Lower Gornal Health Centre, Dudley
Christine came to general practice management after a career in further education, initially as a lecturer and eventually as an assistant principal. She has 17 years of management experience and has a master's degree in business administration. Christine works at a four-partner practice based at the edges of a Midlands conurbation. It has a list size of 8,200 and operates out of PCT-owned health centre premises
I have been trying to think up a suitable analogy for PbC and, having just been through a house renovation project, I think I've found one that's apt …
You go into a renovation project fired up with enthusiasm for the beautiful home you are going to create. You imagine your finished dream house and how much better everything will be once you have finished all the work. You are swept up in an excited fervour as you sign your life away on a mind-blowing 25-year mortgage. Then, as soon as you take ownership of the crumbling shell you are going to transform, you find out that the foundations are shot and your entire budget will be needed just to make the walls secure!
And so it is with PbC.
Practically based thinking
The concept of giving GPs the role of purchasing or "commissioning" from the secondary sector is theoretically sound. It brings decision-making and accountability together with referral and is the most logical way to ensure quality of provision and appropriate pathways of care. It is part of a package of solutions to the increasing demands on the health service: by 2010, more than 50% of the population of this country will be over 50 years of age. GPs are more likely to be creative about commissioning reliable and high-quality community-based services for patients with long-term conditions and to keep their patients out of hospitals as much as possible.
Payment by Results (PbR), the transparent pricing system that now applies a tariff for most secondary-care procedures, is now allowing us to see, perhaps for the first time, just how money is being spent in hospitals. The development of standard lengths of stay (or "trim points") for all procedures, and healthcare resource groups (HRGs), enables us to measure the efficiency of our local hospitals against national averages, and to see how any inefficiency impacts on individual practice budgets.
PbR is also opening up secondary care to private sector and alternative providers on a "level playing field", which, together with the "patient choice agenda", combines the ingredients for a radical reshaping of the NHS.
Having signed up to our indicative budgets for 2006–07, however, we are now faced with having to shore up the foundations of the primary care trust (PCT) as it copes with millions of pounds of its budget being needed to help offset NHS overspends elsewhere!
This top-slicing has totally cut the ground from under the whole concept of PbC in this area. Before the start of the 2006–07 year, GPs had all banded together into one PCT-wide cluster, even though the levels of enthusiasm differed. Now, however, the PCT is asking clusters to make the savings PbC is supposed to deliver, but without the pump priming or incentive funding that was expected to make it happen. Clusters are now expected to work for a whole year with little, if any, prospect of a funding return, and on the promise that there will be jam tomorrow. This is a much harder concept to sell to the less enthusiastic practices and GPs.
Our PCT had already embarked on commissioning innovative community services, which were GP-driven. The orthopaedic triage service and dermatology service are now regularly used by the whole cluster. Since the introduction of PbC, a whole range of other services are under development, despite the funding setback. We are starting on underpinning the walls …
Paying attention pays off
The reality of PbC for practice managers, for 2006–07 at least, is a tedious grind of checking hospital admissions, lengths of stay, trim dates, hospital follow-ups and A&E attendances. The quality and accuracy of data was a concern to many in the early stages, and careful analysis of each patient pathway may be needed to ensure that coding errors are not resulting in higher charges.
Attention to these details will achieve savings, albeit in the same way that everyone turning off their TV, instead of leaving it on standby, will help with global warming. The savings may be small in themselves, but they will add up, and in the process we will become far more knowledgeable about what happens in hospitals and how alternative pathways can complement the currently available services.
One area already repaying attention is nonelective admissions. Each emergency admission costs up to twice the national tariff rate for a planned admission. In the Dudley PCT area, a team of specialist community nurses is assigned to patients with complex care needs, who have been statistically shown to be likely to require nonelective admissions.
These specialist nurses can develop individual packages of care for such patients and help them to access existing services effectively. Their interventions have been shown to have substantially reduced the admission rate for these patients and hugely improved their quality of life.
Other successful community-based services proving very popular and cost- effective are the Heart Failure Service and the Falls Service. The Heart Failure Service provides regular contact with a named nurse, who will visit patients in their homes and be available in case of emergencies.
The Community Falls Service provides fast home assessment and modification services for patients at risk, as well as a six-week confidence and balance training programme. One example of progress as a result of the course was a patient who had become practically housebound because she felt too unsteady when stepping off a kerb. After the six-week course she was able to walk a narrow bar suspended six inches off the ground!
Mind the pennies …
The nitty-gritty of PbC, however, comes down to counting the pennies. We are very fortunate to have an extremely well organised and talented bunch of people at the PCT forming the PbC Business Support Unit. They have spent the last 18 months collecting, understanding, analysing and organising the data coming out of the main local hospitals, and they are now definitely "trim point nerds". They can absorb and turn around the data from secondary care providers very quickly and provide practices with useable and understandable facts and figures.
The Business Support Unit has developed a number of standard reports, provided on a monthly basis. They also carry out research on behalf of practices and are only too happy to "go detective" when a practice raises a query about the care of a particular patient or the charging of a particular procedure.
Practices can receive information about their waiting lists, their patients attending A&E, the number of outpatient appointments attended by each patient referred, any "tertiary" referrals made by consultants and a daily list of all their patients in hospital. This list can be used to keep track of patient progress and highlight any patients exceeding the trim point for their particular HRG.
The practice manager can then alert the designated assertive case manager nurse, who will help to facilitate the smooth discharge of patients. We have often found that patients are kept in hospital longer than necessary, not for any clinical need but because they were waiting for some assessment or action to be taken by another agency or specialist.
The role of practice manager now includes the very detailed contract management function. Managers must understand the budgets and set up systems to monitor regularly the actual expenditure against the planned expenditure on a monthly basis. The budget, while indicative at this stage, will soon be real.
Our cluster recognises the importance of practice managers in the PbC process, and has practice manager representatives on the cluster board, as well as mandatory meetings of all practice managers with the cluster and business support teams. These forums are beginning to ensure that all practices are aware of the initiatives that the cluster is creating and that we are all supporting the newly commissioned services and contributing to cost savings.
Many of the practices in our cluster had already overspent against their indicative budgets, and our cluster managers' meeting gave us the opportunity to look at patterns of overspending and make suggestions to the cluster board about where commissioning changes could help us.
As a cluster, we have commissioned research into self-referrals to the A&E services, which has identified that more than 60% of A&E walk-ins were during normal surgery opening times, and that many of these presentations did not require the specialist services of A&E. We are now looking at how we can provide an effective community-based minor injuries service, which would be more cost-effective and would also take the pressure off the A&E provision.
Service level agreements
The service level agreement (SLA) between the secondary care provider and the PCT is the key to taking more control over the services being commissioned.
The SLA specifies what each individual HRG should contain – for instance, one outpatient consultation, one X-ray, one preadmission assessment, four days in hospital and three follow-on outpatient appointments.
By understanding exactly what we are paying for, it is possible to see opportunities to deliver additional elements of this within primary care. For instance, we are currently looking at all our patients in consultant follow-up, to see who can be transferred to the care of the GP instead. The cluster will then pay the practice for the follow-up appointments, rather than the hospital.
Obviously, changes such as this need to be agreed with the individual consultants, and it is most important to maintain good working relationships and not engender a "siege mentality" within secondary care. By sensibly agreeing which parts of the care pathway can be delivered in primary care, a win–win situation can be achieved, as consultants are able to devote more resources to keeping waiting times within limits.
These changes can then be formulated into the SLAs signed up to by clusters and secondary-care providers.
The future …?
It is predicted that over the next three years £13bn will move from secondary- care to primary-care budgets, and this is attracting huge new players into the sector.(1) If independent practices are to prosper, they need to be making plans to expand their services and become a "provider" to themselves and to others. There is a very short window of opportunity here – once services start being commissioned they will be offered on three-year contracts, which, if delivered satisfactorily, may not even come up for retendering.
As we move forward with PbC past the savings period, the manager will be involved in helping to shape service redesign and, where appropriate, in putting together business cases to deliver services.
Many practices have GPs with specialist skills or special interests who may be keen to develop a community-based service for the benefit of their cluster or wider area. In these cases, the practice manager has a crucial role, not only in the formulation of the business case and tender documentation, but also in the administration of the new services, including keeping its income and expenditure separate from the other work of the practice.
Practice managers may begin to manage the clinical delivery in a very tangible way by a clear understanding of the practice waiting lists, financial implications, and trends and patterns. The practice manager will see the impact of all the individual decisions made by clinicians, and will be required to reconcile these with the resources of the practice.
The manager will need to raise concerns and stimulate clinicians to consider alternative strategies. The focus of the manager, on the health of the business, will be crucial in the primary care service of the future.