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GP Based Commissioning



| Introduction | Principles and Vision | Service Areas | Development of Indicative Budgets | Information to Support Proposed Commissioning | Work Plan and Timetable | Back to Hillingdon On-line |


1.1   In October 2004, the Department of Health published Practice Based Commissioning: Engaging Practices in Commissioning, which set out the intention to enable practices to hold indicative budgets for commissioning services for their patients and local populations from April 2005. This has since been supplemented with further technical guidance published  in February 2005 and a toolkit. The NHS Improvement Plan reinforced the commitment to Practice Based Commissioning, stating that from April 2005, GP Practices that wish to do so will be given indicative commissioning budgets.

1.2  At the same time, Payment by Results is being introduced and this will standardise costs across providers so that rather than block contracts, providers will be paid at fixed rates for the work they do. The effect of this is that funds will follow for the services used by patients.

1.3  The Uxbridge and West Drayton Locality decided to engage in the development of Practice Based Commissioning (PBC) in January 2005 and a Steering Group of GPs was established to formulate ideas and set out a plan. The Group has met monthly and begun to develop principles for commissioning, gathered information and identified potential services that can be delivered in a different way. This paper sets out initial thinking and the basis for taking forward PBC with the aim of changing the way services are commissioned by April 2006.

| Introduction | Principles and Vision | Service Areas | Development of Indicative Budgets | Information to Support Proposed Commissioning | Work Plan and Timetable | Back to Hillingdon On-line |


2.1 PBC provides the opportunity to develop a local accessible  health service that meets local needs and therefore is entirely consistent with, and supports the PCT’s vision. To do this, resources have to be taken out of the acute setting and re-invested in primary care. This can only be achieved through a reduction in referrals to secondary care supported by the development of alternative care pathways with services and diagnostics delivered differently.

2.2 The PCT Local Development Plan (LDP) specifies the plans and actions needed to maintain targets as well as new targets that have been set by the Government. The PBC plan therefore has to be consistent with the LDP and support these targets.

2.3 The main targets are:

·        Achieve financial balance

·        Reduce emergency bed days

·        Reduce referral to treatment waiting times

·        Ensure patients are offered choice of provider within the requirements of Choose and Book.

2.4 In addition the PCT has to implement where possible, the 10 high impact changes published in October 2004. These include more day care, reducing the average length of stay, reducing follow up in outpatient departments and improving access to key diagnostic testing.

2.5 North West London HA has published overarching principles with the purpose that they should form the basis of the approach within NW London regarding the implementation of PBC and to facilitate discussions with practices and the Local Medical Committee. These principles are reflected in the development of the Locality PBC plan:

 ·        Partnership approach – practices should work in partnership with the PCT through the locality structure. Practices can manage a nominal budget and contribute to the Locality Commissioning Group. The Group needs to be formalised with practices participating in PBC being represented. The Group will be supported by the Locality Development Manager, a Commissioning Manager, Finance Manager and Information Manager. Minutes of the locality commissioning group meetings will be shared with practices within the locality as well as the respective locality commissioning groups for North Hillingdon, and Hayes and Harlington.  

·       Delegation of responsibility – for the element of the budget that is agreed with practices, with agreement that practices will be expected to remain within the delegated budget.

·       Achieving national and local targets – the planned commissioning of services has to contribute to meeting targets. As the plan is developed for services commissioned it will be necessary to put in place reporting arrangements for the achievement and management of targets.

·       Risk management -   the basis and process for risk sharing within the PBC will need to be agreed.

·       Governance and accountability – a PCT Commissioning Board will be established with representatives from each of the locality groups to ensure transparency within the decision making process regarding the utilising of public funds.

·       Provision of information – the PCT will provide the necessary information to support commissioning plans.

·       Support to practices – it is envisaged that the locality development manager and commissioning managers together with information and finance staff will provide the necessary support to implement PBC, with any support needed within practices funded from savings in agreement with individual practices.

·       Effective commissioning – negotiation of contracts and performance monitoring of contracts will be on a PCT  basis. To avoid duplication of effort within the localities, work will be co-ordinated by the PCT Commissioning Board and it will be the responsibility of this Board to consider and agree the proposed plan. Minutes of the locality groups will be shared.

·       Patient and public involvement –the lay member for the Locality Management Team will be involved in the Commissioning Group.

·       Local Professional Committees engagement – the Commissioning Board will be run in partnership with the LMC. The plan will be shared with other professional committees.

| Introduction | Principles and Vision | Service Areas | Development of Indicative Budgets | Information to Support Proposed Commissioning | Work Plan and Timetable | Back to Hillingdon On-line |


3.1 The Locality Commissioning Group has considered the range of services that might be commissioned and has gathered a range of information including referral data and capacity and willingness of practices to deliver services in a different way. This also requires practices to consider different referral routes. Information on referrals to secondary care is available and a sophisticated data base has been assembled to enable comparison between practice referral rates to different providers and between specialties.

3.2 In deciding how and what to commission the Locality Commissioning Group has considered a number of principles:

·       The need to deliver savings that can be re-invested in primary care.

·       To adopt an iterative process rather than big bang. This will include areas of service that can be changed more easily.

·       To reduce secondary care activity.

·       To work towards new carer pathways with agreed referral protocols.

·       To streamline where possible, for example more appropriate and timely access to and effective use of diagnostic services and reducing follow up in outpatient departments.

·       Development of the GP role by encouraging specialism (GpwSI). Also considering other practitioners such as nurses, pharmacists and physiotherapists.

·       Avoiding, at least initially, areas of service that are already being developed by the PCT such as cardiology, ophthalmology (cataract and glaucoma) and diabetes. (which will be mainly delivered through a Local Enhanced Service).

3.3 Initially the Commissioning Group considered looking at endoscopy, back pain clinic and radiology. However when referral data was analysed, the Group felt that these were not areas that would ensure significant changes and a wider list was produced. From this the following are now out forward as service areas that should now be developed into commissioning plans:

ENT – external ear problems, vertigo and tinnitus. Possible GP with Special Interest role or consultant.

Minor surgery - 5 GPs  initially expressing interest in this service. (Joint injection and more complicated procedures not included within the Directed enhanced Service).


Dermatology – 5 GPs initially expressing interest.

Ophthalmology – work in hand to agree involvement of optometrists in a new cataract pathway and possibly glaucoma.

Gynaecology – post menopausal bleeding and hysteroscopy.

Urology – flow testing.

Orthopaedic – joint injection, as part of minor surgery.

Cardiology – echoes and management of patients with heart failure, although development of a community based service with 3 GPwSIs may mean this does not to be developed through PBC.

The work in progress by Hayes and Harlington, and North Hillingdon Localities needs to be considered to avoid duplication and agreement needs to be reached on lead locality responsibilities.

| Introduction | Principles and Vision | Service Areas | Development of Indicative Budgets | Information to Support Proposed Commissioning | Work Plan and Timetable | Back to Hillingdon On-line |


To Follow


To Follow


  Item Date
  Discussion at Locality Management Team August 2005
  Discussion at Locality Forum    August 2005
  Detailed analysis of activity and information August to October 2005
  Financial issues and production of indicative budgets August to March 2006
  Identification of small working groups to lead on particular service pathways August 2005
  Detailed proposals developed October 2005
  Plans agreed by Commissioning Board October 2005
  Providers notified of Commissioning Intentions December 2005
  Plans continue to be worked up and resources agreed Ongoing
  Practice Based Commissioning commences   1 April 2006   
  | Introduction | Principles and Vision | Service Areas | Development of Indicative Budgets | Information to Support Proposed Commissioning | Work Plan and Timetable | Back to Hillingdon On-line |