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There are huge changes planned for the NHS. This document looks at one area in particular - Practice-Based Commissioning (PBC).
Commissioning and providing
Most NHS organisations are either "commissioners" or "providers".
Your Primary Care Trust (PCT) commissions (=specifies & purchases) care from GP Practices. Your practice provides the care that the PCT has commissioned from it.
This is the purchaser-provider split.
Think: How might purchaser-provider splits improve patient care and reduce NHS costs? How could they have the opposite effect?
Changes for PCTs
1) The Government intended that PCTs would commission more and more services, and that there would be competition among the providers. The theory is that this would make the NHS more efficient, by improving patient care and driving down costs.
However, much to the Government's frustration, PCTs haven't done this.
Think: PCTs are ideally placed to commission local health care - they are local organisations with knowledge of local problems, and they have local GPs advising their management. So, why hasn't it happened?
Because of this, the Government intends that practices, or groups of practices, will commission local services: Practice Based Commissioning (PBC).
2) Your PCT also provides 30-odd services: district nursing, health visiting, community paediatrics, cottage hospitals...
From October 2006, PCTs will have to commission other organisations to provide these services, and PCTs will also be merged in the hope of making them more efficient.
There is also talk of forcing practices to merge into mega-practices, presumably with the intention of making them easier to manage and more efficient.
Think: Is big beautiful? What are the advantages of merging smaller organisations into larger ones? And the disadvantages? Will PCT mergers and practice mergers result in overall improvement in patient care?
Payment by results
Until April 2005, the Acute Trusts were paid a lump sum by their local PCTs for all their services. The amount was negotiated from year to year.
Now, Acute Trusts are paid a fixed sum of money for each episode of patient care. An episode of care may be an in-patient stay, or a procedure. Examples: inpatient treatment of a patient who has had a stroke; a CT scan.
Think: How is this likely to affect care and costs?
New models of care
The jargon for a model of care is "Care Pathway".
Example: if a patient has a stroke, someone calls the GP or an ambulance, the patient is admitted to hospital, scanned, and kept in hospital until fit enough to go home, when district nursing, GP and social services care are added. OK, it's simplified, but you'll recognise the pattern.
It is possible that the traditional model of secondary (ie hospital) care for some problems isn't the ideal, in terms of quality of patient care and cost.
Preparation for DRC groupwork: Think up and jot down an alternative care pathway for patients that have had a stroke. Tips: forget the system that you are used to. Stop thinking of hospitalisation as being the final common pathway. Think of systems that may give the patient better care and/or be cheaper. Think "out of the box", and forget about what is or isn't available now. For example, diagnostic services don't need to be based in hospitals, and don't need to be performed by an NHS organisation. Remember to include the role of GPs, District Nurses, Social Services, etc etc.
Practice Based Commissioning
Practice Based Commissioning (PBC) is a system where practices form groups to commission Care Pathways, which should:
- improve patient care;
- be either cost-neutral or reduce overall costs;
- be provided in a more timely manner.
The Care Pathway that you have designed for stroke is an example of a project that a group of practices might commission.
In theory, it will work like this:
- PBC groups will choose and develop projects;
- the local PCT will help with costing it up;
- if the PCT agrees that the project is a more efficient use of resources, the PBC group will commission the project from one or more providers;
- the providers may be GPs, district nurses, social workers, private companies, Acute Trusts etc;
- those providers will be paid for that work;
- if the Acute Trust isn't commissioned for this work, or has a smaller role to play than before, it will lose its payments for those episodes of care;
- set-up costs (eg cost of PBC group time) will come out of any savings made;
- any left-over savings may be used by the PBC group:
- to further improve patient services,
- which may include improving practice premises.
- PBC groups have 3 years in which to start making savings;
- however, the PBC group would be responsible for ensuring that the project comes in within budget;
- if over budget, excess costs would come out of those practices' GMS/PMS budgets.
Preparation for DRC groupwork: We've used a stroke care pathway as an example. Think of at least two other problems where a new care pathway could improve care or be quicker than the existing one, and be cheaper. Ask the partners in your practice if you need help on this.
Do we have to do it?
The Government intends that all practices will take part in PBC.
In our patch, most practices are already involved in PBC groups. Those practices that aren't are likely to be heavily pressurised.
There's even talk that eventually patients will be able to commission their own care. There are precedents for this:
- patients going privately effectively commission their own care;
- Attendance Allowance lets patients pay for their own choice of social care.
So, is PBC a good thing or bad thing?
PBC is something that we will be involved with, whether we like it or not.
Preparation for DRC groupwork: List the potential advantages and disadvantages of PBC for:
- patients,
- GPs and practice,
- secondary care,
- society.
Privatisation
This Government is openly privatising portions of the NHS.
Primary care:
- if a private provider offers GP services that are thought to be better and/or cheaper than what we can provide, GPs will be priced out of the market.
Secondary care:
- in future, 15% of secondary care will have to be commissioned from private providers. The consultants in RUH, Bath were recently told by their managers to expect redundancies.
Want to know more?
Download this surprisingly readable 6-page review of PBC: A review of the effectiveness of primary care-led commissioning and its place in the NHS (It's a pdf file, and may take a couple of minutes to download.)
See what you make of Jennifer Dixon's "Personal View" on reforming the NHS in a recent BMJ: BMJ 2005;331:852 (8 October). Ms Dixon is director of policy at the King's Fund, London, http://bmj.bmjjournals.com/cgi/content/full/331/7520/852-a
Written by: Michael Harris, with grateful thanks to Simon Douglass
Last update: 29 August 2007