Published: 10/02/2005, Volume II5, No. 5942 Page 28 29

A relative veteran of PBC, North Bradford PCT associate director of commissioning has valuable advice for those about to take the plunge, writes Alexis Nolan

When a doctor stood up to ask Julie Winterbottom a question at HSJ's practice-based commissioning conference in November, you sense he was only half joking when he opened with: 'I am sure I am not the only GP in this audience who is looking to relocate to North Bradford.' Ms Winterbottom, North Bradford primary care trust's associate director of commissioning, says practice-based commissioning is not just about managing demand and building service infrastructure in primary care but also about 'devolving and aligning responsibility, accountability and authority at a level where it is most effective'.

The PCT has 12 multi-partner practices (all PMS) covering a population of around 93,000. Its current three-year-old PBC model is built on performance improvement and 'markers' (targets) as part of a hospital services incentive scheme.

The practices get money for reaching the markers - a maximum of£15,000 each for prescribing and hospital services quality - and for their financial performance, providing they have met the markers.

The practice can do what it wants with the money: 'The GPs can put it in their back pockets if That is what they want, ' says Ms Winterbottom. But although the financial incentives mean practices can keep 50 per cent of any savings they make against indicative budgets for prescribing and hospital services commissioning, the money must be reinvested in the practice.

The practices also receive an annual 'performance fund' or allowance which equates to£50,000 per 10,000 patients. This funding - originally£2 per head of practice population - was essential in kickstarting the collection of monthly referral data (open across all practices) and electronic booking.

This funding has not just helped practices to monitor, manage and improve their performance, but has also encouraged the development of other primary care services and a shift from secondary services. Orthopaedics referrals have fallen from around 100 a month to 30, for example. And a 200304 target for 60 per cent of dermatology referrals to go to a GP specialist have helped attract special interest practitioners across the PCT. There are now 43 such specialists.

'We have got that culture now where if we introduce a new service, like a GP specialist in ear, nose and throat, we do not need [to use] an incentive any more.

The practices see the benefit from using that service and we simply e-mail to tell them it is available.' This has allowed the PCT to develop more challenging markers around areas such as reducing acute admissions from chronic obstructive pulmonary disease and falls.

From April, the PCT is assuming there will be four different tiers of commissioning within it: practicemanaged (elective and other hospital services); groups of practices (some hospital services); PCT-managed (tertiary) and 'PCT plus' (specialist regional services).

For practices there are two choices. Under option one, every practice will continue to be given its notional budget, together with more robust patient referral information and monitoring.

Under this option, it is up to the practice to do what it wants with the information. 'They could decide just to file it and do nothing more with it, ' says Ms Winterbottom.

But the PCT will continue to report that practice's performance, along with all the others, on how they are performing against budget and incentive markers to the professional executive committee and board.

And even if the practice is not actively involved in PBC it will be able to make savings by using primary care services that have been developed across the PCT.

They will keep 25 per cent of any of these savings.

Practices can choose to go into the more advanced option two at any point in the year. They will receive the same monitoring information as practices choosing option one, but they will have a live indicative budget.

This is the crucial point; there is clearly enthusiasm around PBC, but a 'leap of faith' is needed, says Mr Kingsland. 'Yes we need risk management, accountability and responsibility, but It is also facilitating a brave new world and there are answers we will not know until we do it.' PCTs and GPs favour the light-touch approach the government has taken, crucial for creating the local flexibility, and they expect the technical guidance to address some of the nitty gritty.

'This is about the only thing we have done in recent years that people genuinely liked, ' says Mr Hutton. 'There is a significant amount of enthusiasm and it obviously gave us pause for thought. Could we have got it wrong?' The general consensus is no, or at least not yet.

.Although all practices have to produce a business plan, option two practices will have to show how they are going to recycle resources and where they will invest the savings. Practices will retain 80 per cent of any planned savings and 50 per cent of unplanned savings. They can also receive 25 per cent of the cut of the expected savings quarter by quarter.

If they have under-spent even more than expected at the end of the year, the PCT pays the balance. If they overspend, there is no action to recover that money. 'It is all carrots and no sticks, ' says Ms Winterbottom.

The hospital services budget devolved to practices in the first year will include secondary elective care, outpatient appointments in the locality, an independent treatment centre, out of hours, pathology, direct access, community nursing, primary care mental health, and prescribing.

The following year the plan is to add secondary care mental health, case management for managing urgent care and PCT management costs.

'The idea is that every element of the PCT budget is devolved down to practices and together we decide which bits are added back, ' says Ms Winterbottom.

The support package for practices retains the practice allowance and the quality incentive scheme, but will also include a full-time equivalent nurse per 10,000 patients, to case-manage those needing urgent care. The package also provides a named PCT manager for half a day a week to help work with data and other elements.

The PCT's approach to the tricky issue of budget-setting is, as it is for all PCTs, based on historical data around usage per practice. In the longer term there will be a move to a weighted capitation, using public health information to come up with weightings that are relevant at practice level.

But an intended move to weighted capitation over three years has now been set back to five years.

Find out more

Waltham Forest PCT professional executive committee chair Dr Ken Aswani and National Association of Primary Care chairman James Kingsland will be among the speakers at HSJ's Driving Forward Practice-Based Commissioning conference in London on 28 April.

To register e-mail hsjconferences@emap. com

Practice Based Commissioning: engaging practices in commissioning www. dh. gov. uk

A Review of the Effectiveness of Pr imary Care-Led Commissioning and its Place in the NHS www. health. org. uk

Practice-Led Commissioning: harnessing the power of the primary care frontline www. kingsfund. org. uk