Transcript Practice based commissioning

Practice based
commissioning: towards
integrated care?
Dr Jennifer Dixon
Nuffield Trust
London
NHS reform architecture
Transactions
Commissioning
Providing
IT
HR
Funding
Private sector
PbR
Choice
PCTs
PBC
(FESC)
Foundation
NHS Trusts
Third sector
NHS Trusts
Primary care
Regulation
Health Care Commission
CSCI
Community services
Audit Commission
Monitor
General practice services
 Free at the point of use (except drugs)
 Patients registered
 General practice: mainly group practice, independent
 All practices computerised medical records
 Approximately 50 practices in a primary care trust
(geographically defined)
 Payment: nationally agreed contracts and half practice
income achieved through pay for performance
 No direct regulation of quality of services provided
Reform history of PBC
Timeline
Policy
 1990-96

GP fundholding; total
purchasing pilots; GP led
commissioning with health
authority purchasing
 1996-97

 1998

Locality commissioning
pilots
Primary care groups
 2000

Primary care trusts
 2004

First PBC guidance issued
Features of PBC
 May be undertaken by a single GP practice or cluster
(normally geographically defined)
 An indicative budget is held on behalf of the registered
population
 Support from the Primary Care Trust received and an
incentive payment
 Accountability and governance arrangements agreed
with the PCT
 Voluntary scheme
 Implementation largely left to local discretion
Differences between PBC and
earlier models
 No national framework
 Implementation largely left to local discretion
 PBC not governed by legislation
 PCTs remain responsible for contracting
 No dedicated and prescribed management resources
 Political consensus
Key elements of an indicative budget
Element
Secondary care
 Elective
Description
 Planned hospital treatments
 Outpatient
 Unplanned hospital
treatments
 Consultation(ambulatory)
Prescribing
Prescription drugs in primary care
 Non-elective
Community and
mental health
services
In hospital or in the community
Incentives for GPs to adopt PBC
 Financial incentives
– Direct: national/local
payment for
undertaking PBC
– Indirect: use of
budgetary surpluses,
opportunities to act
as providers
 Non-financial incentives
– Direct: Higher levels of
autonomy
– Indirect: potential for
improving patient care
Source: Lewis R, Curry N, Dixon M. Practice-based commissioning. King’s Fund, 2007.
Expected benefits of PBC for
patients
 Better access to care
 A greater choice of treatments
 An increased range of services locally provided
 More home based services
 Alternatives to hospital admission
 Reduced inequalities of outcome
Expected benefits of PBC for
PCTs
 Better commissioning of services through clinical
involvement
 Better management of referral of patients to hospital by
GPs
 Better information on which GPs base their decisions
 Better management of demand and financial risk
 Contestability of community services
Early results
 Audit Commission: Early lessons from implementing
PBC (2006)
 Audit Commission: Putting commissioning into practice
(2007)
 King’s Fund: Practice based commissioning: from good
idea to effective practice (2007)
 NPCRDC: Practice Based Commissioning: Report of a
survey of Primary Care Trusts (2007)
Results I
(2006/7= 2nd year)

Uptake of incentive payments high

Variable engagement – progress hindered by PCT
reorganisation in 2006/07

Many practices organised into consortia

Quality of underpinning financial infrastructure variable
–
–
–
–
–
Budget setting process opaque
Some not receiving a budget more than quarterly
Methods to manage financial risk unclear
Poor information on activity and costs
Arrangements for sharing or using savings unclear or criticised
(especially when PCT in debt)
Results II
 Redesign of services and transfer from 2 to 1 care slow
 Practices more interested in using budgets to provide
new services than to commission others
 Governance arrangements not always clear (potential
conflict of interests)
 Ownership of shared objectives with the PCT is variable
Results III
 Survey 257 people
 70% practice managers, 25% GPs
 89% receiving information about secondary care use
(55% helpful)
 3% said their PCT involved them in strategic decisions
to a great extent, 21% to some extent
 33% rating support by PCT as poor
 25% not receiving budgetary of financial information
 Of those with a budget, 37% do not fully understand
how it was set
 73% committed to PBC
 41% thought that contracts had not improved quality of
care
 39% thought the biggest barrier to successful
implementation was lack of PCT support and excessive
bureaucracy
Source: Lewis R, Curry N, Dixon M. Practice-based commissioning. King’s Fund, 2007.
Results IV
 PCTs using incentives beyond DES
 In most PCTs practices operating PBC via
clusters (typically 4)
 10% PBC have formal legal status
 60% PBC have budgets narrower in range
than suggested by guidance
Results V
 Clinical priorities: long term conditions, high
volume elective care
 Budgets: still largely set on past activity
 Most with 30:70 savings ratio (PCT: practice)
 Poor clinical engagement
Issues

Practical financial issues need sorting
–
–
–
Accurate budgets (risk adjusted)
Clarity on savings
Better information on activity, costs and outcomes

Are practices really interested in commissioning or provision?

PCT weaknesses in commissioning

Secondary provider strength, and incentives in payment by
results to drive up admissions

Huge agenda to improve care for people with long term
conditions (integration)
The future?
 Moves towards integrated clinical care
 Suggestion of integrated health care providers
managing a risk adjusted capitated budget
(payer/providers)
 May be step too far for policy now, perhaps piloted