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

2. HSMC jshapiro53@aol.com 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

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

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

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

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

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

8. HSMC jshapiro53@aol.combut… Contracting purchasing commissioning Contracting for items I want to buy this, how much do you want for it? Purchasing from a selection Id like the table dhôte, but with chips please Commissioning de novo Ive had an idea for a house… Commissioning is about populations..and needs powerful organisations referrals are about individuals Its the dissonance that matters

9. HSMC jshapiro53@aol.com To refer or to commission? Referrals concern one patient at a time the role of a champion its 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

10. HSMC jshapiro53@aol.com 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 dont help

11. HSMC jshapiro53@aol.com …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 cant 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

12. HSMC jshapiro53@aol.com If PCTs dont 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