Commissioners' Corner: Practice Based Commissioning

Summary

This paper aims to:

• define Practice Based Commissioning (PBC)
• set PBC in the context of the overarching system reforms program in the NHS
• clarify terminology
• identify opportunities for pharmacy

What is Practice Based Commissioning (PBC)?

The Department of Health’s aim is that, by December 2006, there will be universal coverage of Practice Based Commissioning (PBC). By that time all practices will be guaranteed a minimum indicative budget equivalent to their actual historic use of resources. This will be uplifted to 2006 / 07 prices to enable the purchase, on behalf of their patients, of a range of services agreed with their Primary Care Trust (PCT).

Choice and fairness is at the heart of the policy, as is the principle that practices know patients best and are ideally placed to help patients and direct their care choices.

(PBC) is not a new concept but can be identified as one of the key themes of the NHS plan which clearly supports the move that resources will be devolved to frontline staff. PBC is a tool for delivering system reforms, patient choice, plurality and investment and, as such, supports the that commissioning should take place as close to the patient as possible.

PBC compliments the new pharmacy services contract in as much that PCTs and practices will, in the future, be able to commission services from pharmacists.

System Reforms in the NHS

As PBC evolves, GPs and other healthcare professionals in primary care will be able to steer the strategic direction of their health communities in three key policy areas.

• Patient choice - patients should, wherever possible, be empowered to take key decisions about the care they receive from the NHS. Thus far, most national patient choice initiatives, such as 'Choose and Book', have focused on the location of treatment. From December 2005, patients were given a choice of at least four hospitals for their elective treatment.
• Plurality – this refers to a 'mixed economy' of public and private sector healthcare provision. The growth in independent sector hospital provision in England has been mainly led through the creation of treatment centres. Foundation Trusts, which are required to operate as free standing businesses, can also be seen as part of this transition to a mixed economy. It is possible that this plurality may soon be extended to primary care.
• Investment - the substantial financial growth that the NHS has enjoyed in recent years comes with the condition that the money must be spent wisely and efficiently. The national tariff is the new currency by which commissioners pay for hospital treatments. Currently, all elective, non-elective, outpatient, A&E and diagnostic activity is covered under tariff. National tariff is not only the basis of funding for the NHS but also provides a series of benchmarks against which relative costs may be measured.

PBC supports each of these directions because it facilitates the development of genuinely personalised care, making the choice of provider 'real' for the patient. PBC is seen by many as a route to a wider configuration of providers and a greater variety of styles of care provision by unlocking innovation at provider level. PBC involves GPs and other primary care professionals in financial decisions, which is a key to ensuring that NHS resources and tax payers’ money is used wisely and efficiently.

Policy shifts

Two more recent facts have made PBC seem more attractive:

• A shift in policy emphasis during 2004/05 towards chronic disease management and other long term conditions. Successful management of long term conditions relies heavily on effective personalised care.
• In the 2004 Audit Commission report 'Quicker treatment closer to home', it was reported that only some 28% of GPs feel engaged in the commissioning of hospital treatment. PBC should be a way of addressing this.

Practices have been entitled to request an indicative budget from their PCT together with hospital activity reports since April 2005. Further guidance from the Department of Heath has not only accelerated the timescale for this but has also placed greater pressure on PCTs to do this by December 2006. What has not changed under PBC is that PCTs remain legally accountable for financial management and will continue to contract for healthcare services from NHS Trusts, primary care and private providers for their patient populations. Therefore, we can say that PCTs are the "Purse Holders" and primary care clinicians the "Gatekeepers".

The Department of Health's document -'Commissioning for a patient led NHS' -expects universal coverage of practice based commissioning by December 2006, which is 15 months earlier than originally envisaged. The expectation is much further reaching given that GPs and practices account for more than 80 per cent of NHS patient contacts and directly or indirectly commit the bulk of NHS resources by prescribing, treating and referring patients to other clinicians. It makes clear business sense to give control of the budget to those who are responsible for committing those resources. GPs have been vocal in their demands for more say in the commissioning process, quoting some of the successes of fundholding and locality commissioning. A Kings Fund paper2 compared lessons learned from successful models of the past with those now proposed and, while the principles of redesign are similar in those policies PBC is not seen as fundholding by another name for the following reasons:

• it is not governed by legislation
• there are no direct financial incentives
• PCTs remain responsible for contracting
• there is no clear national model - it is largely left to local discretion
• there is no dedicated and prescribed management resources (although this will change from April 2006 with the introduction of a PBC Directed Enhanced Service payment)

The Government has responded to the challenge of improving commissioning by re-energising the internal market in healthcare, introducing:

• a national tariff for secondary care procedures;
• incentives for private providers and the independent sector
• payment by results (PbR) - funding hospitals on the basis of work carried out
• stand-alone foundation trusts.

Up to 90 per cent of NHS procedures will be covered by PbR and the national tariff by 2008. It does not apply to services in primary care – so, in effect, pro-active practices can beat the tariff price. By using PBC effectively practices will have:

• an ability to influence commissioning
• the flexibility to provide more services in-house or elsewhere in primary care funded from efficiency gains from hospital budgets
• the chance to fund improvements to premises from efficiency gains, providing these improvements will benefit the wider health community
• more choice for practices and patients
• the ability to build more quality clauses into provider contracts for care
• an opportunity to lead service redesign

What are the advantages for patients?

There are a number of potential advantages for patients. These may include:

• a greater choice of treatments
• an increased range of services provided locally
• more services provided in the patient’s home
• alternatives to hospital admission
• seamless care between providers
• reduced inequalities and improved outcome

What are the advantages for PCTs?

There are a number of potential advantages for PCTs:

• a chance to improve partnership working and engage practices and clinicians working in the community in commissioning decisions
• more effective demand management for secondary care referrals
• improved information on referrals
• better data streams to support commissioning
• better decision support for service redesign

The real potential for PBC is to enable a transfer of funds from secondary to primary care to accompany the shifting of work. Practices can develop clinics, employ nurses, pharmacists, GPs or even consultants, and fund them from their budgets at an alternative pay rate to provide accessible high quality services at a lower cost to their budgets.

Commissioning Defined

Commissioning is the process by which practices identify the health needs of the population and make prioritised decisions to secure care to meet those needs within available resources. Practice based commissioning is only one model of commissioning healthcare. It needs to be an integral part of a whole systems framework for commissioning which covers the total of the PCT’s commissioning budget.

What are the opportunities for Pharmacists?

The new pharmacy contract in conjunction with practice based commissioning could offer opportunities to pharmacists to provide services either directly to patients or to GP practices. There could be mutual benefit to the patient, pharmacist and the GP practice if the pharmacist took responsibility for medication reviews and health promotion e.g. smoking cessation. Pharmacists could also play key roles in the management of patients with long term conditions3.

Community pharmacists should be encouraged to engage with practices to establish how the practice or group of practices plans to use practice based commissioning as a way in which to influence change and improve healthcare locally. This could also open up opportunities for medicine managements teams in primary care organisations. Equally, hospital clinical pharmacists could work with PCTs and practices to meet the demands of patients with long term conditions.

The drive to introduce PBC.

The revised technical guidance on PBC released in January 2006 strengthens the Department of Health commitment to continue to drive system reform through the NHS. Practice based commissioning is a tool for delivering system reform, and the newly formed PCTs will be expected to support their GPs and other primary care professionals to become more responsible and more accountable for the taxpayers money they are spending – and offer more freedom to get the services that their patients and users need.

PBC gives primary care professionals, including community and hospital pharmacists, the freedom to innovate and to reshape the boundaries between primary and secondary care. It will allow them to look critically at all of the care pathways that patients and users follow. If there is an alternative that is better for the patient and better for the NHS, then practice based commissioning gives practices the freedom to change the way that services are delivered.

All practices will become practice based commissioners at some level and mechanisms are being put in place to help PCTs work in partnership with practices and other health professionals to achieve this sooner rather than later.

REFERENCES

• 1.Commissioning for a patient led NHS, Department of Health, July 2005
• 2.Richard Lewis, Commissioning a patient-led NHS, Kings Fund, 2004
• 3."Improvement, Expansion and Reform – Modernising Primary Care – How community pharmacy can provide cost effective patient benefit", South East Region of Local Pharmaceutical Committees, 2004

Since this article was written the following has happened:

• The Department of Health has placed greater emphasis on implementing PBC and strengthening the commissioning process
• Practices are to be offered this year a Directed Enhanced Services (DES) payment of 95p per registered population as an incentive to become involved in PBC, a minimum of a further 95p per registered population payable in 2007 for acheivement against the practice or group of practices plan
• PCTs are reporting monthly through their Stategic Health Authorities to the Department of Health on PBC progress for meeting the December 06 target date for universal coverage
• PCTs also reporting on the number of practices who have elected to establish groups or consortia to manage PBC