Posts Tagged ‘Practice-based commissioning’

GPs to be given purse strings in NHS shake up

BBC Health - 9th July 2010 8:22 am

GP practices are set to be handed responsibility for most health services under ministerial plans for a radical shake-up of the NHS in England.

Local trusts and strategic health authorities would be sharply scaled back to make way for their new role.

Health Secretary Andrew Lansley believes GPs are best placed to understand patients’ needs and to decide where money should be spent.

But there are concerns GPs may not have the skills or will to take on the role. Others have questioned how they would be held accountable.

Discussions with doctors’ representatives over the plans are continuing, and the government has confirmed it will publish further details in a white paper next week.

Read more at BBC Health.

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Understanding NHS finance, budgets and commissioning

By Mike Broad - 23rd July 2009 3:24 pm

Political expectations are growing that hospital doctors will get to grips with NHS finances and get more involved in budget management and commissioning.

With the NHS facing a funding shortfall of up to £10bn for the three years after 2011, there’s increasing political pressure on doctors to help identify areas where savings can be made.

Lord Darzi also called for hospital doctors to be more involved in commissioning and budget management to help drive the quality agenda. In High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review (July 2009), he calls for the extension of practice-based commissioning from GPs to hospital doctors and nurses.

To this end, the Academy of Medical Royal Colleges has teamed up with the Audit Commission to produce a guide on NHS finance for doctors. The guide says: “This is not about turning doctors into accountants; it is about enabling doctors properly to engage with finance colleagues so as to make the best use of NHS resources for patients.”

Commissioning - the background

Commissioning is the process of determining the health needs of the population, the resources available and how to organise service provision. Commissioning currently occurs mainly at PCT level and they’re responsible for buying services from local providers. This can be from NHS trusts, foundation trusts, themselves (or other PCTs) or from the independent sector.

The first step in this process is a Joint Strategic Needs Assessment. This is a process conducted in partnership by local government, PCTs and the local community to identify areas of priority for action to improve local health and wellbeing. It informs the Local Area Agreements, helping commissioners to specify outcomes that will help providers design local services and it’s been a statutory requirement since 1 April 2008.

Practice-based commissioning

Commissioning at PCT level can be seen as relatively remote from patients and clinicians. So, GPs have been given more say in how they deliver services to their patients because they’re closer to them. Theoretically, under practice-based commissioning, services better represent patients’ preferences.

PBC has also been developed with the aim of making the NHS more patient-centred by extending choice in elective care.

GPs can take on the commissioning and financial responsibility for large parts of PCT budgets and change the patterns of service provision. Practices can group together but the PCT retains legal responsibility. Practices can use 70% of the savings made for reinvestment for new services or more equipment.

While benefits have been seen in primary care, there’s little evidence so far that any form commissioning has greatly affected hospital services in the past 20 years.

Despite PBC being introduced in 2004, most GPs are really only now developing formal commissioning relationships with PCTs.

World Class Commissioning

World Class Commissioning is a government programme to improve commissioning and thus the quality of care. It strives to secure maximum improvement in locally prioritised health and wellbeing outcomes from existing resources.

There are 11 competencies for a PCT to become a World Class Commissioner. They include locally leading the NHS, working with community partners, collaborating with clinicians, engaging with public and patients, prioritising investment and promoting innovation. Commissioners will be assessed against them by an annual commissioning assurance process.

Understanding Payment by Results

If hospital doctors are to get more involved in finance, they need to understand Payment by Results. PBR was introduced in 2003 and is a rules-based approach for paying for hospital services in the NHS. It is a key part of the current reform programme in the NHS and was designed to directly link the payments that healthcare providers receive to the activity they undertake. PBR underpins patient choice by enabling the money to follow the patient.

A national rate, or tariff, is set annually for each type of service, with services classified by health resource groups. Commissioners are then required to pay for healthcare provided to their patients at this tariff.

PBR has significant implications for NHS organisations. Both hospital providers, and particularly PCT commissioners, face greater financial risk and reduced financial control.

With the price set nationally, contract negotiations focus on the volume of activity to be provided. Without the protection of fixed value block contracts, providers need to maintain a certain level of activity and ensure that costs do not exceed the national tariff in order to remain financially viable.

Budget management

Once an organisation has set its overall strategy and its service and financial plans, these need to be translated into a budget. Setting a budget in this way will ensure that resources are allocated in line with the organisation’s aims and objectives.

Good budget management is achieved where budget holders are held to account for managing their budgets; reports monitoring performance against budgets are accurate and provided regularly to budget holders; monitoring reports do not just contain financial data but are linked to information about performance and service improvements; and, variations against budget are identified and investigated, and corrective action is taken.

Financial management is about explaining and accounting for what has happened in the past and forecasting income and expenditure in the future. Using budget statements, budget holders should be able to identify the areas where they have spent less and spent more than their budget.

Service-line reporting provides a framework that enables NHS bodies to understand the combined view of resources, costs and income, and hence profit and loss, by service-line or specialty rather than at trust level. Managing at this level allows managers and clinicians to make more effective decisions about, for example, growing or reducing services on the basis of efficiency and profitability, where cross-subsidisation is occurring, or where services might be better provided in the community. PBR has encouraged more trusts to adopt a more comprehensive approach.

There is also a growing impetus for trusts to introduce patient-level information and costing systems. It involves a bottom-up approach to costing, using information about individual patients’ resource consumption. The costs of individual patients are aggregated to generate costs for differing groupings, for example by HRG, by procedure or by consultant.

This provides a much better understanding of what drives costs and how to make efficiencies.

Making changes and efficiencies in NHS services

Efficiency savings can either be cash releasing or non-cash releasing. Cash-releasing efficiency savings result in the cost of the service provided being reduced. Non-cash releasing efficiency savings occur when more activity is provided but the cost of delivering the service remains the same. An example of this could be a reduction in average lengths of stay, which resulted in more patients being treated.

Improvements in quality and efficiencies are expected to be secured through better procurement, commissioning, organisation and management, with any additional savings being reinvested in new or better local services.

There are a variety of reasons why changes to service delivery might be made; for example, to improve the patient experience, the need to meet efficiency targets or to move services from secondary to primary care.

The financial consequences of such changes should have been determined and set out in a business case.

Developing a business case

A business case is a document developed to support decision making for new investments or to change or develop a new service. It sets out the case for undertaking a project, weighing up the objectives and benefits against the estimated costs and risks. Business cases should include: measurable objectives; an appraisal of all the options available (including the ‘do nothing’ approach, an indication of the preferred option and an explanation setting out why it is favoured); demonstrate the affordability and value for money; provide a timetable reflecting the life of the project; and define the roles and responsibilities of those involved.

It should make a compelling case to the audience that is going to judge its merits and should be subject to a robust appraisal process which evaluates its relative costs and benefits, both financial and non-financial.

Financial training for doctors

The report, A Guide to Finance for Hospital Doctors, by AMRC and the Audit Commission also suggests that clinicians should receive financial training to help them understand budgets, commissioning and their monitoring.

Related stories

PBR needs overhaul

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Darzi Review and NHS modernisation: at-a-glance guide

By Mike Broad - 17th July 2009 5:01 pm

The government’s plans to reform the NHS over the next 10 years were laid out in the Darzi Review.

In 2007, colorectal surgeon Lord Ara Darzi was asked to conduct the review on health services in England and consulted with strategic health authorities and clinical pathway working groups to set future priorities.  

Darzi suggested that while the NHS was two thirds of the way through its modernisation programme - as set out in the NHS Plan in 2000 - further steps were needed. While the health service had increased capacity and driven down waiting times, quality and outcomes needed to be improved.

Other aims of the Darzi review included ensuring services were better joined up, care was more accessible and integrated, and services provided more patient control, choice and local accountability. There’s also been a drive to put clinical decision making at the centre of the reforms.

As the Darzi review took shape it echoed the themes of the white paper Our Health, Our Care, Our Say - particularly on choice, personalisation and community services - but there was a change in how it would be delivered. It was no longer about top down targets with a focus on outputs, but about quality and local determinism.

The key devices to achieving this are improved information on clinical performance, greater choice and control for patients and strengthened incentives for providers.

High Quality Care For All

The final report High Quality Care For All - NHS Next State Review Final Report was published in June 2008. It sets out how the NHS should move from centrally driven, target based management to one of empowered local services focused on quality as well as activity.

Darzi’s focus on raising quality

One of the key drivers of change will be a range of local quality indicators that will enable clinicians to benchmark and improve their performance. Areas measured will include mortality, complication and survival rates and patients’ views. 

Financially, funding formulas and contract payments will increasingly be linked to quality outcomes. All providers - NHS, private and third sector - will be required from April 2010 to publish Quality Accounts explaining how they made a difference.

Clinical Excellence Awards will be more focused on quality improvement. New awards conditional on clinical activity and quality indicators, and encourage clinical leadership and innovation.

Patient rights

The review proposed the new NHS Constitution, which spells out its principles and values and enshrines patient rights.

Patients will have a greater choice of GP practice, and ‘choice’ is a tenet of the constitution.

Patients are now guaranteed access to the most clinically and cost effective drugs and treatments. All patients will receive drugs and treatments approved by NICE where the clinician recommends them. NICE’s appraisals process is to be speeded up. Some have criticised it for being toothless.

In his first major speech as health secretary Andy Burnham outlined the developing system of accountability in the NHS, initiated by Darzi, and founded on a smaller number of agreed patient outcomes and fundamental rights. The NHS Constitution will sit alongside service guarantees linked to a minimum set of standards - rather than lots of volumetric targets - that will need to be maintained.  

Services closer to home  

Darzi had just produced his 10-year plan for the reorganisation of the NHS in London when he started his review. The London plan proposed the creation of larger specialist centres for the treatment of conditions such as stroke and heart attacks. This was combined with a network of 150 GP-led health centres providing a combination of services traditionally offered by GPs and district general hospitals.

Many of these ideas were also reflected in the interim report Our NHS Our future: NHS Next Stage Review

published in Oct 2007. This report included recommendations to introduce MRSA screening for hospital admissions and create 100 new GP practices in deprived areas.

It also controversially proposed to create 150 new health centres around the country which would provide extended range of services and longer opening hours. Polyclinics are intended to improve access and better integrate primary care practitioners with diagnostic and specialist services.

They are intended to reflect local needs and priorities, and be open from 8am to 8pm every day to fit with people’s lifestyles. Any member of the public can walk into a polyclinic regardless of which local GP service they are registered with, and people will be offered the opportunity to register at these new facilities.

However there are concerns that, despite a lack of clarity over their purpose, they are being rolled without being piloted.

And that polyclinics will compromise the coordination of care, prompt staff shortages and end up primarily nurse-led.

It’s looking increasingly likely that polyclinics will only be established in London.  

Personalised services in Darzi review

When consulting for the review, Darzi commented: “Patients have told me that they still sometimes feel like a number rather than a person…they lack ‘clout’ inside our health care system.”

Along with clarifying and strengthening patients rights, and giving them more choice over who treats them, the review also gives them more power over how they are treated.

Everyone with a long-term condition will have a personalised care plan and personalised health budgets will piloted, with direct payments used where possible.

Andy Burnham described personal budgets in his first major speech as the “ultimate expression of power and influence being handed down to the individual patient”. The DoH is due to pilot them among 5,000 patients with chronic conditions. “These pilots will give patients the power of the purse strings: making decisions with the help and guidance of GPs or consultants that directly affect their own budget is spent.”

A more preventative approach to public health

The NHS, through partnership working, will focus on improving health alongside treatment. Every PCT will commission comprehensive wellbeing and prevention services in partnership with local authorities. And there’s a new coalition for Better Health with voluntary agreements between the Government, private sector and charities to improve health. GP’s Quality and Outcomes Framework is to be improved to provide incentives for maintaining health as well as providing care. 

Better guidance and regulation

The Care Quality Commission will have new enforcement powers to improve safety and reduce healthcare associated infection.

NICE will be expanded to set and approve more independent quality standards. A New National Quality Board will set priorities and feedback to government.

Promoting innovation

There is new emphasis on innovation and fostering an enterprise culture. Strategic health authorities will be under a statutory duty to promote innovation and regional innovation funds will be launched to invest on a commercial basis in good ideas. There will be a pilot programme of ‘health innovation and education clusters’ to stimulate partnership working between clinicians, universities and business.

Empowering staff

More support is promised in the Darzi review for clinicians who want to move out of the NHS to set up independent social enterprises. Their pensions will be protected. Integrated care organisations will also be piloted, bringing together health and social care professionals together. There is also a pledge to reinvigorate practice-based commissioning and give greater freedoms and support to high-performing GP practices to develop new services for patients.

Clinical leadership will strengthened, with medical directors and quality boards featuring at regional and national level.

Darzi review update – one year on

Darzi launched a new set of proposals in High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review one year on.

Clinical budget ownership is to be extended to hospital doctors and nurses, with the aim of promoting entrepreneurship and innovation in service delivery.

Two “obsolete” clinical targets are also to be removed: the 13-week outpatient and 26-week inpatient performance targets. A review into other targets was also launched.

A voluntary peer review accreditation system will also be introduced to assess the standards of clinical teams and create competition among clinicians to improve. The royal colleges are currently developing a consistent approach, and it will be overseen by the National Quality Board.

Darzi’s resignation

Lord Darzi resigned, in July 2009, returning to research and surgery. While the public reason for his early departure was his concern for his patients, it’s been suggested he found the culture of Whitehall challenging.

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Darzi wants consultants to own budgets

By Mike Broad - 1st July 2009 2:00 pm

Clinical budget ownership is to be extended to hospital doctors and nurses, health minister Lord Darzi announced this week.

It’s one of a new set of proposals in High Quality Care For All: Our Journey So Far, which charts the progress of the Darzi Review one year on.

The report says that through giving consultants and nurses ownership of their clinical budgets - like with GPs and practice-based commissioning - entrepreneurship and innovative delivery of services will be promoted. They’ll also be more patient focused.

Lord Darzi said: “Quality is what we aspire to and innovation is how we achieve it. High quality care is better for patients and often better value for tax payers.

“The progress made since last year in the quality provided to patients and the safety of their care was not driven through top-down targets but by giving responsibility to the staff at local level.”

But Stephen Campion, chief executive of HCSA, doubted whether trust finance directors would give clinicians the level of ownership and protected funding required for them to make a real difference to how their services are delivered.

He said: “The principle of budget ownership by clinicians has been around for some time. It has largely failed because the responsibility to manage these budgets is not matched by giving effective authority to clinicians.”

Two “obsolete” clinical targets are also to be removed: the 13-week outpatient and 26-week inpatient performance targets. A review into other targets was also launched.

A voluntary peer review accreditation system will also be introduced to assess the standards of clinical teams and create competition among clinicians to improve. The royal colleges are currently developing a consistent approach, and it will be overseen by the National Quality Board.

Professor Ian Gilmore, president of the Royal College of Physicians, welcomed the report.

He said: “The challenge for the NHS is to ensure that the components of the quality agenda are practical and deliverable ensuring that the laudable aspirations can be transferred from paper into practice, especially in an increasingly cash-strapped environment.

“The College is delighted to be leading the national pilot project on the accreditation of stroke services. Service accreditation is a highly complex area but we believe it is a logical extension of our existing programme of guidelines and audit. We believe that service accreditation will complement the regulatory work of the Care Quality Commission and provide the organisational context for individual medical revalidation.”

The Department of Health report also highlights a number of successes over the past year such as a significant reduction in hospital-acquired infections and longer opening hours at many GP surgeries.

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Practice-based commissioning extended to hospitals

Pulse - 30th June 2009 6:50 pm

Practice-based commissioning is to be extended to cover hospital staff in a move that may intensify the competition for funding between primary and secondary care.

Under the plans, outlined by health minister Lord Darzi, hospital trusts will be encouraged to buy in services under PBC.

Consultants, hospital nurses and allied health professionals - including physiotherapists and midwives - will be given the opportunity to reorganise healthcare services and develop proposals for new income streams.

Lord Darzi, speaking on the anniversary of his NHS Next Stage Review, said widening out commissioning powers was now seen as a more effective way of driving improvements than setting a new array of central targets.

But PBC leaders warned the plan risked further undermining GP engagement in PBC, and could divert money into hospitals’ coffers.

Read more at Pulse.

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