Practice-based commissioning – the evidence Kath Checkland Steve Harrison Anna ColemanHealth Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
Project outline• Stage 1: Analysis of documents and interviews with policy makers – what were the official intended outcomes for PBC?• Stage 2: Questionnaire survey March-June 2007 of all PCTs in England, focusing on the development of PBC structures and processes – reported to DH Nov 2007• Stage 3a: Qualitative case studies in 3 ‘early adopter’ PCTs (5 consortia) – focusing on details of PBC implementation – what is happening, what are the problems and issues? Reported to DH May 2008• Stage 3b: Detailed qualitative study of 7 PCTs (2 from stage 3a followed up longitudinally, a total of 13 consortia), focusing on PBC ongoing development. Completed Feb 2009 Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
Qualitative case studies (stage 3a and 3b): methods• Total of 14 consortia in 8 PCTs• Interviews (131) with a variety of stakeholders and participants• Observation of meetings (130) including PBC board meetings, meetings with rank and file, meetings with PCTs and with providers (total approx 325 hours observation)• Documents analysed, including business plans, meeting minutes and a variety of documents tabled at meetings• Data collected from Jan 2007 to Feb 2009• Interim report to DH Jan 2008, final report to DH May 2009 Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
1. Clinical engagement in commissioning• Substantial engagement in all our sites• ‘engagement’ best conceptualised at different levels – what is needed is a cadre of committed activists, along with acknowledgement from the mass of GPs that PBC (and actions taken in its name) is legitimate• ‘legitimacy’ of PBC helped by: – Formal sign up arrangements to join a consortium – Being kept fully informed about developments and services – Tasks to be undertaken not too onerous – Financial incentives reward work appropriately – Perception that progress being made Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
• Legitimacy hindered by: – Concern that the DH might substantially alter or abolish PBC – Excessively tight control by PCTs & overly bureaucratic processes – ‘hi-jacking’ of PBC meetings by other agendas – Disputes over budgets and savings – clarity vital. Legitimacy helped by allowing PBC groups reasonable access to savings, even if not 100% clear where they came from Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
2. PBC structures• Most common structure: consortium with an elected board who meet regularly, make executive decisions and report back to mass of GPs via regular (eg quarterly) meetings• No ‘one best way’• Important that groups feel they have had choices• Single consortia have some advantages wrt overall integration of PBC with commissioning and with LA services, but PCTs cannot make this happen without consent Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
3. PBC outcomes• Vary from local schemes eg ECGs in practices to involvement in the wider redesign of services across the whole PCT• Most successful where PBC integrated into the wider commissioning agenda of the PCT. This requires: – Positive attitude to PBC from senior PCT executives – Overall responsibility for PBC resting with manager who has an overview of commissioning – Structures and processes to involve GPs in the overall priority setting process and with the redesign of services. This needs to be ‘real’ engagement, not just a token representative sitting on a committee – Willingness of GPs to engage beyond their individual practices and to work with PH Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
4. Budgets and savings• Potential source of discord and dispute• Formal agreements, both between practices WITHIN consortia and between the consortium as a whole and the PCT, help to ensure that disputes don’t arise• The scope of the budget devolved enables or constrains the action possible through PBC – many PCTs were limiting consortia to control of PbR and prescribing, but we found considerable appetite amongst consortia to also look at community services and mental health• Clarity about budgets and savings is vital, and formal ‘sign- up’ arrangements both within PBC consortia and between the consortia and the PCT may facilitate this. It helps if consortia have thought in advance how savings will be used Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
5. Management resources• Adequate management support vital• Need dedicated staff, without other commitments• A variety of models used, including seconded staff, directly employed staff and external consultants• Hiring external consultants is not of itself a shortcut to success• No one model showed obvious benefits• It is vital that there is clarity over who does what, and that managers responsible for PBC don’t have too many other responsibilities Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
6. Provision of services• All groups keen to provide services themselves• Some had set up (or were setting up) formal ‘provider arms’• PCT concerned about conflicts of interests• We saw no obvious problems with services provided by GPs, utilising existing premises and expertise and integrating well with existing service provision• Provision of some services by GPs does not necessarily generate meaningful conflicts of interest, and procurement arrangements should be proportionate• The development of formal ‘provider arm’ arrangements may distract from the core business of commissioning, and it seems sensible for such arrangements to be kept ‘at arms length’ from PBC consortia Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
7. Unintended consequences• New willingness by GPs to engage in peer-review and performance management of each others’ work, although some preferred to talk about this as ‘levelling up’ general practice or ‘education’.• Mechanisms observed included: – practice visits to discuss performance against budgets – publication of named performance data; open discussion of such performance data in meetings – the use of PBC as a mechanism to implement an unrelated performance assessment framework.• Peer review of performance under PBC is a significant positive outcome. Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
8. Patient and public involvement & engagement with LAs/Public Health• PPI Rudimentary in all sites• No agreed definition of what it might look like or how it might work• Evidence of some engagement with Local Authorities – easier in sites with unitary authority and similar boundaries• Engagement with PH variable – from complete integration to complete disconnect Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
Summary 1• Evidence from PBC gives some pointers for GP Commissioning Consortia . In particular: – Reducing referral/prescribing costs requires close engagement between practices, with Consortium management seen as legitimate. This implies smaller groupings (?could be locality groups within larger consortium?) and some sort of official/formal sign up and monitoring process – However, the need for risk-management wrt rare and expensive treatments implies a need for financial risk-sharing across larger groupings – Potential sources of conflict in the future include budgetary issues, the spending of savings/management of losses and contentious decisions such as rationing/service reorganisation. Experience with PBC suggests that consortia need to establish mechanisms to deal with these issues IN ADVANCE – Good management support is vital, and consortia need to think about exactly what these needs are, and plan as soon as possible for their provision. The use of external consultants is not a panacea – Focusing upon provision of services may be a distraction – PPI likely to be difficult Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
Summary 2• But evidence from PBC does not help us with the following: – How will GPs cope when faced with managing the entire budget? – How will GPs engage with health and well-being boards & public health? – How will GPs commission for unregistered patients? Health Policy, Politics and Organisations Group (HiPPO), School of Community-based Medicine
The NHS under the Con/ Lib Dem coalition: 2010 onwards - 1• White paper Equity & Excellence (2010) continues & accelerates developments begun by Labour governments from about 2000 onwards: – NHS as a ‘brand’, under whose aegis public money used to purchase public services from effectively independent providers. – Accordingly, the concept of ‘commissioning’ health care is retained; despite paucity of evidence about any beneficial effects, it is a necessary condition for the desired policy of privatising and pluralising health care provision. – Involvement of GPs in commissioning, sought under Labour in form of ‘practice-based commissioning’ (though originating as GP ‘fundholding’ under the Conservative governments of 1990s) has become the central aspect of policy. – Necessity of competitive markets for health care is taken more seriously than before, hence intention to turn Monitor into an economic regulator as in UK utility markets. 16
The NHS under the Con/ Lib Dem coalition: 2010 onwards - 2– Patient choice taken more seriously than before: • free patient choice of GP, irrespective of proximity of residence to surgery; • free patient choice (in non-emergency situations) of ‘any willing’ secondary and tertiary (and presumably community) care provider; • patient choice again (in non-emergency situations) of ‘named consultant team’ for secondary and tertiary care.– ‘Conceptual commodification’ (Harrison 2009): conceptualisation of as much health care as possible in standardised terms such as HRGs or ‘patient pathways’ that can be priced and traded) looks likely to be strengthened. 17
Ingredients of commissioning consortium ‘success’ - 1• Central focus on commissioning, not providing• Need to make and effectively defend in public prioritisation/ rationing decisions (context of NICE changes)• Commissioning coverage (despite role of Nat Comm Board) fairly comprehensive (unlike GPFH & PBC) - consortia need to plan strategically rather than concentrating on services in which they have a particular interest.• Necessity to deal with paradox of commissioning & being funded for registrants whilst other agencies are planning for geographical populations .
Ingredients of commissioning consortium ‘success’ - 2• Handling conflicts of interest of several types – Secondary to primary care shifts – Possibility of commissioning decisions that destabilise local secondary care providers – Interests of consortium may not coincide with those of constituent practice or individual patients• Managing risks – ‘insurance risk’ of natural variation in prevalence of (expensive?) medical conditions amongst practice registrants – ‘practice risk’ of systematic differences in prescribing/ referral propensities between practices
Ingredients of commissioning consortium ‘success’ - 3• Internal consortium organisational arrangements – Formal ‘sign-up’ arrangements – Establish levels at which consortium participation req’d • Strategy & governance • Specific tasks/ projects for consortium • Representation of each practice within consortium • Recognition of consortium legitimacy & implementation of patient pathways etc – Internal surveillance/ performance regimes – Management support – functions & specification – Public & patient ‘involvement’
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