More power to the gatekeepers

With the policies of patient choice, payment by results and national tariffs, acute hospital trusts have an incentive to increase their activity to generate income. In an NHS that is struggling to achieve financial balance, this would lead to less money being available for primary and community care.

To balance the behaviour of acute hospital trusts, it is necessary to enlist the support of the gatekeepers to hospital services – largely primary care clinicians – to adopt more accountability for their referrals into secondary care and for the redesign of services to provide patient-centred care, value and support for those in greatest needs.

Introduced in April 2005, practice-based commissioning (PBC) will enable primary care clinicians to do this. It is intended to promote clinical leadership among GPs, and other primary care professionals, and recognises they are in the prime position to redesign local services to meet local needs. The mechanism for doing this is to provide them with more information about the budgets that are available for their practice and the level of patient activity that occurs outside the practice for the registered population. The intended benefits are:

• A wider variety of services.
  
• More providers.
  
• Care delivered closer to home and in a more convenient setting.
  
• More efficient use of resources.
  
• Greater involvement of front-line doctors and nurses in commissioning decisions.

From April 2005, primary care trusts should have provided each practice with an indicative budget outlining their historic use of NHS resources outside the practice, adjusted for the new tariff prices for 2005-6. Practices choose which areas of the budget they wish to take responsibility for and devise a business plan for commissioning services within those areas. Practices are required to consult staff to inform this process and seek to engage service users in any service redesign.

There is an inherent tension in the development of local patient care pathways and unlimited patient choice. By engaging service users in the redesign of services it should be possible to inform them of the impact of certain choices on the cost of health care delivery and to integrate some of the choices that people wish to see included within the limitations that a finite resource demands.

Although there is no prescriptive process for commissioning it would normally include the following steps: local needs assessment; agreeing priorities between practices and the PCT; planning service delivery; contracting with a service provider; and monitoring outcomes against the contract.

Practices are encouraged to deliver more services and the PCT is responsible for overseeing the quality of those services. In addition, the contracting responsibility rests entirely with the PCT to ensure probity with any arrangement where the practice is the commissioner and the provider. Other providers can also be used. Indeed, to increase competitiveness, more are being encouraged from outside the traditional NHS sphere.

If a practice delivers a saving against the budget it is entitled to at least 70 per cent of that saving to re-invest in patient services. Up to 30 per cent of the saving can be retained by the PCT to meet any existing financial deficit or for service improvement. The exact level of savings to be retained should be agreed between the PCT and the practice. The strategic health authority acts as arbiter when the PCT and practice are unable to reach agreement.

The intention is that care moves out of secondary care into a community setting with the resource following the activity. There are no set tariffs for delivering work in the community as these are agreed locally between the PCT and the provider.

The nature of delivering health care can be complex due to the number of agencies involved and the overlap with social care.

While practices may be leading on PBC, for the service redesign that follows to provide more integrated care it is imperative that all the agencies that provide care within that service make a contribution. Some areas will be the remit of health care professionals alone but there are many areas where greater partnership between health and social care may benefit service users. Two priority areas for practices are to reduce unscheduled admissions and reduce the length of stay in hospital.

One common frustration familiar to both practices and those working in social care is the necessity for admission to acute hospital for “social reasons”. This usually occurs when a small medical problem tips the balance of a precarious social care situation. If only there could be more investment in detection, prevention, joint management planning between health and social care, rapid response social care packages and intermediate care, many of these admissions may be prevented. With PBC there is a chance to invest in these things using the savings that would come from reducing unscheduled admissions.

Johnny Marshall is GP partner in the Westongrove Partnership in Wendover, Buckinghamshire, and is treasurer of the National Association of Primary Care.

Click here for the next Health Special article Time to put the chisel away.