Practice basedcommissioning

Practice-based commissioning – the
evidence

Kath Checkland
Steve Harrison
Anna Coleman

Health 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


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


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

• 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


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

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


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

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


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

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.


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


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


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?


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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