ࡱ> UWT` 1bjbjss *D)"""""""6zzz8,6:%$$$$$$$$%hX($"$""$WWW""$W$WWrY"t""# 0OB2*z #$, %0:%#B)>B)##B)"#Z`@W4$$X:%666D z666z666""""""  LMC STATEMENT ON PROGRESS ON PRACTICE-BASED COMMISSIONING Summary The LMC advises that practices should now seriously consider participating in a local commissioning consortium. As a minimum they should have identified a lead commissioning GP and manager and decided on their preference for a commissioning locality. Introduction Although the position of the LMC on practice based commissioning has not changed substantially from our previous papers, pressure to implement PBC continues even in the absence of any clear guidance as to the structures and resources that will support it. The announcement of a Directed Enhanced Service to fund practice activity is a step forward, as is the participation of Somerset in the National Primary Care Development Team collaborative as a first wave site. However, we still have little understanding of the key tasks of commissioners or even their primary and secondary objectives. The LMC view is that PBC offers more opportunities than threats but to be effectively run it will require considerable time and skilled staff input as well as a significant financial commitment. Effective PBC is therefore more likely to be provided by groups of practices who are able to pool resources. The Commissioning Environment Politically PBC is seen as the counterbalance to Payment by Results which otherwise would drive an increase in secondary care activity. This would be directly in opposition to the objectives of the latest White Paper Our Health, Our Care, Our Say. Implementation is therefore an NHS priority. However, as the PCTs enter a period of uncertainty with the inevitable consequent attrition of key staff practices cannot rely on them to establish the kind of structures that will be flexible enough to cross existing NHS boundaries, and also adaptable enough to meet the uncertain requirements that PBC will throw up. At the same time, provider Trusts are struggling to accommodate many changes such as the demands of Choose and Book and the NPfIT as well as Practice Based Commissioning. As well as having a provider perspective on the process, they too will lack the capacity to contribute much to the preparatory work. This means that it will be largely up to practices to do the job. LMC Suggested Model Commissioning decisions within the NHS need to be made at different levels for different types of services. For example, basic physiotherapy may be commissioned by even a small practice but complex neurosurgery from the tertiary centre needs to be organised for a large geographical region. We propose a modular model that will allow such decisions to be made by an organisation of sufficient size and capacity to make appropriate choices in every clinical area. The key to success is to allow practices to form different groupings according to the service that is being commissioned. These groups may be vertical; that is conglomerations of smaller ones, or horizontal, where practices cluster with different colleagues for different purposes Tier 1 The practice would constitute one unit at tier 1 and each will wish to directly commission more or fewer services according to their size, locality, and other circumstances. Tier 2 Commissioning decisions above practice level would be made by localities of practices sharing a common interest. Typically these would be geographical but, for example, a group of rural practices surrounding an urban centre may jointly commission a mobile service whereas their town colleagues would require a static one. We anticipate that a cluster of practices serving a population of about 30,000 would be a useful functional size, but any practice may be in several different clusters according to their commissioning needs. Tier 3 Much commissioning could be done at locality levels of between 100,000 and 150,000 patients, roughly equivalent to an old PCT but not necessarily following existing boundaries. This is probably the best level at which to establish the shared service organisation that would be required. It is likely that setting up and running this should be contracted out to a management organisation. Higher Tiers Tier 4 would cover the entire Somerset Primary Care Trust area and tier 5 the counties covered by the Strategic Health Authority. We might conceivably require a tier 6 which would be one or more geographical regions with a population of up to, say, 10,000,000. These would be valuable for commissioning tertiary services, but also for bringing political and economic pressure to bear to providers who may, for historical or other reasons, be disinclined to listen to local purchasers. Even the largest Foundation Trust would be a small organisation beside a commissioning network purchasing for a population of this size. Practice Participation in the Consortium Clearly different practices will have different levels of interest and expertise and will wish to do more or less work on an individual basis. However, all practices will recognise that there are limits to the range of services that they can individually commission. Some practices may wish to have very little involvement in commissioning but a service still needs to be provided for their patients and in our view this is much better done in an integrated way rather than piecemeal. Leaving gaps in commissioning coverage will be inefficient and could tempt the PCT to consider putting parts of the service out for private tender. Structure and Funding of Consortium Although the sums available to each individual practice for commissioning are modest if a proportion of these are pooled even a fairly small locality should be able to accumulate sufficient resources to establish a commissioning structure. We suggest therefore that each tier should be funded by top slicing a proportion of the funding available through the DES. A significant proportion of the money would be retained in tiers 1 and 2 so that active practices would keep more resource in-house compared with those who preferred to have less direct involvement. Consortia would need to be legally structured and appropriate documents for doing this are available at modest price. Whilst it would be premature to establish form before their function is defined, we foresee these organisations needing a reasonably senior executive (PCT senior manager/associate director equivalent) with both administrative and clerical support as well as a physical base and infrastructure support. Some of these costs could be met by the PCT either directly or by secondment, and ultimately the whole organisation may be jointly funded. There are significant benefits to be gained from having access to a very experienced senior officer with PCT/Trust Chief Executive status who would be able to negotiate on equal terms with her or his opposite numbers within the NHS. Such an officer should be shared appointment between a number of Tier 3 consortia. Benefits of the Model PBC is complex and negotiations with trusts and PCTs will require skilled knowledge and expertise. The organisation undertaking this work needs to have enough resource to afford the right calibre of person as well as to support its own infrastructure. The modular/network structure proposed allows practices to form groups that are appropriate for the matter under discussion. A consortium at tier 6 would have much more influence over a foundation hospital than a group of local practices. Political pressure to move PBC on means that PCTs, who are already in flux, may be forced into adopting unsuitable models and deploying inappropriate staff to the commissioning process. A powerful consortium would act as a counter-balance and would ensure continuity through the period of PCT transition. A GP led consortium would also ensure that patients clinical needs and practices organisational needs were subsumed by neither the political whim of the day nor the management agenda of PCTs and health authorities. Funding Although there may be savings that can be released by improving commissioning, experience suggests that these cannot be sustained. The inexorable year by year rise in emergency activity, and the pressures of demography and medical advance mean that budgets will never be adequate in the longer term. For both practical and ethical reasons the commissioning structure should rely for base funding on money that can be released by practices and the PCT from any relevant management envelope and not service delivert savings. Practices will need to decide whether they are prepared to participate on this basis, but the alternative of individual commissioning is likely to be attractive only to the largest groups Next Steps 1. The LMC will organise a series of meetings in March to which practices are invited to send a nominated partner to discuss the general principles in this paper. If these prove acceptable in the locality the LMC will then support the preparation of a timetable for specific action. 2. Negotiations should starts with PCTs soon to establish an interface between the localities and PCT Commissioning Managers and to explore in detail how PCT commissioning will occur at locality level both over the next 12 months of transition and under the new arrangements. We suggest that practices nominate a lead person in each locality to do this work on the understanding that he or she will have first call on shared funding once established. 3. Detailed work needs to be undertaken on the methodology of budgets setting, data verification and activity analysis. Somerset and Dorset PCTs will have online access to secondary care data and ultimately it is hoped that real time information will be available to practices. The LMC considers that this is primarily the responsibility of the PCTs but will seek to represent Somerset practices in this process. In the meantime we suggest practices consider in outline how their locality would wish to use the resources of the consortium in this context. 4. The LMC will support pilot work in all the PCTs to try and clarify the whole process of PBC, but specifically including financial flows, service improvement markers, clinical responsibility and outcomes, best use of resources and provider stability. 5. If there is general agreement on the suggested model the LMC will prepare a paper on funding options in April which will be the first of a planned series of working documents. 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