While GPs have not greeted the role of commissioner with universal enthusiasm, its proponents believe that when the right skills and flow of information are in place, it will transform PCT performance, says Rob Finch
For years sceptics have said there is little time to save the NHS. But if the NHS needs saving, enthusiasts of practice-based commissioning believe it the best tool for the job.
At its best, practice-based commissioning could use clinicians' expertise to transform traditionally fragmented, institutionally based and expensive care into integrated, value-for-money care that saves more patients' lives.
Coupled with this, since December the Department of Health has been driving to make commissioning "world class" - a drive that goes far beyond a mere attempt to "save" the health service.
Practice-based commissioning, put simply, is an attempt to address a perceived lack of skills in commissioning at a primary care trust level and to gain better patient care by placing responsibility for health provision spending in the hands of groups of GPs.
In principle, this should mean that practices should have won first refusal over most commissioning decisions by the end of 2006. Yet the reality of practice-based commissioning lags behind this aspiration. It has been dogged by numerous factors, not least primary care trusts' need to hit short-term financial targets, shifting focus from the programme.
Meanwhile, GPs have proved reluctant to engage - perhaps haunted by memories of the abolition of fundholding - and PCTs have found it difficult to relinquish responsibilities as well as provide useful data to inform commissioning decisions.
Indeed, there is little overt criticism of the fundamental principles of the scheme, but operational problems with it are regularly flagged up. Earlier this year, a report on the GP contract by the National Audit Office said: "Many PCTs lack the advanced commissioning skills needed to identify and analyse local health needs and negotiate appropriate services with local providers.
"Money earmarked for enhanced services has not been spent as intended, partly because of overspends which have occurred in other areas of the contract and PCTs' inability to implement effective local commissioning."
Worse still, latest government data on participation in the scheme shows a stubborn reluctance among GPs to get involved, or a lack of belief among practices that they have been fully engaged. Less than half have actively commissioned services, and less than two-thirds have an agreed commissioning plan.
NHS Alliance chair Dr Michael Dixon, a Devon GP, says: "Practice-based commissioning cannot properly get off the ground until commissioners have access to accurate, meaningful, real-time information. That is absolutely basic."
And chair of the National Association of Primary Care Dr James Kingsland, who is also a Wirral GP, agrees. He says: "PCTs are not giving budgets, they're just saying how much you've spent as a measure of activity. Sadly that's still in the majority.
"It still feels uncomfortable to me. PBC is not dead in the water, but it's the minority who are doing it in the way it was described.
"The places where commissioners are enthused is where there's a facilitative chief executive. Where they're not, practice-based commissioning stagnates."
With the GPs who might be considered the apostles of practice-based commissioning a little frustrated and anxious, it might seem there is scant hope for the policy.
But Steve Field, chair of the Royal College of General Practitioners, suggests: "The planning needs to be over a longer time span. If we could look over a three to five-year time-plan and have more sensitivity to look at patient needs then we would have a system where the influence is at the coalface with patient and public involvement."
Indeed, such a long-term view is already being taken in Somerset, where PCT facilitation, coupled with a motivated provider and active practices has led to a three-year contract being swiftly agreed for services for chronic obstructive pulmonary disease.
Professor Field believes that despite such good examples, more could be done to help kick-start practice-based commissioning.
"A more compelling vision needs to be articulated for what's being done for GPs and the public," he says.
That is where world class commissioning comes in. The architect of the scheme is Mark Britnell, NHS director general of commissioning. He says that world class commissioning is "a statement of intent" to raise ambitions to create the first comprehensively implemented quality commissioning programme. The somewhat clichŽd vision is "adding life to years and years to life".
NHS Confederation Primary Care Trust Network director David Stout echoes this. "It sets an ambitious goal - a direction and focus that is very welcome for most people," he says. "I think it sets a challenge to PCTs in the way they currently operate. The most immediate challenge is the assurance framework. There's no PCT that currently claims to be world class in every element of that."
At the core of world class commissioning is an attempt to improve health, reduce inequalities, improve treatment quality and give people choice. It is also underpinned by a need to make "considered" investments.
In order to become world class, PCTs and general practices are being asked to take a longer-term and more strategic approach to the commissioning of services, with a focus on providing a proactive rather than reactive health service. To do this, commissioners need strong knowledge management and analytical skills to ensure they develop a long-term view of community needs. Of utmost importance is PCTs' ability to listen and communicate back to their communities, as well as developing stronger negotiating, contracting, financial and performance management skills.
The DH acknowledges the National Audit Office's criticisms of the current state of commissioning and, to support the development of world class commissioning, is helping to create a support and development framework to give commissioners advice on driving improvements.
Alongside learning from the outcomes of other commissioners' work and training existing staff, he says PCTs will look to buy in skills where they are missing, adding that for some areas PCTs will be breaking new ground and "leading the world".
Apart from this "vision", world class commissioning is defined by a set of "competencies", with an assurance system and a support and development framework. The main focus of world class commissioning is on the 11 competencies, across which there is considerable overlap. Fortunately, for each of these competencies there is an outline of the outcomes that will show whether the commissioner is truly world class. These competencies are as close to performance management as PCTs are ever likely to get. As Dr Dixon says: "It will become a determinant of whether PCTs rise or fall."
So to make things easier, the DH is also promoting use of the framework for procuring external support for commissioners, which gives PCTs the option to buy commissioning expertise in a range of areas such as data analysis, contract management and public engagement. More than 80 PCTs have already shown interest in buying in the expertise they need through the framework. Others are learning from experience or attempting to train staff up. Mr Stout explains: "The kind of structure people are thinking about is a learn-share-buy framework."
Despite this, some still perceive the framework as a threat, serving to spur PCTs to succeed or have their commissioning function entirely replaced by an outside agency, as was feared when the scheme was announced. And if the world class commissioning competencies come to be seen as a "star rating" for PCTs, this threat could become greater. Time is of the essence, as these competencies are likely to be assessed within the 2009-10 financial year.
If PCTs are to succeed, they are likely to want to focus on practice-based commissioning, which is a major factor in achieving the first four of the world class commissioning competencies. In particular, clinicians must be seen to be actively engaged and PCTs will be assessed on their ability to show this is happening in reality as well as on paper.
The King's Fund has been investigating practice-based commissioning for the past two years, and senior fellow in health policy Dr Nick Goodwin says: "The vision for world class commissioning is that the local health economy takes collective responsibility. Practice-based commissioning is one element of a range of partnership arrangements to get a collective responsibility for change."
He says that a lack of policy clarity has meant "the rules of engagement" between PCTs and practices have taken a long time to work out. Early efforts in practice-based commissioning "turned GPs off" because PCTs were too disciplined in getting GPs to create full business cases for every potential service change.
He warns: "One of the things we're seeing is PCTs using it as a demand management tool. We're seeing referral centres being established and some GPs might be being encouraged to do this, as they're seeing they can save money to reinvest. But it's not commissioning - it's demand management."
So what can be done by PCTs to ensure that not only think tanks like the King's Fund but also the DH, clinicians and the public believe their commissioning is world class?
Currently there is very little evidence to demonstrate how commissioners can best influence healthcare providers, and use the commissioning process to achieve improvements in the health of the population. That at least is the conclusion of researchers from Birmingham University's Health Services Management Centre.
Professor of health policy and management at the centre Chris Ham says: "While it is encouraging to see the government providing a framework to help commissioners understand and develop their role, there must also be an understanding that it will take time to build up our knowledge of what approaches work best. Commissioning is just one part of the health system and its success must always be seen as part of wider investment and regulation in the system as a whole."
The centre's Towards World Class Commissioning Competency review says that although the health service already has many of the competencies required, there is much that could be done to mobilise these more effectively and to bring in new expertise from elsewhere.
The report, published almost simultaneously with the world class commissioning vision, identifies the importance of getting public health expertise to reduce the demands on the healthcare system and to involve local people in priority setting and decision making. It says a focus on commissioning "competency" in isolation will never achieve the desired results.
So to make the NHS truly world class, commissioning needs empowered and motivated people given the right tools to make it work.
Locally lead the NHS
Work with community partners
Engage with public
Collaborate with clinicians
Manage knowledge and assess needs
Stimulate the market
Promote improvement and innovation
Secure procurement skills
Manage the local health system
Make sound financial investments
Commissioning chronic obstructive pulmonary disease services in Somerset
Reducing emergency admissions for chronic obstructive pulmonary disease has long been identified as one of the most simple and effective ways of improving patient care and saving money for the NHS.
This is being tackled in Somerset by a concerted effort from the GP practice-based commissioners, the PCT and a little private sector involvement that has helped dramatically reshape COPD services.
Initiated by WyvernHealth.Com, a consortium of GPs representing 71 of the county's 75 practices, Somerset PCT has invested more than£500,000 in a service that has taken provision away from the traditional secondary care-based provider.
A partnership between nursing and supplies firm Clinovia and the GP-led firm Avanaula Systems won the three-year contract offered by the PCT for providing routine case management and support for people with COPD to help cut hospital admissions.
The service includes pulmonary rehabilitation and information classes and oxygen assessment clinics for people with respiratory problems on long-term oxygen. It also runs 24/7 urgent response, including home visits, as well as in-hours unscheduled care rapid support.
Implementation will take place over the next six months, rolling out across the county in phases to allow time for feedback.
The new service has the support of patients, who were engaged in the commissioning process. On the day the new system went live, the PCT held an event to explain to patients how the new service operates.
Chair of the Yeovil Breathability Support Group Jennie Woolmington says the PCT showed "eagerness to listen" to COPD patients during the tendering for the service. She adds: "It is hard for people to understand what it is like to live for years with chronic breathing problems. Many of our members find it leaves them unable to do most of the activities the rest of us take for granted.
WyvernHealth.Com chair David Rooke says the advantage of the new service is that it takes away some of the fragmentation.
Dr Rooke says: "All too often patients who suddenly experienced a worsening of their condition could find themselves having to be admitted to hospital because there is not sufficient support within the community.
"This new service is intended to offer patients care close to, or in, their own homes and reduce unnecessary hospital admissions.
"For patients who need to go to hospital, the new service will facilitate a timely and safe discharge."
Dr Richard More, a Somerset GP and operational director of Avanaula, says the company entered into a partnership to bid for COPD services when it realised "more was being said than being done" about reducing emergency admissions. He says the COPD service shows how well commissioning can work when you have a motivated provider, good practice-based commissioners and a "facilitative PCT".
"That's what I perceive - that Somerset are ahead of the curve on world class commissioning: they did exactly what the public would want. Somerset marked the tenders in a very vigorous way. As a taxpayer, I believe it was good value as they gave us a good grilling - it was not a cosy number."