Primary care-led commissioning: Primary care-led commissioning: risks and opportunities for policy risks and opportunities for policy

and practiceand practice

Judith SmithSenior Lecturer, University of

Birmingham, UK

AgendaAgenda

Defining primary care-led commissioning The UK context for PCLC The research evidence about PCLC Where PCLC fits within the wider continuum of

planning/commissioning The risks presented by PCLC to a health system The opportunities offered by PCLC to a health

system Implications for policy and practice

Project teamProject team

Health Services Management Centre, University of Birmingham (Judith Smith, Hugh McLeod)

Health Services Research Unit, London School of Hygiene and Tropical Medicine (Nicholas Mays, Nick Goodwin)

King’s Fund (Jennifer Dixon, Richard Lewis) University of Glamorgan (Siobhan McClelland) Scottish School of Primary Care (Sally Wyke)

Our researchOur research

Funded by The Health Foundation A review of the evidence concerning the

effectiveness of primary care-led commissioning Attempt to identify and describe good practice Literature review Interviews with key informants Two stakeholder workshops Synthesis into report published in October 2004

Our methodsOur methods

Systematic review of published literature (HMIC, HELMIS, Medline and Embase)

Search combinations:Primary care and commissioningPrimary care and purchasingPrimary care and contractingPrimary care and fundholdingPrimary care and budget

1,507 references, plus 180 from research team Core of 37 references developed by research team

Our methods (2)Our methods (2)

Informant interviews (34):14 managers (some of clinical background)10 clinicians7 policy makers3 academics

Stakeholder workshops (2):28 participants in total, plus research team and THFPresentation of emerging findings, challenged by 2

discussants, plenary discussionGroup work on agreed key themesSynthesis of overall conclusions

Defining primary care-led Defining primary care-led commissioningcommissioning

Commissioning led by primary health care clinicians, particularly GPs, using their accumulated knowledge of their patients’ needs and of the performance of services, together with their experience as agents for their patients and control over resources, to direct the health needs assessment, service specification and quality standard setting stages in the commissioning process in order to improve the quality and efficiency of health services.

Key elements of PCLCKey elements of PCLC

Part of a healthcare market with purchasers and providers of care

GP as an informed critical agent for patients/users Acts for patients as well as ensuring that the

public’s goals for health sector are achieved Focus on GP involvement in leadership and

decision-making in the wider health system Inextricable link between GP decisions and

accountability for wider health system resources

The UK (English) context for The UK (English) context for PCLCPCLC

Purchaser-provider system of the Thatcher Govt retained and now extended

Primary care trusts the main local commissioning/resource allocation body (also providers of primary/community services)

Strong set of national priorities and targets focused on ‘modernising the NHS’

Improving access to care, assuring quality of care, and providing choice for patients

The UK context (2)The UK context (2)

Govt driving private sector involvement in the system – target of 15% of provision

Policy of Patient Choice ‘Choose and Book’ New funding system ‘Payment by Results’ based on

HRGs New independent foundation trusts A return to GP budget-holding – ‘practice-based

commissioning’ from April 2005 An external market – compared to the Thatcher

internal market?

The impact of primary care-led The impact of primary care-led commissioningcommissioning

Little evidence that shows PCLC (or any other approach) to have made a significant or strategic impact on secondary (hospital) care

PCLC, where clinicians have influence over budgets, can improve responsiveness

PCLC has made most impact in primary, community and intermediate care

The impact of primary care-led The impact of primary care-led commissioning (2)commissioning (2)

Given a sustained opportunity to innovate, highly determined primary care-led commissioners can achieve innovation in the local health system

Primary care-led commissioning increases transaction costs in commissioning

Developing primary care-led Developing primary care-led commissioningcommissioning

There is no ‘ideal’ size for a commissioning organisation

A single organisational solution is neither appropriate nor possible

Meaningful clinical engagement is key But a balance to be struck with public and

management accountability PCLC organisations have struggled with public

engagement

Developing primary care-led Developing primary care-led commissioning (2)commissioning (2)

Adequate management support is vital and has a relationship with outcomes

Timely and accurate information is crucial, and routine data could be used much more

PCL commissioners need headroom to commission according to local priorities

Relationships with providers need to avoid being cosy – ‘contestable collaboration’

A degree of stability of organisational arrangements is needed

A continuum of commissioning modelsA continuum of commissioning models

Primary care-led commissioning should not be considered in isolation

Part of a continuum from which health funder/planner chooses according to local health needs and service configuration

Challenge is how to select an appropriate mix of commissioning approaches, and having a rigorous process for this

A continuum of commissioning models A continuum of commissioning models in the UKin the UK

Level of Commissioning

Individual --- Practitioner --- Practice --- Locality --- Community --- Region --- Nation

Patient Choice

Multi-practice or locality

commissioning

Primary Care Organisation

/PCT commissioning

National commissioning

Single practice-based

commissioningJoint

commissioning

Lead PCT/LHB/HBcommissioning

Choosing a mix of models – Choosing a mix of models – assessment criteriaassessment criteria

Ability of the model to:

- shape different types of services- offer a degree of choice of provider, contestability

& responsiveness- manage budgets and financial risk- minimise transaction costs- develop and sustain clinical engagement- address health needs and tackle inequalities- improve and govern clinical quality

Risks presented by PCLCRisks presented by PCLC

That GPs (and others) will not want to be engaged That the transaction costs will be prohibitive That the patient rather than the population perspective will

dominate That it will focus exclusively on primary and intermediate

care That it will be unable to bring about real change in

secondary/hospital care That it will struggle to account to the public, government

and staff for decisions made That there will be insuperable conflicts of interest

Opportunities offered by Opportunities offered by PCLCPCLC

Innovation in the design and co-ordination of primary health and community services

Increased engagement of GPs, nurses and others in shaping the wider health system

A means of understanding and managing demand for secondary care (and diagnostic/pharmaceutical) services

Reinvestment of resource in services outside hospitals A route for implementing public health priorities at local

level Redefining the place of primary health care in the overall

system

Implications for policy and Implications for policy and practicepractice

To what extent are GPs legitimate agents for patients? What is the role that we want GPs (and other primary care

professionals) to have in the wider health system? How can PCLC play a part in wider system redesign along

with other commissioners? Is PCLC a vehicle for moving towards a more population-

focused model of primary health care? If so, how should the system support and develop primary

care-led commissioners? What should the governance and accountability framework

for PCLC look like? How can the impact of PCLC be measured?

Contact detailsContact details

Judith Smith

Senior Lecturer

Health Services Management Centre

University of Birmingham

UK

www.bham.ac.uk/hsmc

j.a.smith.20@bham.ac.uk

+44 121 414 7073