Boards for each function can be created and kept separate from each other

• Read PBC: practical implementation, guidance published by the Department of Health in November last year.

9 Don't reinvent the wheel

You aren't alone in this. Other consortiums will be willing to share work they have done. You should also use the national bodies, such as the Improvement Foundation, GPC, National Association of Primary Care, NHS Alliance, and the Department of Health.

10 Don't forget the other essentials

There is so much more to consortiums than the basics described above. Don't forget about:

• Leadership

• Innovation

• Public engagement

• Sustainability

• Consortium development and growth.

Dr Luke Twelves is a GP and chair of HuntsComm consortium. For more details email luke.twelves@nhs.net or log on to huntscomm.nhs.uk

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