Practice - based commissioning

Practice-based commissioning is the transfer of the commissioning of healthcare services from the primary care trusts in England to GPs. But will the new system be any more effective than the fundholding of the 1990s? And is it the right way to counter the activityfocused drive of payment by results, (see Frontline, 20 June) and ensure investment in chronic disease management and public health? This fifth article in our series looks at these and other key questions. ~ Reports and research by Andrew Cole and Gary Robjent

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What's happening and why?

The driving idea behind PbC is simple: involving GPs, the clinicians responsible for spending the largest slice of the NHS budget, in the planning and organising of services.

For the last five years PCTs have been responsible for commissioning most healthcare. But ministers are concerned that PCTs have done little to change approaches to care and treatment. Notably, they have largely failed to achieve the shift from secondary to primary care that was part of the reason for creating them.

PbC was launched in April 2005. The scheme allows GPs to run local budgets and buy in services. And with practices able to keep 70 per cent of savings made, there are big incentives to ensure the new services are cheaper.

Some will see echoes of GP fundholding. The big difference is all practices are expected to take part in PbC and PCTs will continue to hold the ring, setting the strategic framework within which practices buy services and remaining legally accountable for all commissioning.

In March the government announced that 96 per cent of all practices had signed up. But support is patchier than that fi gure suggests. A survey by the NHS Alliance and the King's Fund indicated that although three-quarters of practices supported the policy, almost as many failed to agree a PbC budget last year.

Most experts believe no more than a quarter of practices actually buy in services, and they may only be commissioning a small range.

The home front

PbC is an England-only initiative although, as with a number of the England reforms, Northern Ireland appears to be following a similar path. Community commissioning associations are to be established in each local commissioning group and will comprise GPs, other primary healthcare professionals and representatives from the voluntary and community sector. The CCAs will have a special focus on long-term conditions. In Scotland and Wales, however, such decisions will continue to be taken at board level.

What does it mean for healthcare?

"Not all GPs are interested in spending their time in this way. Many see their lives as quite full enough in trying to provide services" Chaand Nagpaul, Chair, BMA commissioning and servicing committee.

Health ministers anticipate PbC could revolutionise the shape of much healthcare. Engaging clinicians directly in the planning process will, they say, help to cut substantially the number of hospital referrals, reduce prescriptions and accelerate the shift from secondary to primary care.

There is some evidence to support that. Practices already involved in commissioning are now conducting a range of diagnostic tests from their premises and running gynaecological, dermatology and diabetic outpatient clinics.

Figures released by the Department of Health show hospital referrals dropped by between 25 and 33 per cent in early commissioning practices - the equivalent of cutting 2.5 million referrals.

Longer-term, the hope is PbC will lead to a radical redesign of services and clinical pathways, refl ecting more accurately local need and helping to ensure more patients receive services closer to home. And these services are likely to be cheaper, although this is by no means certain.

As with other NHS reforms, this will be driven by a bracing dose of competition. The DH is determined to introduce a plurality of providers who will compete for contracts from practices. One controversial element is the move to encourage PCTs to divest themselves of their provider services.

So far change on the ground has been considerably slower than intended. One reason has been the turmoil in PCTs, most of whom have experienced major organisational upheaval, while a sizeable minority are heavily in debt.

Practices also seem to have little incentive to take over commissioning from a trust if it simply means they will be taking on its debts and have little room for manoeuvre.

Another widespread complaint is that the information and support trusts are giving GPs is inadequate. A lot of the commissioning data, about referral patterns and health needs, is out of date or incomplete.

Meanwhile the financial information may be incomprehensible to people not versed in business matters. Finally, it is still not clear how many GPs want to get involved in commissioning. There may be different levels of involvement. Many GPs are combining into clusters in which a few enthusiasts take on commissioning on behalf of colleagues. Others want to be involved at every stage, while yet other GPs cooperate with clinical pathways, local protocols and prescribing policies but won't do any more.

Hopes and concerns

Hopes

  • better responsiveness to individual patient needs
  • better demand management
  • better management of long-term conditions
  • development of wider range of practice-based services
  • reduction in use of A&E services through the direct enhanced services incentive scheme
  • reduction in use of out-patient services (through DES)

Concerns

  • universal sign-up by GP practices, but are they engaged in the process?
  • possible adversarial relationship with secondary care providers
  • is there adequate PCT/management support, especially as practices will be negotiating with foundation trusts and the private sector?
  • lack of timely, accurate and pertinent data?
  • additional transaction costs

On the ground - Lancashire

GP Mark Spencer admits he couldn't wait for the launch of PbC and the chance it would offer to bring in a revamped therapy-based service to tackle chronic pain. Nearly half of the patients he sees at Mount View practice in Fleetwood are suffering from some form of chronic pain, he says. But until 2005 the only options were referral to hospital or to a hugely over-subscribed specialist pain service, or 'reaching for the prescription pad'.

As soon as PbC arrived, Dr Spencer's practice, working jointly with the PCT, seized the chance to set up a multidisciplinary service, including physiotherapy, acupuncture, TENS and pharmacy, to offer rapid assessment and treatment for all patients.

The new service has already had a big impact. The practice has reduced its prescribing bill by around £50,000 a year and cut orthopaedic referrals by 20 per cent. Meanwhile waits, which used to be four months, are down to a week.

The patients love it - especially the fact that clinics are held in the evenings rather than the day, according to Dr Spencer. 'Even if this were costing exactly the same as the previous system, the patients think it's a much better service that they're getting,' he says.

He is employing private rather than NHS physiotherapists, partly because the work is sessional and uncertain, but also because 'NHS physios were already working flat out'.

On the ground - Airdale

Priestthorpe Medical Centre in Bingley, West Yorkshire, which comes under Airdale primary care trust, has been running an extended scope physiotherapy service for patients with musculoskeletal problems for the past three years.

Patients who can be managed non-surgically by local to the physios by local GPs to the physios who assess their needs and, where appropriate, offer a range of physical therapy treatments.

The service has helped cut the number of hospital referrals by around a third while offering a more personalised service, together with shorter waits for patients.

So on the face of it the service would seem to be tailor-made for PBC, particularly given that in the past year it helped save the practice £50,000 on its orthopaedic services budget. But GP Andrew Jackson, who leads the service, remains sceptical.

'I haven't yet seen it benefi t the service, I've only seen it hinder it,' he says bluntly. One of the main problems, in his view, is that the expansion of commissioners has led to a fragmentation of services, making it more diffi cult to introduce a standard pathway for all musculoskeletal patients.

At the moment, he feels there is a 'bit of a question mark' over the future of the service, particularly given the demands of the 18-week waiting target which means one can't afford to keep patients in the community for long while the clock is ticking.

He is confi dent the service can evolve to meet this new challenge but less confi dent of PCT support. 'I can see how things are shaping up well ahead of the PCT - but the difficulty is getting them to take this on board.'

What does it mean for physiotherapy

"If the commissioners don't understand what we do, then there is a chance they won't know what it is they should be choosing or commissioning" Fiona Jenkins, Non Medical medical director of therapies, South Devon healthcare trust

Practice-based commissioning has had little impact on physiotherapists so far - but that could be set to change. On the face of it, the new policy offers big opportunities for physiotherapists. The new general medical services contract pays the practice the same amount for clinical activity, regardless of whether a doctor, nurse or physiotherapist does it, so there is a big incentive for practices to consider alternative, cheaper provision. Some of this is already happening in areas such as pain and musculoskeletal management where enterprising GPs are working with extended scope physiotherapists to reduce hospital referrals and treat patients closer to home (see case studies).

But the possibilities are almost limitless for redesigned care pathways involving physiotherapy. Recent health department guidance, for instance, lists a number of areas, including chronic obstructive pulmonary disease, long-term conditions, heart disease and podiatry, where pathway redesign could make a rapid difference to patients.

The big concern, however, is that many commissioners - whether at PCT or practice level - have little idea what physiotherapists can do . At the same time many physiotherapists employed by PCTs are worried about their future.

Although the health department has backtracked on its original proposal to divest PCTs of all provider functions, it is committed to greater choice and diversity in the provider market. That will almost certainly mean an end to the old certainties for many physiotherapists, who may find themselves pushed into more entrepreneurial roles, either in alliance with other health professions or as independent practitioners.

They could also find they are competing with other physiotherapists. Some fear a marketplace for physiotherapy services could lead to a dilution in skill mix.

A service consisting largely of band 5 physios might be more attractive - though not necessarily more effective - than a more hierarchical service including extended scope physiotherapists.

But others are more optimistic, seeing some exciting opportunities for professionals to form their own groups and become independent contractors offering their services to commissioners.

What are the opportunities for physios?

Liz Sargeant, a former physiotherapist and now an independent consultant in organisational and personal development as well as a PCT non-executive director, believes there are huge opportunities - if physiotherapists are prepared to seize the chance.

But one of the biggest challenges, in her view, will be providing hard evidence that what they do is effective. Practice-based commissioning is likely to lead to a more thorough scrutiny of the cost and effectiveness of allied health professions services. And that could lead to some awkward questions.

'Physios have got to stop doing things that don't make a difference,' she says. 'For instance, there is quite a lot of research that shows we don't need to treat everybody with low back pain - we don't even need to see them to assess them.'

Once PBC is fully operational, she predicts practices will be more likely to commission care pathways involving a range of different services rather than a service from a single professional group. So physiotherapists will need to market themselves differently and make alliances with other professionals.

One option might be to go into partnership with GPs, which could give them much-needed commissioning power as well. 'The fact is that GPs like physios so it should be easier to get their foot in the door. And the good news is they'd probably still have an NHS pension.'

But all providers will have to be willing to change the way they deliver care to meet the needs of commissioners.

To do this physios will have to be brave and prepared to take risks, Ms Sargeant says. That could mean challenging some traditional professional boundaries - and even their own professional body.

No change, however, is not an option. 'Don't wait for it to happen to you,' she warns. 'Physios can't wait to be asked, they must go out and make their case.'

Useful references and resources

  • Department of Health [2006]. Practice-based Commissioning: Early Wins and Top Tips
  • CSP [2006]. Practice-based Commissioning (and Other Changes in Primary Care). A Simple Guide for Physiotherapists
  • Department of Health [2006]. Practice-based Commissioning: An introduction for a Local Authority Audience
  • Kings Fund, NHS Alliance [2007]. Practice-based Commissioning: From Good Idea to Effective Practice
  • See also: www.nhsalliance.org

This text on this page was last updated on 18 Jul 2007.