SCOTT MCKENZIE
Independent Consultant
Scott has an extensive background in business, project and account management. Scott McKenzie Consultancy is one of the leading companies offering specialist management support to strategic health authorities, PCTs, commissioning groups and individual practices for all aspects of PBC
The uptake and drive of new services through practice-based commissioning (PBC) has been relatively slow.
Much of the frustration stems from a poor/variable understanding about why PBC was developed and therefore those involved, both primary care trusts (PCTs) and consortia, remain confused about its main aspirations. This in turn often leads to a failure to utilise, to maximum effect, all the levers and incentives available through PBC.
PBC places primary care clinicians and practice managers in a unique position; it allows them to work in partnership with all stakeholders, including patients and the PCT, to assess the care needs of the registered population and then go on to commission high quality and appropriate care for their patients, ensuring that scarce NHS resources are utilised to bring about optimal outcomes.
PBC allows clinicians to tailor the services to the health needs of the local population; it is an invaluable tool that supports the move of funding to frontline staff to enable the delivery of innovative system reforms, patient choice and plurality of provision. The end goal is to improve services for the local health needs. The key to success for PBC is for clinicians to be integral to the commissioning process.
PBC can be delivered through single practices or via a consortium of practices; however, there are significant economies of scale to be realised when practices formally engage to create a consortium. Because of these economies of scale, it is recommended that a consortium comprises practices that share a similar ethos, vision, values and goals. Included within the requirement for this similar outlook is that all practices sign up to a robust governance arrangement that holds people and practices accountable for the work they deliver under PBC. Any shortfall in delivery must then be addressed.
Next steps
Each practice within the consortium needs to be held accountable on what it delivers. In turn, the consortium needs to evaluate its ability to deliver tangible outcomes. In our experience, a tiered approach is best. In order, this approach is:
- Incentive scheme plan.
- Commissioning intentions plan.
- Commissioning plan (pathway redesign).
- Provider plan (pathway redesign); this requires the formation of a completely separate legal entity. Provider opportunities can only come from (someone) commissioning a pathway. Therefore, by default, if practices want to form companies to become providers, they first need to become excellent commissioners.
In my experience, this approach keeps practices focused in the correct way to become successful within PBC. With this in place, any redesigns and/or freed-up resources can be reinvested to:
- Improve health and reduce health inequalities.
- Improve the quality of service offered to patients.
- Improve equity of the services available.
- Improve the health and wellbeing outcomes achieved by patients.
- Embrace the principles of cost-effectiveness and improving value for money.
Once a consortium has been set up, there is often a debate as to its first piece of work.
Clearly, improving overall demand (resource utilisation), quality, patient outcomes and budget efficiency will give the consortium, and PCT, freed-up resources, which can be reinvested in services for patients. Some of these may be income generating.
However, this often proves to be too big a first step to take, and therefore those consortia looking for an early quick win to kickstart the collaborative approach could do a lot worse than start with medicines management.
To explain: the principles of PBC, in terms of decommissioning something to commission something else, are exactly the same as those that underpin medicines management.
You need to keep two things in mind:
- Prescribing management is “cash-releasing”; typically 5–10% of expenditure (depending on current performance).
- Savings can pump-prime new PBC services and a predetermined portion dispersed to practices.
Indeed, only this month I heard a PCT medicines management lead describe PBC and medicines management as “a match made in heaven”.
You also need to keep in mind that redesigning medicines management services will play a part in every redesign, as within every pathway medicines are used at some point. Practices and consortia therefore need to ensure that medicines management is considered in all relevant commissioning arrangements. This includes:
- Linking the use of medicines into the commissioning process.
- Working with commissioners on developing policies around high-cost drugs.
- Developing medicines management programmes.
- Improving cost-effective prescribing.
- Providing medicines input into care pathways.
- Linking into health economy policies and Area Prescribing Committees.
It is a fact that medicines are the most frequent healthcare intervention used in our NHS. It is therefore imperative that PBC looks hard at how to optimise the prescribing budget. One key group of professionals who need to be at the centre of this are pharmacists. As experts in the field of medicines management and correct usage of medicines, they are well placed to provide this service.
Furthermore, medicines management is an area that practices are already familiar with, as this service is usually provided by PCTs. In addition, freed-up resources can be realised quite quickly and are likely to be recurring, allowing them to be redeployed into other proposed service redesigns.
Other outcomes that can be achieved by effective medicines management are:
- Supporting the achievement of key NHS targets and optimising (Quality and Outcomes Framework) outcome measures.
- Ensuring patient pathways take account of appropriate, evidence-based prescribing and medicines management.
- Avoid unplanned admissions by supporting patients with long-term conditions.
- Reducing workload in general practice to release resources to deliver PBC priorities.
- Supporting medication review within clinics and, where appropriate, utilising independent prescribing skills.
The two models I use for this type of work are illustrated in Figures 1 and 2; key to each redesign are the practical steps. From there, so long as you retain a patient-centred focus, are prepared to negotiate and are willing to compromise to achieve the end goals, you can achieve with PBC.
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