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Moving practice-based commissioning forwards as a solution and a priority |
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GP, Chair, NHS Alliance |
Dr Michael Dixon |
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The modest progress of commissioning so far is partly due to its lowly starting point. World-class commissioning (WCC) is really the very first serious attempt to get the wagon going, and it will take time before creating ‘bite’ in the system. Part of it is historical inertia, but other priorities like 18 weeks and (paradoxically) staying in budget have diffused the focus on commissioning - even though commissioning is the answer to both of them. WCC is finally beginning to concentrate minds, but it won’t produce change for many months. Waiting for PBC In terms of practice-based commissioning, I fear WCC may not achieve its best effects until the results of the PCT assurance framework are in the public domain in 2010. This means that we need other means to progress in the meantime. The DH have recognised that there’s a disjunction between WCC and PBC. That’s symptomatic of a new honesty about where we’ve got to and what we need to do now, thanks to Mark Britnell and Gary Belfield and their team. In the past, the DH has had an ‘Emperor’s new clothes’ tendency towards self-congratulation and insularity. NHS Alliance were warning the DH three years ago about huge problems with clinical disengagement from commissioning, and we were told ‘clear off, it’s not an issue’. The rest is history, and now it’s accepted as a huge issue. Unfortunately, we’ve seen some of the same sort of thing with PBC. We were warning over a year ago about the lack of impetus in the system to get PBC up and running. It’s a credit to Mark and Gary that that message has now been accepted loud and clear. I’m pretty sure that the national increase in non-elective referrals is partly a symptom of the failure to get PBC up and running quickly and efficiently. PBC - a solution, not a problem PBC is clearly a solution to various NHS problems. So it needs to be given added impetus in the minds of the boards of PCTs, SHAs - and the DH too. Without PBC, we’ll be trying to balance the NHS books without any realistic means - unless we want a return to big waits, or less access and choice. Number One priority To make PBC advance, we need various steps. It’s always helpful for the centre and ministers to reiterate that not only is PBC here to stay, it should be seen as the Number One priority, and not as a poor relation to 18 weeks, balancing the books (or generally pleasing the SHA chief executive in other ways of their choice). The DH’s survey of general practices was also a good beginning. It started a year ago, and reports monthly, and still shows (sadly) that: · 25% of practices have no indicative budget; · almost 50% have no commissioning plan; · and less than 20% of GPs think that PBC has been delivered effectively so far. We’ve had those results, but no-one’s been ‘taken out and shot’ as a result. Why not? We need to harden up a bit on exactly what each PCT and SHA is doing to ensure that PBC is getting moving in their local health economy. That means we should ‘take out and shoot’ anyone whose PBC consortia don’t all have indicative budgets and commssioning plans. Target innovation We also need to make sure there is a minimum amount of innovative redesign plans going through each commissioning round as a performance standard. As well as that, we need to ensure we get some money to pump-prime would-be innovators. The front line feel as if there’s no spare cash around. In particular, we must ensure that the Darzi innovation funds go specifically to front-line innovation, and aren’t swallowed in acute trust innovations. We need these innovation funds to be unbureaucratic, and to ensure that their use is properly in line with the aspirations of front-line clinicians and managers. They should not given out by some remote body who don’t see front-line PBC needs. Effective support It’s also time to get effective PBC support. This is partly about making sure PCTs and PBCers are doing business properly over access to the right data and support systems, but it’s also partly about non-techie stuff – ensuring peer leadership within each SHA to light the fires among PBCers and PCTs, and ensure that PBCers aren’t being repressed and that PCTs aren’t being bamboozled. Through peer pressure and nothing else, we could support, flag up and celebrate good practice. But we need hands-on stuff, not more announcements or bits of central help that may not be relevant to PBCers or PCTs. Definitive definition Finally, we need to definitively enunciate what PBC is. Throughout the country, it ranges widely in practice. In some places, the PCT does 100% of commissioning with some advice from local GPs and practices. In other places, PBCers set themselves up as almost-entirely independent enterprises to the PCT, expecting the PCT to listen - who may feel in turn that their PBCers don’t understand national and local priorities. Those are extreme examples: we need to articulate a happy medium, and the added value of PBC in getting primary care clinicians talking to secondary care colleagues to work out appropriate care pathways - which is still not happening, on the whole. Practices remain remote from the secondary care process, which is not a good thing. Into the LDP We also need to think about how we can get PBCers becoming fully involved in forming PCT local development plans (LDPs); and also about getting away from some of the rhetoric that PCTs are for strategy and PBC is for implementation. You can’t divide the two: if PBCers are not signed up to the plan, they won’t carry it out. |
