Primary care-led commissioning: risks and opportunities for policy and practice Judith Smith Senior Lecturer, University of Birmingham, UK

Agenda  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 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 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 methods  Systematic review of published literature (HMIC, HELMIS, Medline and Embase)  Search combinations:  Primary care and commissioning  Primary care and purchasing  Primary care and contracting  Primary care and fundholding  Primary care and budget  1,507 references, plus 180 from research team  Core of 37 references developed by research team

Our methods (2)  Informant interviews (34):  14 managers (some of clinical background)  10 clinicians  7 policy makers  3 academics  Stakeholder workshops (2):  28 participants in total, plus research team and THF  Presentation of emerging findings, challenged by 2 discussants, plenary discussion  Group work on agreed key themes  Synthesis of overall conclusions

Defining primary care-led commissioning 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 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 PCLC  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)  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 commissioning  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 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 commissioning  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 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 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 in 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 commissioning Joint commissioning Lead PCT/LHB/HB commissioning

Choosing a mix of models – assessment 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 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 PCLC  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 practice  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 details Judith Smith Senior Lecturer Health Services Management Centre University of Birmingham UK