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Gatekeeping and the PCT: make or break time

Gatekeeping and the PCT: make or break time. Jonathan Shapiro University of Birmingham May 2004. Gatekeeping and commissioning. Most patient care happens in the community 99% of activity, 30% of cost self care (90%) general practice and community services (9%)

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Gatekeeping and the PCT: make or break time

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  1. Gatekeeping and the PCT: make or break time Jonathan Shapiro University of Birmingham May 2004 jshapiro53@aol.com

  2. Gatekeeping and commissioning • Most patient care happens in the community • 99% of activity, 30% of cost • self care (90%) • general practice and community services (9%) • Most cost is incurred in institutional care • 1% of all health care activity, 70% of cost • Institutional care depends on referrals • approx. 70% from GPs • rest from A&E, walk in centres etc jshapiro53@aol.com

  3. Centre The generic shape of services Health ‘authority’ GP GP GP GP Institutional sector jshapiro53@aol.com

  4. Centre The shape of services: 1990 DHA GP GP GP GP Purchaser Provider Institutional sector jshapiro53@aol.com

  5. Centre The shape of services: 1996 Health authority Purchaser Provider GP GP GP GP Institutional sector jshapiro53@aol.com

  6. Centre The shape of services: 1998 Procurer Health authority Provider PCG/T PCG/T PCG/T Institutional sector jshapiro53@aol.com

  7. The shape of services: 1998 Centre StHA Commissioner PCT PCT Provider Institutional sector jshapiro53@aol.com

  8. but… • Contracting  purchasing  commissioning • Contracting for items • I want to buy this, how much do you want for it? • Purchasing from a selection • I’d like the table d’hôte, but with chips please • Commissioning de novo • I’ve had an idea for a house… • Commissioning is about populations • ..and needs powerful organisations • referrals are about individuals • It’s the dissonance that matters jshapiro53@aol.com

  9. To refer or to commission? • Referrals concern one patient at a time • the role of a ‘champion’ • it’s what clinicians do all the time • Commissioning is strategic • can appear heartless to an individual patient • a real culture shift for any clinician • but is it a desirable one? • The effective organisation combines both • strategic decisions informed clinically jshapiro53@aol.com

  10. Tools for effective commissioning • Size and clout • management of risk • clinical, technical, financial, legal • power • or perception of power • capacity and capability • Co-ordination • increases all the above • Maturity • commissioning is what grown-ups do • testosterone and acting out don’t help jshapiro53@aol.com

  11. …and so PCTs have to… • Grow up • develop capacity and capability • probably by co-ordinating and sharing • change the clinical culture • maintain autonomy while developing corporacy • changing culture can’t be done by coercion • Combine clinical and managerial expertise • Come to terms with internal commissioning • Believe they are grown ups • perception is reality • for them and their partner organisations jshapiro53@aol.com

  12. If PCTs don’t evolve.. • Commissioning will be confiscated • PCTs will be relegated to pure provision • StHAs will become more operational • some already have itchy fingers • …they failed to control acute sector last time • Acute sector will continue to drive system • Foundation Trusts already in ascendency • Basis of NHS will be threatened jshapiro53@aol.com

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