Lesley Hill On primary care

Published: 13/05/2004, Volume II4, No. 5905 Page 31

Two contracts; two highly contrasting experiences.At North Bradford primary care trust, we have recently negotiated a contract with Nations Healthcare to develop an independent treatment centre. Signed last month, the deal took several months to develop and demanded a huge amount of effort from the five commissioning PCTs involved, the Department of Health, legal and commercial support and Nations Healthcare.

Negotiations were often not easy: many hours were spent finding a way around problems. Difficulties always needed to be resolved using face-to-face meetings.However, we now have an agreed contract. An ITC is due to open in early 2005 and 'interim'work is already under way. In North Bradford, we are now seeing waiting times fall as patients are treated through the interim agreement and we know the additional capacity provided by the ITC should keep our waiting times at under three months.

The development of the second contract - the foundation trust agreement with Bradford Teaching Hospitals trust - has been very different. PCTs received the contract a few weeks before the end of the financial year and no legal or commercial support was available to enable robust negotiations. Timescales meant it was impossible for a contract to be negotiated. The standard foundation trust contract needs a lot of work to localise it and develop new sections to reflect information requirements, clinical - and other - quality standards, arrangements for changes to the contract during its lifetime and payment mechanisms.

However, the most fundamental issue with the foundation contract is how it fits with wider policy initiatives within the NHS, including payment by results, choice and chronic-disease management, and national targets. The pressure to deliver the four-hour wait target in accident and emergency has, in some instances, increased the number of very short-stay admissions.

Payment by results is encouraging improved coding and counting, which is of positive benefit to planning and commissioning.However, until healthcare resource group charges are changed to reflect this improvement, the result will be that secondary care receives additional income in exchange for little real additional activity.

Detailed work is needed to ensure that payment by results does not destabilise integrated care and chronic disease management programmes.A specific example would be the lack of a zero length-ofstay HRG price. This does not mean that payment by results is flawed - it should encourage more efficient delivery of services.However, it does need some further work so it supports integrated care and chronicdisease management and does not provide perverse incentives for acute secondary care. This then needs to be embedded in contracts.

PCTs and foundation trusts need time and assistance to develop contracts to which all the partners can agree. If this does not happen, the current arrangements for payment by results and foundation trusts could significantly undermine the excellent work taking place across primary and secondary care.

Lesley Hill is deputy chief executive, North Bradford PCT, winner of the prime minister's award for excellence in healthcare management at last year's HSJ Awards.