Title: Practice-Based Commissioning: From good idea to effective practice.
Authors: Richard Lewis, Natasha Curry and Michael Dixon
Institution: All of the authors hold positions at the King’s Fund, London
Title: Practice-Based Commissioning: Learning from a Development Programme.
Authors: Beverley Slater and Jacquie White
Institution: Both authors hold positions at the Improvement Foundation.
Practice-based commissioning (PBC) is the devolution of commissioning roles from primary care trusts (PCTs) to general practice teams, together with financial accountability for “indicative budgets”. These two reports pull together some of the most recent findings on the development and implementation of practice-based commissioning, which is one of the government’s flagship policies on health and (potentially) social care. In both cases the findings are mixed, with some evidence of progress set alongside a range of ongoing implementation problems.
Lewis et al consider the current state of PBC implementation and how a course of action might be adopted to move the idea from the status of “good idea” to “effective practice”. The work is based upon a “straw poll” of 257 GPs and practice managers designed to gauge front-line opinion. Slater and White describe the first year of a PBC development programme commissioned by the Department of Health (DH) and run by the Improvement Foundation, to which the authors belong. Several waves of this programme have been held, and by the end of 2006 it had engaged with 106 PCTs covering 2,450 GP practices and 23 million people. Both studies therefore consist of quite large samples.
The two reports tend to treat PBC as an NHS issue rather than something that is part of a wider inter-connected system. Lewis et al explore the views of GPs and practice managers and report a mixed bag:
● Most respondents say that their PCT has been unsupportive in developing PBC, with only 3% saying their PCT involves them to a great extent in strategic planning.
● 70% did not have a budget agreed with their PCT for 2006-7 and of those who did, over a third did not understand how it had been set.
● 72% think there are barriers that prevent effective PBC, notably lack of PCT support, high levels of bureaucracy, financial shortfalls and PCT reorganisation.
● 31% reported a “very high” commitment to PBC and 42% “quite high”.
The authors bemoan the way in which PBC and PCTs seem to be “fighting for the same air-space” and argue instead for a “powerful commissioning synergy”. They consider the scope for greater financial incentives to persuade GPs to engage more fully with PBC but conclude that the recent rise in GP income from other sources makes this only marginally attractive. Instead the authors rather optimistically stress the need to “harness the professional competitiveness of GPs and foster a sense of pride among them for their PCT”. All of this is somewhat at odds with the more positive spin put on the implementation of PBC by the government.
Whereas Lewis et al report upon the findings of a national questionnaire, Slater and White are able to draw upon more qualitative evidence from their development programme. They conclude that as a result of undergoing the programme, delegates improved their knowledge of PBC and their preparedness to implement it in their own patch. However, like Lewis et al, they refer to tensions between PCTs and PBC around agreeing practice budgets, providing usable information and obtaining analytical support. Despite some positive findings, the authors conclude that the engagement of GPs with PBC is “a fragile commodity”. It is said that the common agendas between primary care and secondary care, and between primary care and social care, have not yet been fully explored, and that it is too early to say whether PBC will lead some GPs to provide integrated care from a primary care base.
Both reports have methodological limitations. Lewis et al accept that their straw poll is not a representative sample, but nevertheless argue that the findings give a valuable insight into the views of front-line general practice. Slater and White, on the other hand, are reporting on their own organisations’ activities rather than researching as independent investigators. Nevertheless the two pieces of work are of importance and do tell us more about a key aspect of government policy about which we still know relatively little.
What are the implications of this work for social care? Rather alarmingly the reports have little or nothing to say about social care or the wider local authority relationship with PBC.
Slater and White give data on the service redesign foci of the sites participating in their first wave programme and these largely focus on demand management activity such as stemming the increase in emergency admissions and providing better and more comprehensive proactive services for people with complex or long-term conditions. Arguably these tasks cannot be effectively accomplished without a much closer relationship between PBC and social care – something the authors themselves describe as “the longer term direction of travel”, but about which there is no map for implementation.
The relationship between PBC and social care has become even more pertinent following the recent DH consultation document on commissioning for health and wellbeing which identifies PBC as a way in which person-centred care can be enhanced. PBC, it is said, would support “discussions between GPs, social care practitioners and individuals, together with their families and carers, about how health and social care resources are best deployed to better fit an individual’s needs” (p19). For this to happen there needs to be an effective mechanism to ensure that patients are managed seamlessly through the boundaries of primary, secondary and social care, yet there is little evidence from these two pieces of research that this requirement is understood.
The main proposal for linking PBC to social care appears to be the proposal to encourage PCTs and PBCs to be more flexible in using NHS funds where by doing so they can provide a more appropriate alternative to hospital admission or avoid more expensive interventions which may also reduce independence. Several examples are given of what the DH would consider “reasonable flexibility” in the use of NHS funds, including:
● Purchase of respite care.
● Supporting carers of terminally ill people.
● Crisis avoidance and intervention.
● Supporting healthy lifestyles.
● Supporting greater independence for people with long-term conditions.
● Provision of citizens advice, other advocacy and return to work advisor sessions at practices.
● Support to parents.
● Practice-based multi-disciplinary mental health resources.
● Developing social and practical support for isolated older people.
Health minister Ivan Lewis has gone so far as to state that in future GPs commissioning social care should become mainstream, but it is far from clear that GPs will wish to take on any such opportunities – the more common scenario is the implicit transfer of tasks (but not funding) from the NHS to local councils. The two pieces of work reported here are both of national scale and significance, and the worrying implication of the findings is that social care simply does not yet seem to have appeared on the PBC implementation radar.
Practice-based commissioning has many implications for social care and social care practitioners, and there is no evidence from these two pieces of research that these have been thought through. These implications include:
The future of integrated teams: Where localities have gone down the route of integrating social care professionals with community nurses and perhaps other professionals, there will need to be clarity about the attitude of budget-holding GPs who may be tempted to pull out ‘their’ nurses back into practice-based activities.
The future of self-directed support: The trend in social care is to promote control, choice and flexibility for service users through the development of self-directed support and personalised budgets. NHS monies are currently excluded from this approach even though much of it is tied up in people with long-term conditions who are experts on their own conditions. There is an important debate yet to take place on the intersection between self-directed support and PBC.
Means-testing and charging: The proposal to encourage PBC for the purchase of social care will leave some people receiving NHS funded social care free of charge whilst others get means-tested support from their local council – an untenable situation.
Whole system approaches: GPs are somewhat notorious for concentrating upon changes in their own practices rather than the wider population. The key local mechanism for binding GPs into wider local relationships will be the new statutory duty to produce a local Joint Strategic Needs Assessment, and it remains to be seen how far this will be effective.
Bob Hudson is visiting professor of partnership studies at the school of applied social sciences, University of Durham
Links and resources
● The report from Lewis et al
● The paper by Slater and White has been published in the Journal of Integrated Care, 15(2), April 2007, pp13-25, published by Pavilion Journals
● The website for the Improvement Foundation
● The recent DH consultation on commissioning, commissioning framework for health and well-being
● The DH website is awash with publications and guidance on practice-based commissioning
● Explorations of the relationship between PBC and social care are less common, but two useful sources can be obtained from the Integrated Care Network. The publication, Practice-based commissioning: an introduction for a local authority audience gives a useful overview of the situation, and this is complemented by a 17-minute podcast discussion that spans the general challenges for general practice and community based care. Both can be downloaded from the ICN website