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How we are taking on real budgets

GPs in Cambridgeshire will be among the first to get their hands on real commissioning budgets later this year. The process began over a year ago and has thrown up key lessons for the rest of the UK, as consortium chair Dr Pauline Brimblecombe explains

Andrew Lansley is our local MP and when I bumped into him at a party recently I said words to the effect of: ‘You’ve given GPs quite a lot to think about in the white paper.’ His reply was that he trusted us as a profession to make it work.

The process of taking on real budgets is all about behavioural change – not just on the part of GPs but also on the part of consultants, managers and patients as well, and if we are going to make it work, we all have to get on board.

Consultants will have to stop just taking patients over and become more involved in the whole process. Patients will find themselves on defined clinical pathways rather than being passed around.

There are two-and-a-half years to go before the plans take full effect nationally but what we’ve realised in our local preparation work for taking on real budgets is that it is probably going to take all of that time for everyone to get on board.

First steps

Our journey into the world of real budgets began in July last year, in what we termed the ‘storm scenario’, when it became apparent that our PCT – NHS Cambridgeshire – was operating with a financial gap of £11m. After some modelling work, this was projected to grow to more than £100m by 2012/13 unless we took steps to change our strategic direction dramatically.

We had a one-day, professionally-facilitated brainstorming meeting with trust chief executives, patients’ groups, the private sector and the King’s Fund at which GPs suggested for the first time that we could take on the budgets ourselves.

The theory was that GPs are in fact commissioning every time we refer but generally have no idea how much it will cost. However if the money were to come out of our own bank account, there would be a real imperative to do things differently. If you thought you could save £150 by not referring a patient but by arranging an alternative solution for them, you would.

The real budget concept was then developed by Andy Vowles, our PCT’s director of strategy and delivery, and there followed a ‘big conversation’ covering all of NHS Cambridgeshire to sound GPs out on getting involved – with mixed results. Some GPs were quick to see the benefits – for example of being able to bypass the unwieldy system of business-case plans every time you want to do something – but others did not.

Initially, the PCT thought that about 10% of practices might sign up for real budgets. In the end, we got about 40% covering half of NHS Cambridgeshire and involving three consortiums. The first wave of clusters taking on real budgets are five of the 30 practices that make up our current PBC consortium CATCH (Cambridgeshire Association to Commission Health) covering 52,000 patients, plus one practice in Huntingdon and another in Histon.

The project is part of NHS Cambridgeshire’s strategic plan for the next five years.

Setting the budgets

In terms of setting the budgets, the initial arrangement is that we’ll have an allocation per weighted capitation per practice, including the management allowance for three years. We plan to block back the budgets for highly specialised services and things like learning disabilities and ambulance care so these will be commissioned by NHS Cambridgeshire.

The budget will be in one big pot and we’ll be able to decide how much of it to spend on management as we see fit. The budgets are still being finalised and will be run on an ‘open book’ accounting basis – completely transparent to the PCT.

Initially, we have decided to second specific people over from the PCT to manage all this. The Huntingdon cluster has actually employed somebody. But the private sector is expressing an interest and it may be that they will have increasing involvement as things go on. KPMG has already held talks with GPs to see if they want to outsource the management of consortiums. I have been inundated with emails from the private sector – organisations like McKinsey and pharma companies – wanting to know how they can help. They see it as a big opportunity. Where else is management support going to come from?

Care pathways

The process has involved exploring ways to find the most cost-effective pathways for the management of common conditions in general practice and as CATCH, we have already spent a lot of time on this putting proformas, guidelines and protocols up on our website. The plan is, in time, for agreed clinical pathways to become the ‘contracting currency’.

Locally, our real budget clusters do not want to take savings as profit because of probity issues and patient relationships – as well as not wishing to take personal financial risks in an area like ours where we still have a historic debt to pay off.

What happens to savings?

In theory, general practice could generate income by providing some of these services themselves. GP time could be freed up by using resources to employ other professionals such as specialist nurses for their work, and by the cluster more efficiently decreasing its expenses through sharing back-room activities such as payroll, HR, health and safety, bulk buying and so on. But this will be the by-product rather than the raison d’etre for taking on real budgets.

The PCT is now looking at setting up a hit squad covering things like IT and finance that they can deploy to the real budget clusters to sort administrative issues out.

Legal status

Meanwhile, the next step for us is to develop the legal status that we need to hold the funds and set ourselves up as a company. We are having talks with Assura, which is offering support on this. Once that is accomplished we should be able to go live later this year.

The clusters see real budgets as a way of doing PBC as it was really designed to

be – delivering the best and most appropriate health services to their registered populations and particularly by doing more for patients in house. The purpose of the budget is to give the freedom of shifting the current use of resources from the acute spend into resourcing community and primary care. I have always believed that GPs are capable of doing much more than they currently do given the time, support and extra resource and this opportunity is what we have wanted all along.

Looking ahead to plans for each consortium to have an acountable officer, my worry is that if I am the one named GP who is taking the risk, what sort of risk am I taking on? Are named GPs liable for overspends? I want to be with GPs who really want to do it, not with passengers. Having done PBC for four years

I have seen that there are already a lot of passengers. There are still a lot of practices who can say they are doing commissioning because they are in a consortium but who still do not want to do things really differently.

CATCH was formed as a big group (30 practices) specifically because I thought we’d need to be big and powerful in order to deal with Addenbrookes, our local trust, which has such a strong national and international reputation. However, it has not really worked because we have not had budgets.

Future plans

In terms of the white paper and the plans for 500 big consortiums, I am still not clear how you make GPs who became GPs only to do clinical care get on board. My worry is that it will dilute the enthusiasm and drive that exists in a group the size of ours.

If groups get even bigger, the worry is then that we will lose the local and personal touch. In our cluster, we know exactly how many diabetes patients we have and what their needs are. That gets a bit more difficult on the larger scale. The bottom line is that those involved all have to have the same vision of care.

For the future, I think once our cluster has tried a few things with our real budgets, others will see the benefits and get on board. I expect that by 2013 (when consortiums take over full responsibility from PCTs) the remaining members of CATCH may have come together as a large consortium or perhaps a federation of consortiums.

There are other good things in the white paper too. It will be good to have the local authority involved so they understand the decisions made at the bottom and will be part of the decision-making process.

But the plans for primary care in the white paper are still only a half-written book. The ‘i’s are not yet dotted and the ‘t’s are not crossed. The Government is looking for leading-edge GPs to pioneer this for them and make it work – and we’re happy to take it on.

Dr Pauline Brimblecombe is a GP in Cambridge, a GP trainer, a GPSI in community gynaecology and chair of Cambridgeshire Association To Commission Health (CATCH), a PBC consortium of 30 practices

Dr Pauline Brimblecombe: ‘It was GPs who suggested we should take on the budgets ourselves’ Dr Pauline Brimblecombe: ‘It was GPs who suggested we should take on the budgets ourselves’