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Commissioning - Time to dismantle PBC barriers

GP-led, multi-specialty organisations will transform commissioning, say Dr Judith Smith and Julie Wood.

With the NHS facing possibly its greatest management and financial challenge for a generation, it is vital that GPs and other clinicians are engaged in decisions about how patient services are designed and delivered, and how NHS money is spent.

Beyond PBC
Practice-based commissioning (PBC) was supposedly the magic bullet that would breathe new life into clinically-led commissioning but it is has had limited success.

The barriers GP commissioners face, such as delayed budget allocations, have stifled progress and bureaucracy over approving business cases.

The challenge now is to look to a future beyond PBC where GPs, working with other clinicians, could take on real budgets and assume responsibility for the health outcomes of their local communities.

Local clinical partnerships
A recent report, Beyond Practice-based Commissioning by the Nuffield Trust and NHS Alliance proposed a way that might solve this conundrum: multi-specialty clinical groups, led by GPs, with real budgets and responsibility for designing, delivering and commissioning a range of local health services.

These groups would come together in local clinical partnerships (LCPs) and be accountable to PCTs and regulators.

GPs would set up their own LCPs comprising a group of family doctors with the active involvement of secondary care clinicians, primary and community care nurses, pharmacists and allied professionals.

They would include specialists contracted from foundation trusts (FTs)/other acute trusts or community providers, employed by the LCP, or with a stake in the organisation as partners.

GPs would decide on the form of ownership of their LCP, depending on whether they want to be purely provider organisations or groups with both provider and commissioning responsibilities.

There is little appetite, politically or within the NHS, for further large-scale policy or organisational upheavals, but LCPs could evolve a form relevant to their local scope, size and history. FTs, social enterprise models and multi-professional partnerships show promise. Tolerance of a variety of organisational arrangements will be key.

Ideally, LCPs would be based on a geographical community, but the crucial factor is that they develop from the front line as independent groups of clinicians committed to working together. They would need to be big enough to manage clinical and financial risk and to keep management and transaction costs in control.

Real budgets
Why would this tempt GPs? This approach would address a fundamental problem holding back PBC: there are virtually no financial or other incentives for GPs to take on greater responsibility. Currently, GPs hold only notional budgets and are unable to redirect significant resources to commission services closer to patients' homes.

LCPs would hand real budgets to GPs, budgets that are population-based, capitated and risk-adjusted. LCPs would be able to take 'make or buy' decisions, doing what clinically-led organisations do best - developing improved and extended community-based care for local people.

They would use this as the basis for commissioning specialist advice, diagnostics and care beyond what the LCP itself could provide.

Significant incentives
A key incentive for GPs may be that LCPs could enact decisions about service development and commissioning quickly and without seeking PCT permission. They could negotiate with primary care, community health and specialist providers for services to be commissioned or decommissioned.

Other incentives might include opportunities for shared education and development across the LCP's practices and specialists; joint arrangements for out-of-hours care; resources pooling to enable better cover for staff absences and career development for practice clinicians and managers.

To make this work, GPs would need to see the direct benefit of engaging fully in budget-holding and service development beyond their own practices.

They would want the right to reinvest any savings, albeit they would also have to share the risk of financial overspends.

GMS and PMS contracts
It is likely the GMS and PMS contracts would need revising to link to the work of practice teams with the collective activity and priorities of a budget-holding LCP.

Personal and organisational incentives would also have to be aligned to a national specification for GPs to avoid repeated and protracted local negotiations with PCTs.

What we need, and what our report seeks to provide, is an explanation of how budget-holding and service development by GPs and other clinicians could be made to work.

The time is ripe to move beyond PBC. The challenge is to build on what has worked so far and ignite the interest of a new generation of clinicians who have never taken responsibility for, nor seen, the benefits of this type of budget-holding and service development.

  • Dr Judith Smith is head of policy at the Nuffield Trust and Julie Wood is director of PBC at the NHS Alliance
Local clinical partnerships
  • LCPs would hand real, population-based, capitated budgets to GPs. Robust methods for allocating these risk-adjusted budgets would be critical.
  • GPs would assume responsibility for health outcomes and financial risk.
  • GPs would take 'make or buy' decisions. Savings could be kept by the LCP and used in a not-for-profit way.
  • LCPs would be developed and owned by GPs and other clinicians. Governance must be sturdy and proportionate with clear accountability.
  • Personal and organisational incentives must be aligned for GPs to avoid repeated/protracted local negotiations.
  • Experimentation and innovation must be encouraged enabling radical service improvements to be made.

 

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