New guidance from the Department of Health on practice- based commissioning (PbC) outlines how primary care trusts (PCTs) and practices should be starting to work together to deliver this key policy.
The document, Practice-Based Commissioning: Achieving Universal Coverage, makes it clear that PCTs must give every practice the opportunity to become involved in the initiative to one degree or another by the end of December 2006.
Many practice managers have until now been frustrated by the lack of data they need to make PbC plans and set budgets. The good news is that the new guidance insists PCTs must start giving practices relevant, accurate and up-to-date information from April.
PCT information packs
Practices can expect to start receiving monthly information packs containing benchmarking, financial and activity information. PCTs will be given templates to ensure all practices receive the information in a digestible and consistent format.
PCTs will be expected to supply activity and financial information on:
- Elective activity – inpatient and day case.
- Nonelective admissions, including information on length of stay.
- First outpatient appointments and follow-up appointments.
- Use of diagnostic tests and procedures.
- Consultant to consultant referrals.
- Community and mental health services.
- Primary care, including essential and enhanced PMS and GMS services.
- Accident and emergency attendances.
PCTs are also expected to provide benchmarked data that will enable practices to compare themselves with other practices in the PCT area and with the national average.
Practices can expect benchmarking data on the following:
- Referral rates.
- Admission rates.
- First outpatient attendances.
- Follow-up rates.
Practices will also benefit from receiving information on the needs, demands and demographics of the local population. This will enable the practice to make informed clinical decisions, improve the public’s health and set the context within which those decisions are made.
By April, PCTs will also be required to provide practices with indicative budgets. For 2006/07, PCTs must provide information on the practice’s share of the PCT allocation and they must agree with the practice the scope of services to be included in its indicative budget.
Practices will develop a PbC plan for the services in their indicative budget, which will include their proposals for improving services and reallocating freed-up resources. This budget must include, as a minimum, all services covered by the national tariff under Payment by Results in 2006/07 and prescribing, but the plan can identify one or two key areas within this to focus on initially. In some instances where data is robust enough, practices and PCTs could agree to include community services and mental health. This is particularly relevant to practices planning to shift services out of secondary care into primary care.
The indicative budget will be calculated on the basis of:
- Actual 2005/06 activity converted into 2006/07 prices.
- Current formulae for prescribing, which includes the appropriate inflationary uplift.
- Weighted capitation for any services within the agreed scope for which no historic activity data is available.
- Any uplift to meet agreed additional activity during 2005/06.
Dr David Jenner, NHS Alliance lead on practiced-based commissioning and a GP in Cullompton, Devon, says this new guidance will give PCTs the impetus to start providing practices with the information they need.
But he warns practice managers not to expect too much too soon. “The frightening thing is that sometimes the PCTs haven’t got the activity information themselves. Until last year, when payment by results came in, most of the activity was on big block contracts and measuring each last thing didn’t make an awful lot of difference. But now PCTs will be forced to provide the information.
“However, the system isn’t yet in place so it is likely to be slow and it will be a very steep learning curve for PCTs.”
Dr Jenner says that if the PCT data is not adequate, in the interim period practices could persuade their PCTs to purchase a licence to obtain data from the commercial information supplier, Dr Foster. He says this data is easy to understand and will suffice as a starting point, though as yet lacks fine details of some activity that more avid commissioners will need.
When the information starts filtering through to practices, practice managers will have to ensure they understand it and can validate it. A cautionary tale is provided by one of the early adopters, East Devon PCT, which discovered early on that quite a bit of data they had was actually wrong. They discovered that 15% of activity data was not backed up by any discharge summary.
Scrutinising the information
For practice managers to validate the data they will need to ensure that it is broken down to single patient activity and will have to check that what people are being charged for correlates with what their notes say they have had done. One way of double-checking, suggests Dr Jenner, is to get clerks to check details when scanning discharge summaries into patient notes.
He says practices should not be reticent about seeking help from their PCT. “My advice is be assertive with the PCT and don’t be afraid to quote the requirements of the guidance at them. But do bear in mind that the PCT will be under a lot of pressure at the end of the year and they will often also be under considerable financial pressure.
“Invite the PCT out to meet you at the practice and ask how the practice, with PbC, can help the PCT deliver its key targets and priorities. If you meet face to face you may well find some mutual benefits.”
Dr Jenner says he is optimistic that PbC can improve patient care. “There is still more work to be done in winning the hearts and minds of GPs and practice staff, but the new guidance provides a good basis to begin that.”
- Department of Health. Practice based commissioning: achieving universal coverage. Department of Health; 2006. Available from:http://www.dh.gov.uk
- Department of Health. Practice based commissioning: early wins and top tips. Department of Health; 2006. Available from:http://www.dh.gov.uk
- NHS Alliance. The nuts and bolts of practice based commissioning. NHS Alliance; 2005. Available from: http://www.nhsalliance.org