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Practice-based Commissioning. Dr Richard Lewis Independent Healthcare Consultant & Fellow, King’s Fund. What is practice-based commissioning?. What makes commissioning practice-based? Identification of practice-level activity
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Practice-based Commissioning Dr Richard Lewis Independent Healthcare Consultant & Fellow, King’s Fund
What is practice-based commissioning? • What makes commissioning practice-based? • Identification of practice-level activity • Practices involved in the design of services used by their patients • Practices face incentives related to performance against agreed objectives • Does not have to include contracting function
Why do it? • Patient benefits • Care can precisely meet individual needs • Incentives to shift from treatment to prevention • Efficiency benefits • Managing demand • Political benefits • Engagement of primary care • Accountability of primary care
Brief Look at the Evidence • Little evidence that commissioning makes a lot of difference to delivery of hospital care (Smith et al 2004) • GPFH (later evidence more compelling) • Shorter waiting times by 8% (Propper et al 2000) • Reduced elective hospital admissions by 3.3% (Dusheiko et al 2003) • Reduced prescribing costs (Audit Commission 1995) But • Transaction costs high (Goodwin 1998) • Inequitable funding (Dixon et al 1994)
Brief look at the evidence (2) • Total Purchasing Pilots • Relatively modest impact (Wyke et al 2003) • 69% of TP pilots reduced occupied bed days and 13% reduced admissions (Wyke et al 2003) • Single-practice and small TPs better at risk management than large TPs (Baxter et al 2000)
Brief look at the evidence (3) • Locality/GP commissioning pilots • Improved collaboration between GPs across practices • New corporate management arrangements • Peer review-based approaches to prescribing (Smith et al 2000) • Smaller increase in prescribing costs (McLeod et al 2000) • Obstacles included workload for clinicians, lack of HA support, IM & T (Smith et al 2000)
Overall messages from history • Little research evidence demonstrating that any commissioning impacts on secondary care • Primary care commissioning can secure more responsiveness • Greatest impact of pclc in primary and intermediate care, new forms of quality assessment, new forms of specialist primary care, new alternative community-based services, prescribing practice • Can change longstanding working practices • Will increase transaction costs Smith et al 2004
There is a new policy context that is important • May expect fewer problems regarding equity and transaction costs • PBR/national tariff reducing ability to secure preferential rates and lower transaction costs • NSF, national standards, NICE guidelines leading to greater standardisation • Existence of PECs to balance strategy with clinical engagement • Capitation budgeting to ease equity fears
Implementing practice-based commissioning Key dimensions of pbc • Collectivity • Individual practices • Semi-corporate associations • Multi-practice corporations • Scope of services • Spectrum of incentives • Peer pressure to hard budgets
Implementing practice-based commissioning (2) • Important trade-offs between ‘autonomous dynamic’ practice level commissioning and ‘strategic collective’ commissioning
Implementing practice-based commissioning (3) • ‘Autonomous dynamic’ practice level may be welcome when: • Complex re-design not required or sustainability of major local providers not in doubt • Is a range of alternative providers available • Services in question are ‘referral sensitive’ • Trade-offs exist in medium/long term between primary care prevention and treatment (e.g. chronic care)
Implementing practice-based commissioning (4) • ‘Strategic collective’ commissioning welcome when: • Service in question is highly specialist • Complex service redesign required (especially requiring multi-institutional co-operation and new care pathways)
Managing the tensions • Incremental decisions may not always aggregate to coherent strategy - role of the Local Development Plan vital. • Issues of scale – how big is big enough, how big is too big? • Protecting patient choice and value for money/propriety • Revisiting public accountability • Engaging the public • What PCT targets can be devolved? • Ensuring clinical quality and safety within a competitive market • Neither PCT nor practices have a monopoly of power, will need to negotiate local approach
