PBC: the case for pharmacy engagement Print E-mail
Written by Neal Patel   
At first glance the term “practice-based commissioning” (PBC) seems to have little to do with community pharmacy. Commissioning, a task previously associated with primary care trusts (PCTs), is not a function to which many community pharmacists will have been exposed, and the fact that this new type of commissioning is practice-based implies that those who are not based in ‘the (GP) practice’ are excluded. Indeed, there are some who are happy for this misconception to be propagated, but being excluded from this process will close down many opportunities to extend community pharmacy practice.
This article will discuss what PBC is, why it’s here and why it’s likely to stay. It will also explain why community pharmacy must engage with PBC and give some pointers as to how this could be achieved. The first task is to deconstruct the term “PBC” and look at its component parts, explaining the rationale for this policy.

What is commissioning?


Commissioning describes a series of tasks performed by an organisation that would like someone else to provide a service on its behalf. Before PBC, PCTs were the commissioning bodies responsible for health commissioning in their locality, commissioning services on behalf of patients. Some see PBC as a recognition that PCTs have failed to act as effective commissioners and the recent PCT reconfiguration as a strengthening of PCTs’ ability to commission.

However it is worth noting that the existence of PBC does not relieve PCTs from their responsibilities to commission effective healthcare for their local population; hence terms such as “indicative budgets” are used when describing the budgets available to practice-based commissioners.

The tasks involved in commissioning are often represented as a cycle, the implication being that the commissioner undertakes activity before, and continues to have a responsibility after, a service is provided. This differentiates commissioning from the simple purchasing of services, although purchasing remains an important component of the commissioning cycle. However, the first task of a commissioner is a needs assessment that includes the needs of the local population, the economic needs of the NHS, the performance management needs of regulators and government, and the needs of current and future providers.

Establishing these needs will lead a commissioner to begin to shape the care pathway for the patient. In PBC, the care pathway is often defined as the journey a patient takes after being referred from the GP onwards for more specialist, usually hospital-based, care. Once broad decisions have been taken about the care pathway (i.e. will this activity be undertaken inside or outside hospital?) then more detailed plans are drawn up to guide potential providers.

Both these tasks will be performed by practice-based commissioners, typically GPs, in partnership with the PCT. The next phase of commissioning involves tasks that remain within the exclusive domain of the PCT, although in reality blurring certainly can and does occur. Once clinicians and managers have agreed detailed care pathways, the care must be purchased from potential providers. How this purchasing is done will depend entirely on the type and size of service. For large complex tenders e.g. all sexual health services in a PCT, then it is likely that a formal tender notice will be issued with providers competing for the business.

In today’s modern NHS, providers will come from the private, voluntary, not for profit ‘social enterprise’ sectors as well as the public sector. In smaller service redesign projects, a tendering process may be inappropriate e.g. the modification of the process associated with treating acute myocardial infarction. Here the clinical pathway may be refined within the current service model.

The final stage of the cycle (before beginning the process again) is to monitor and performance manage the provider both financially and qualitatively. In some cases this will be done through the monitoring of key performance indicators that, if breached, may have contractual consequences. As the NHS now operates through a mixed economy of providers, performance monitoring and management of this type will become more common. Data provided by the service provider should also provide intelligence from patients and other stakeholders, allowing for continuous refinement.

Why base commissioning in practices?


Having established that the commissioning activities in PBC involve needs assessment, service redesign and associated care pathway production, one may ask why practices have been chosen to undertake these activities. The answer lies in another policy brought to life before PBC and the probable reason for the acceleration of PBC implementation, with all practices to be included by the end of 2006.

The other policy is payment by results (PbR to those in the know), which effectively puts an end to the up-front agreement of block contracts between PCTs and hospitals. Now for each operation, diagnostic test or  procedure carried out in secondary care, an associated charge is made by the hospital to the PCT. This funding change is an incentive for hospitals to carry out more work as increasing hospital activity leads to an increase in income. As each activity is costed according to a national tariff, hospitals compete on quality rather than price to attract commissioners.

Although many benefits can be seen from a system that allows the money to follow the patient, there are serious financial consequences to a policy that gives the acute sector incentives to increase activity. So-called “gaming” of the system could include A&E admissions (allegedly occurring to avoid breaching the four-hour maximum A&E wait) with the added side-effect of a charge via PbR to the PCT. Once the patient is in hospital a full diagnostic work-up with perhaps some inter-consultant referral adds to the NHS bill. Policy makers soon realised a counter weight was needed to avoid costs spiralling out of control.

PBC engages GPs in a system that links clinical decisions with financial responsibility. Many GP consultations will end with a decision to prescribe or in some cases a decision to refer the patient to a specialist centre for diagnosis or treatment. In PBC GPs are made aware both of the costs of their own clinical decisions and those of their peer group for comparison.

Most importantly any savings (with certain caveats) made through prescribing or referral can be kept by the practice to invest in patient care. Other ways of creating savings can be found by redesigning services to avoid costly hospital referrals. For example a GP with a special interest (GPwSI) in dermatology may be able to deal with patients who have previously been sent to a hospital consultant. The patients who are redirected to this service would include those from GPs in other practices. Shifting care from hospital to primary care is likely to reduce costs, improve waiting times and offer a more convenient setting for patients.

However, even greater reward is on offer for those who can reduce non-elective or emergency admissions. So-called “unplanned care” often involves the rapid deterioration of a patient with a pre-existing long-term condition such as diabetes. Improving the preventative care of these patients can reduce the likelihood of an unplanned hospital admission and, again, savings can be retained by the practice for reinvestment.

For some practices, realising savings through commissioning for reinvestment is not the only benefit to PBC. As with the GPwSI in dermatology example above, if a practice can both commission and provide a service then a virtuous circle is formed ensuring financial health for the practice as well as improved care for patients and a reduced bill for the NHS. But what of other providers who may wish to compete or perhaps collaborate in the provision of services?

The invitation isn't in the post


Community pharmacy is not alone in its concern that PBC introduces a common role of commissioner and provider that may stymie the opportunity for other professionals to be involved in both the commissioning and provision of services. Bulletins issued by Primary Care Contracting and the Department of Health describe how allied health professionals, pharmacists, patients and the public should be engaged in PBC. Although this guidance is useful, following it is not compulsory. A proactive approach is most likely to yield success.

The fact that medicines-related problems are implicated in about one-tenth of hospital admissions among older people should entitle pharmacy to a seat around the table. Once there, an appraisal of the nationally funded new contract services designed to improve concordance should be of interest to a practice-based commissioner. Moving on from the contract, the integration of pharmacy services into care pathways and redesigning care to provide more services in community settings such as pharmacies are the real prizes for successful engagement. Most would agree that those are prizes worth pursuing.

 
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