Practice clinicians are being seen as the linchpins of future local procurement of quality care services, as Andy Cowper explains

Practice based commissioning is at the heart of world class commissioning of health and care services. The rationale is that commissioning is at its most effective when it is the product of a strong partnership between primary care trusts and clinicians, who are best placed to know about quality and the needs of their communities.

Practice based commissioning provides the means for PCTs to work closely with local clinicians to draw up strategic plans, design and commission services that build on the current clinical evidence base, maximise local care pathways, and use resources effectively. The message is that it is here to stay.

Both NHS chief executive David Nicholson and Department of Health director general of commissioning and system management Mark Britnell emphasise its importance. Mr Britnell has stressed it "will play a key role when it comes to defining clinical outcomes, assessing provider performance and, in some cases, delivering personalised local services".

Practice based commissioning has had a slow start, as the relevant consortia and groups have been learning, growing and in some cases merging. Results from recent surveys indicate much willingness among GPs; but more local support arrangements are wanted.

Reorganisations and a subsequent year of instability in the NHS hampered the growth of relationships and trust between practice based commissioners and PCTs. Now the dust has settled, it is surely time for PCTs and GP commissioners to look to the future. Where PBC is working well and producing genuine changes in services and behaviour, there are lessons to learn and foundations on which to build.

Clinical engagement

Leodis Healthcare is a practice based commissioning co-operative in Leeds, owned by its 30-practice membership of 126 GPs. Leodis covers a listed population base of just over 203,000 patients. It enjoys good relationships with Leeds PCT, and both chair Andy Harris and chief executive Chris Reid agree that their success rests on strong clinical engagement.

Dr Harris says: "From a PBC perspective, what makes Leodis work is membership and practice engagement - members must feel ownership and direct input.

"You need a robust governance structure, but also to ensure that GP members feel ownership of the governance arrangements. You do also need a subtle change in the GP mindset - people can retain their local practice's individuality, but must learn more corporate ways, especially about managing the commissioning budget on a group basis with a strategic view".

Dr Harris adds that this also has the beneficial effect of demonstrating "to the PCT that PBC can be effective - early on, we were able to change things in a very quick way".

None of this happens without PCT support, as Mr Reid emphasises: "This involves key people in the PCT executive team. Matt Walsh is the director of commissioning at Leeds PCT, and he's been key in acting as co-ordinator with other PCT executives, getting them to see the benefits."

Dr Harris adds: "That's not simply support as in 'good idea', but about meeting the real need for clinical and managerial support in PBC groups - PBC can't work without that. We have an ongoing conversation with our PCT about managerial support."

Dr Harris confirms this conversation is about resource, but adds it's "also about the PCT's capacity and technical expertise". Have they looked to the framework for procuring external support for commissioners for technical help? "We have looked, but we're going forward with our PCT to help identify areas where support is needed".

Mr Reid adds: "One example where we agreed with the PCT that locally we lack skills is developing predictive modelling tools and practice based disease registers to help manage long-term conditions. Another crucial area is public health, and we enjoy good arrangements with the PCT public health team to give us vital information to target preventive work."

Dr Harris explains they are working across a range of clinical areas where they have agreed business cases with the PCT to deliver dermatology using GP premises, ear, nose and throat services and enhanced services for residential and nursing home patients. "There's a city-wide evidence based diabetes care pathway which has been around for some time, and we acted as a catalyst to allow it to be effective," he explains. "It's level 3 clinical care [low complexity, traditionally delivered in acute settings], which we've taken on. One of our key themes is to identify level 3 low-complexity care that we can provide closer to home such as diabetes, ENT and dermatology."

Leeds PCT has been non-prescriptive, Dr Reid says: "In allowing PBC groups to storm off on our own. We moved from about 10 initial groups, and now we're at the final stages of 'storming and forming', with three to four PBC groups in total.

"The PCT also recognises the different ambition and sophistication in PBC groups, and gives different levels of funding for the different levels of strategy. The PCT is also keen on the next stage of the process, whereby PBC groups reaching development and maturity can make decisions about how to work."

He adds: "The PCT produced a paper on earned autonomy, recognising that some groups are more mature than others. It looks at how to give Leodis and other mature PBC organisations more autonomy."

Dr Harris says that the key link between practice based commissioning and world class commissioning is "for PCTs to work hand in hand with PBC groups". Mr Reid adds: "It's got to be clinically led. We hope that the Darzi review will further PBC opportunities to move forward and develop new care models."

Formal support

Developing the right governance framework will be critical. PBC consortia and groups cannot develop unless there is formal managerial and financial support.

PCTs are responsible for providing proper management support and funding for practices to deliver their commissioning activities. However, this has not got as far as practices and top policy makers would like. A 2007 survey by the King's Fund and NHS Alliance revealed that the data being provided for practice based commissioning was not always as good as it could be. Reports from the Audit Commission and others have echoed this point.

NHS Alliance chair Michael Dixon is a GP adviser to the Darzi strategy review. He says PBC "is not just about the right data; it's about the right data in usable form so you can change behaviour in referrals and use of diagnostics, and check that you've got what you paid for".

PCTs will be held to account through the world class commissioning assurance system for the quality of their support and the effectiveness of their partnerships with practice based commissioners. The levers and incentives are being lined up, and local clinicians have a chance to see what could be achieved.

The traditional partnership model has produced the responsive, well-loved general practice we know and love. However, that very partnership can be inward-looking, replicating what has been delivered in the past, while lifestyles and patterns of ill-health move on. If practice based commissioning is delivered in an inter-related manner between practices and clinicians, commissioning localities and PCTs can deliver high-quality responsive care and release resources from traditional hospital services.

Its proponents believe that practice based commissioning represents an enormous opportunity for frontline clinicians to make local health services more responsive and to improve the use of taxpayers' money. What's not to like?