Practice Based Commissioning- where are we now?

(Published October 2006)

Practice Based Commissioning- where are we now? by Mike Sobanja, NHS Alliance Chief Executive and Non Executive Director of Health Direction

The Department of Health have taken the unusual step of publishing information it collects from Strategic Health Authorities to monitor the progress made in implementing policy on practice based commissioning. This makes interesting reading, but sometimes seems a little divorced from the real world. What does it tell us?

PCTs that are meeting the following four criteria are said to be implementing arrangements for PBC:

1. Provide practices with indicative budgets covering the practice’s share of the PCT allocation. If practices take up practice based commissioning, the practice and the PCT will agree the scope of services covered by the indicative budget delegated to the practice;

2. Provide practices with information about their clinical activity and historical spending patterns and comparisons with local and national indicators

3. Offer practices an incentive payment (the DES or locally agreed alternative) and support to take on practice based commissioning; and

4. Set out the governance and accountability arrangements for practices if they take on practice based commissioners. If practices take on practice based commissioning, these arrangements may be tailored to achieve agreement by both the PCT and the practice.

A PCT must have met all four criteria in order to be recorded as implementing the arrangements for PBC.

The data looks at different trajectories and performance by SHA and the position in September for instance varies from 100% to 69% with a similar variation in achievement – conclusion – PBC implementation is patchy across the country.

The second area looks at take up of incentive payments as measured by the Directed Enhanced Services or a local alternative incentive. Here again we see significant variation in take up – from 60% in the North East to 88% in the South West; remember that take up the DES doesn’t necessarily mean anything is happening – merely that a plan has been drawn up and a payment has been made at the rate of 98p per patient population covered by the practice.

Overall

• PCT progress is at 69% against a trajectory of 72%
• Practice uptake is at 74%, up from 65% in July

From the Health Direction PBC Analyzer we know that there are over seven hundred localities, neighbourhoods or clusters together with a much smaller number of individual practices identified as starting to operate PBC and of those some 40% have declared priorities.

All pretty rosy then – NOT!

Experience on the ground suggests that the blue touch paper of PBC is still pretty damp in many places with the enthusiasts and those actually making a difference still in a significant minority and confined to specific disease areas. The difficult issue here is to understand who is making a difference, where and to what. Many will struggle to demonstrate an impact for some time yet.

The need for local intelligence has never been greater and whilst this can be sourced from reputable commercial companies, those seeking detailed information should ask themselves how multi dimensional the information is and how it can be related to other key areas of NHS change. Single or “flat” information presented as directories of names is of little use. Secondly, representatives have a rich knowledge of anecdotal information on the ground and this needs to be integrated into information systems so that what is in individuals heads can become a corporate resource – not only for successors but also for use across the territory for different players.

The more difficult area is to understand the softer elements of information that really comes into intelligence. For example, this would include an understanding of:

• The extent to which primary care is being commissioned by PCTs and how this fits with PBC
• Relationships between PCTs, PBC localities, and Practices
• The nature of performance and accountability agreements
• Emerging arrangements for contracting hubs
• Arrangements for patient and citizen engagement in PBC
• The involvement of Allied Health and other Primary Care Professionals in PBC
• Local priorities – both at Local Delivery Plan and more localised levels
• Relationships with Local Authorities and other stakeholders

Finally the real challenge is not to take PBC as a discrete element of the reform programme, but rather to assess the impact of the total programme. Chasing PBC will be worthwhile, but only as part of the overall changes now hitting the NHS. So we need to know:

• What are the new PCTs looking to hit?
• Where are the new Foundation Trusts coming on line?
• How much use of the private sector is being made?
• What is the overall financial picture and distance from target?
• Where are the managed clinical networks at?
• What’s happening with specialised commissioning?
• And so on

Oh? And by the way, how exactly does this all correlate with my sales figures? Over to you…