It may appear premature to talk about the resurrection at Christmas, but the recent joint report by the Nuffield Trust and NHS Alliance, Beyond practice-based commissioning: the local clinical partnership, by Judith Smith, Julie Wood and Jo Elias, offers a viable alternative option to practice-based commissioning (PBC).

Which is handy. Because in terms of its vitality, PBC is a Norwegian Blue, as David Colin Thome admitted at the Wellards conference recently. None of the DH’s attempts to revive or reinvigorate PBC had any impact: they flopped without trace. (Metaphysical question here: if a policy is relaunched in a forest, and nobody hears it, did it happen at all?)

The report is a well-argued analysis of the possible contribution that local clinical partnerships (LCPs) could make to the oncoming financial storm. It is a strong collaboration between NHS Alliance (COI: for whom I do bits of work sometimes) and the Nuffield Trust.

I am content in my bias that NHS Alliance is A Very Good Thing – indeed they seemed to be the only ones keeping PBC off the critical list until Everton fan Colin-Thome publicly consigned it to the Liverpool Care Pathway.

The Nuffield Trust has refocused its seriousness under Jennifer Dixon’s direction. A series of good and useful reports from authors including incoming Kings Fund maestro Chris Ham have followed, dragging Nuffield out of venerable obscurity and towards the centre of the policy conversation. Their recent hiring of former Kings Fund comms player Daniel Reynolds will prove a good acquisition.

Smith and Wood iterated their arguments in a conversation and discussion with the audience at a seminar in the NHS Alliance conference in October, and the report was launched late last month in an evening reception by the Nuffield Trust.

Clinicians: the natural managers
The Local Clinical Partnership report acknowledges the truth of the words in Roy Griffith’s 1980s NHS report for Margaret Thatcher: that “clinicians are the natural managers”. The smarter organisations have known this for some time, which is why the failure of PBC is such a depressing reflection on the smartness of many PCTs.

Smith, Wood and Elias are also clear that it will be crucial to devolve real budgets to these organisations, which must bring together not just primary care clinicians but also hospital-based specialists.

Having studied similar organisations elsewhere in the UK, USA, Australia and New Zealand, they argue that while challenging to extant organisational forms and contractual arrangements, there is no intrinsic reason LCPs could not develop as one part of the answer to the oncoming financial storm. With hard budgets, of course, would come legal and ethical responsibility to account for performance.

As well as real budgets, they suggest that size and geography will be a crucial factor initially – the working assumption is of populations around 100,000: small enough to ‘feel local’; yet large enough to manage the management and transaction costs.

Likewise, the geographical location fits with some form of capitated population-based budget, although constraints of geographical location should matter less than willingness to work with a LCP’s corporate and clinical governance.

They also identify the vital importance of clinical involvement and ownership in developing a legitimised sense of corporacy, and participating clinicians ‘doing it to themselves’. Taking on the considerations of management is extra and in many cases, somewhat unfamiliar work. So they are perceptive on the issue of ‘ownership’.

This will in turn involve another of their key points: developing suitable and aligned incentives to attract participants from primary and acute are into theses new organisations. The down-side risks of new ‘start-ups’ must be countered by something that will be a positive and consistent incentive to leave the comfort zone of an established organisation.

Of course it is easy to pick on issues such as pensions, access to capital (because if we’re providing care closer to home, we may need buildings). There are also significant questions about whether LCPs would work to primary or secondary standards of risk-management (the former being much higher), and whether a private sector organisation could become a LCP (some could argue that Circle Healthcare have done so).

There is also an apparent need for some gatekeeper or regulator to ensure quality thresholds and also to ensure that ‘hobby’-standard services are not developed by clinicians with the enthusiasm to “do a bit of dermatology / cancer / etc” but without the expertise to deliver acceptable care.

No matter: this is a very good first shot at a difficult issue. It would be interesting to see the work iterated with other sectors, perhaps a classically acute sector such as gastroenterology. It would also be interesting to develop conversations with social care and the third sector.

Below this are my uncorrected notes from the discussion at the launch and at the NHS Alliance conference session.

Launch of Beyond PBC – the local clinical partnership report, Nuffield Trust / NHS Alliance
Monday 23 November 2009
uncorrected notes

Judith Smith

evidence of effectiveness of physician organisations

international (Australia, New Zealand, US, UK)

tend to bring together previous index small or solo
enable new services to be developed, core standards and peer review (in 90s profound cultural change in UK GP)
shared financial risk and purchasing
joint management and infrastructure support
potential to tae ‘make or buy’ decisions

the local clinical partnership

purpose, next more radical incarnation of NHS clinicians’ provider development and commissioner activity
to build on what has worked in PBC
drawing on international evidence. vibrant, FFP etc, focus on improving health outcomes, ensuring improved efficiency

group of clinicians, most phys led, developed bottom-up
involves other primary / community clinical staff

active involvement of sc clinicians
formal entity owned by clinicians, and able to withstand NS reorganisations –not committee of PCT

configuration
ideally, based on geographical population
willingness of clinicians to work together most important
of apt scale critical mass for commissioning risk management nd reducing management costs (100,0000)

responsibilities
real, risk-adjusted and capitated budget
provides or commissioners most or all p and comm. health services
plus some specialist advice, diagnostics and care ‘ office medicine’
able to take ‘make or buy’ decisions
able to take make or buy
held to account on health outcomes, patient experience

Julie Wood – how make this work practically?

scope – plural model, vary in size and scope, acc to local interests and priorities
some LCPs will grow out of PBC or PMS organisations
all will be providers, some will also commission to differing degrees

determining form
for will need to be apt to size, function extant arrangements (company limited by guarantee; multi-professional partnership or mutual; virtual network of practices with social enterprise for commissioning FT

engaging GPs
critical issue of aligning personal and organisational incentives
ability to reinvest savings along with commitment to sharing financial risk
other incentives – timely service development; peer review and support; training and education; shared service provision

renewal of GMS, PMS contracts to connect core work of practice teams with LCP
might over time move responsibility for GMS / PMS into the LCP, but would need careful governance
more realistically, ‘beyond PBC activity’ become core pat of contracts as an extension of provider work

engaging specialists
might be contracted to LCP, in a partnership with GPs, or employed by LCP
the ‘offer’ would be critical
pay, portable pension, CPD
specialists would expect rapid access to diagnostics, admitting rights to hospital
might create ‘chambers’ and contract to LCP

setting budgets
robust methods will be critical
person-level resource allocation techniques being developed by Nuffield and others
high-quality integrated data and IT systems will be critical
also critical can plan for broader population health and outcomes

accountability
importance of benchmarks for service quality, health outcomes and financial performance
accountable to PCT via contract, also for GMS / PMS funds (in most advanced form)
regulation via CQC, Monitor (if org form of FT) – both provider and commissioner activity – latter new role for monitor
effective user and public involvement
and choice of LCP also a possibility

reshaped role for PCT – larger and fewer, become funder, priority-setter, assurer of standards and health outcomes
become ‘brain and conscience’ of wider local health economy
fewer, larger, pure commissioners,
role holding ring as LCPs develop

from here to there
big bang vs slow burn enabling and permissive policy context with phased implementation
no appetite for massive structural upheaval
LCPs to determine models / pace of implementation
perhaps start by working with the willing and encouraging bold innovation

poss models
1. LCP with ring-fenced GMS taking on capitated locality budget to deliver increased range of services
2. 2. PMS / APMS orgs join forces with FTs along clinical pathways to form LCP
3. 3 LCP developed from ICOs taking on make or buy decision fo whole pop
4. 4 most advanced and risky takes whole local budget incl. GMS and PMS, via practices and clusters integrating delivery, make what can; buy what can’t in partnership or via PCT

The deal 7 key features / issues

Michael Dixon: form of future, but where stumbling over last 10-15 years, perhaps predictable end point

this must happen as things must change, not just fin and PBR not working in climate, PBC not working, and not using out-of-hospitals payment. about disconnect between clinicians like me spending and managers over there, between PC and SC, all clinicians and DH / politicians. LCP is an answer to those disconnects.

two effects will follow: first, monetary savings – back to locality commissioning pilots, only allowed 1 yr, huge savings in prescribing quite extraordinary, NZ IPA first year of their largest 35% saving on diagnostics. No PBCer here yet looked at – potential to make 10-20 n saving. make and buy issue – total dysfunction great idea, not complicated, put in business case, wait average of 1 year and finally poss get a no. bureaucracy, red tape and inertia stultify and give up. this version ,idea and have money and can do it

1. ownership, ability to develop own model. in past, hand-me-downs – clinicians can own, design and mould.
2. clinical leadership – how make clinicians amenable to what want to do? heal open gaping bleeding wounds between clinicians, managers and government
3. incentives – most clinicians don’t see why should bother from a financial point of view or go to meetings 7-8 pm. Get incentives right in piece rates and for outcomes not juts money, and means to make a difference, see headroom to really change things, will happen

Pauline Bramblecombe GP, GP trainer and gynaecology GPSI
GPs were traditionally not trained in health economics and health policy (now in GP curriculum)

don’t believe incentives must be financial, can be quality of patient care

budgets will be critical Cambridgeshire is £11 million overspent this year and by 2013-14 will be over £100 million. most of us can’t manage PBC budgets now, and formula must be looked at. referrals inversely linked to deprivation. to manage budget, patient involvement and political interference has to be attacked, can’t gatekeep if all is possible. get over in partnership with patients, but not if politicians fuel public demand

secondary care specialists – Julie Wood suggested that ‘consultants have higher status than GPs’ have tried and tired to work with. why take the headache. BCCTH as consultants will not leave ivory towers, need sea change and have to be in their self-perceptions. we have community geriatrician funded from PBC savings, tried dragging consultant out of acute, fear can’t change specialists into generalists Assura LLP for intermediate services, ICO something really looking at, but only if PCTs back off and not want to tender everything else. use redesign potential and innovation within present providers. I think trust issue will stymie everything. For GPs, DH, SHAs, PCTs and acutes do not trust us. patients love us listen tot hem. courage to trust and empower general practice, GPs problem solvers, now don’t understand problem, when dom will find solution

Minoo Irani:hones to on strengths and challenges, sure lot of clinical support, community specialists will find lot of common themes, take to my acute colleagues, say we are most effective PCP, why change, Why in era will acutes fail, how will PC-;ed model work> have ot reassure sceptics won’t get worse than current deal. so what, say the sceptics? hospitals great fort episodes of care, fine for medical surgical. MLTC or minor v cost-ineffective, preventions sickness wellness not cracked. acute processes v expensive, dismantle and reassemble o bad for some medical conditions.

Choice and competition, choice v limited, only got choice of dates and times, can relate choice by this model. competition is non-existent once referral into acute, costed environment, little can do.

how reassure? specialists not queueing up to come out, used to big organisations with good governance and safety nets, so any new environment must be as good or better. reassure not just used to boost GP income, make difference to patients. if LCPs get together, FTs and PCTs won't barrier them. contacts, Terms and conditions; clinical excellence awards

incentives for specialists to come out. clinical leadership, now non-existent, not as clinicians don't want to lead but barriers, clinical autonomy has been suppressed, sense of ownership of programme, and pride lost in acutest? responsibility, huge, quality (big agenda), risk, financial and other, and managing conflicts of interest for LCPs vs. FTs.

Nigel Edwards: The logical conclusion is, ‘what about social care?’ it's a missed opportunity to include that. also, ducked issue of GMS contract. real problem of different contract types in same org. QOF will cause major problems with internal tensions. specialist bit crucial, convinced, much more in emergency care, 100,000 enough for outcome measure and bargaining power for emergency care. managing acute downsizing and procurement rules. don’t mention must be way of doing medicine within this, a ‘way we do this here or highway’. what do if you’ve not get Cambridgeshire GPs? Ealing / Enfield?

Norman Lamb (Lib Dem health spokesman): here's exciting potential to re-engage clinicians who feel disillusioned and that they've lost control lost. potential to align incentives, and aims, seems to make lot of sense. Three points:

1. surely need reference to social care, Kaiser lessons about integrating not only PC and SC but health and social care
2. talked about size of 100,000 – my N Norfolk, whole constituency – if one org covers all that vast rural area, horrible absence of choice, and one driver of improving quality and standards is patients saying rubbish off elsewhere
3. how to get GPs on board? Pauline’s comments and concerns, and fundholding divide? real potential for this to take off

Judith Smith: we thought about social care, but focused on primary-secondary care intyerface as we think that is hardest thing to do in terms of the power differential

Julie Wood: size and emergency care – working with one another on emergency care LCPs co-operate so get localness and also sense of bulk of budget but also clout where needed. How Ealing or N Norfolk GPs/ Challenge, but down to aligning incentives, if get GPs to re-ignite their professional pride. Excited but frustrate how to deliver

Assura delegate: add make and buy together. GPs love problem-solving – start delivering services quickest way to get this going. On size, 680,000 in Nairn’s, ours anything from 60,000-250,000. GPs motivated by not making losses! Inner-city PCTs more controlling of general practice. Tower Hamlets ICO pilots.

management teams threatening staff with disciplinary measures if talk to us. (Assura). consultants from out of area looking to trespass over borders

Michael Sobanja: engagement = about organisations’ legitimacy. something in accountability to local communities moving forward, if not command respect of local community. what when people don’t want to play. If it's to be a big bang, recent experience has shown how the smaller bang has a habit to run into the sand. policy always falls short if it's not developing.

Pauline B: if I don’t get most of my budget, cant shift into community. from local health organisation to local health partnership, social care integration, joint budgets in Cambridgeshire. community and preventions stuff motivates GPs. Health is often little to do with medicine and all to do with with social care, for health need social budget too. medical budgets will have to go to social care cuts

Chris Ham: love the paper, fear the incentives! if PBC failed, is there enough here to engage GPs? Should we see LCP status as a prize, not automatic, only if show infrastructure, capacity, etc. appeal to competitiveness FT problem. also fear emphasis on PPI rather than clinicians. Principia in Notts, network of 120,000 GP practices, PPI built in right through. shift balance there from clinical aspect

Nick Black: patient choice, partnership choice of clinician. benefit to establishing outside public sector or not work – NZ or ISTCs able to enrol those they wanted to work with. how we do it here. can engage with discussions, if you do not like our way, you're not for us. capability to interview those want to work with. orthopaedics in ISTCs, NHS ISTCs and NHS organisations: in the two NHS ISTCs, orthopaedic surgeons told managers what they would do and it involved 10 different ways of working and so 10 separate forms of procurements. ISTC maybe wrong but justified protocol. where is equivalent in this model, then patients cold differentiate

commissioning GP –about relationships, over 1-1 real fracture, not only between GP groups but with SC colleagues, my institutional memories, lots of acute and PCT CEs come and go, clinicians are the only ones with an institutional memory. deeply unsatisfactory. PCTs conspicuously ailed ot manage contracting prices, deliberately separated it from clinicians, so contract talks with SC separated form clinicians – in acute too. Massive disconnect. in relationship[p with patients, hear gossip about you. GP more office-based mentality, and informal influence on how provide gradually lost. some contracts. FT ability to spin wheels and make more money as do things repeatedly. acutes walked away from demand management – corporate responsibility or responsibility to local healthcare population? Our FT board locally is just realising that it's not in their interest to bankrupt the local PCT. Acute bigger than GPs o own.

v large – 4 localities, commission based on patient needs. like prize, for last 18 moths as PBC group, trying to prove you can do this, how much have to prove? maybe some of prize as lead commissioners for end-of-life service pathway commissioning, done it swiftly, also specialists palliative care so consultants. some of this links to incentives, something about reduction in variation.

Jennifer Dixon: takes time – 20,30, 40 years in high-performing ICOs, growing a local not-for-profit business

On size and speed of financial challenge, is devolution only option as not time for incremental. SW London workforce rally changing female and part-time, partnership not important, OOH, types of professional engagement for these, limited capacity to influence businesses they work in.

100,000 feels small enough to engage in. community staff in last third of career.

pulling specialists
complexity and competition,
social care
incentives
access to capital

Judith Smith: specialists – still think critical first to have robust clinical grouping at local level. as much challenge for community an primary are in this as for acute sector, lot to do, efficiency and quality, how community services interact, importance of strong groupings. competition – don’t go far toe explore, other than should people be able to choose.

Julie Wood: incentives and prize / aspiration – entry criteria and who decides? when look around country, if seen as PCT , is that not being prize some will go for. what if create matters of failure and performance regime / how to get benchmarks right, in terms of patient experience, health outcomes and financial performance, so there's no hobby provision. how get benchmarks right that clinicians, managers and population want? Incentives right for people wanting great role in this.

NHS Alliance 2009 conference session: Beyond PBC: creating clinical collectives

Julie Wood: David Nicholson didn’t put his hand up to Phil Hammond’s question ‘do you, the audience, know what PBC is?”!

Judith Smith: this is a piece of joint work between Nuffield Trust and NHS Alliance. Origins in May: 15 years researching primary care commissioning, just back from 2 years in Aus / NZ. Disappointment with PBC – in Aus and NZ strong general practice organisations

Medical groups and PCOs quite evidence-rich area.

Publishing 23 Nov 2009.

Growing consensus PBCX failed to deliver what was intended. Construed as delegated function of PCT, so not belonging to or led by general practice.
lack of real budgets to have proper clout - evidence suggests
examples of significant innovation via PBC exception not rule

context – compulsory move to PCTs in 2002 spelt end to clinically-owned PCOs in the NHS “corporatisation by the state”. excessive bureaucracy stifled innovation.

Need to put in place clinically led organisations to reshape services (meet financial challenge; enable integrated care for LTCs; reshape primary community care into ‘office medicine’; align financial and clinical incentives with patient outcomes)

Vision of clinical mutual – group of clinicians established as own org / entity assume real and risk-adjusted budget; take responsibility for local population health outcomes; decide make or buy; within apt governance framework that is sensitive and apt; assessed on patient experience, heath outcomes and financial performance (Rosen and Ham’s holy trinity’)
an accountable care organisation (Fisher 2006, US)

evidence suggest
clinically led and owned
excellent senior management support
real budgets enabling local service development and improvement
integration of data and info
aligned financial and professional incentives for professionals
able to demonstrate clear benefits

How get there?
Big bang – move beyond PBC; invite medical groups to bid for contracts to assume a global risk-adjusted budget for local population
if local groups don’t bid, PCT will contract with another NHS or private organisation.
enable to contract with or employ com health staff and specialists
manage GMS resource within overall medical group contract
groups choose to access specialist and tech support from PCTs or others (choice?)
PCTs become purchaser / governance entity, commissioning specialised services, holding ring or local orgs and ensuring overall service provision

Slow burn
reshape PBC as medical group-based provision with ability to make or buy
in willing pilots, turn PBC budgets from virtual to real, and ensure risk-adjusted
agree outcomes
strengthen incentives to hold budgets
enable PCTs to contract with groups over time

What are preconditions?
The deal:
- groups owned by clinicians
- budgets must be real
- make or buy decisions must be possible
- risk must be handed over and assumed
- responsibility for outcomes must be taken
- accountability must be clear
- experimentation must be encouraged
- compelling narrative required

Niti Paul
looking at HMO-based contract with PCT. practice medicine. new PBC? dunno. Keen reply vs. Luddite.

GPs are commissioners and providers, separating has been bloody nightmare.
HMO-based GP contract SBHMO (socially based, sharing incentives and disincentives, designing bespoke solutions, more in control, proper use of info and data
Success – real market development – DH talk, but has died a death. 3 Darzi practices next door to me. Relationship between commissioner and provider. I have 2.5 year waiting business cases

In Somerset, the PCT is being tasked to support secondary care, audit of repeat admissions, we found not people trapped in acute, LTCs managed in acute, reasons trapped in acute are mental health issues, social health issues, and alcohol. NHS bases on acute data, which is fundamentally flawed. Focus on acute data, miss trick, focus on actual things that are not broken. Until focus on our data and not acute, built on sand. Told secondary care trusts cannot be allowed to fail. HMOs allow us as GPs to be much more provider of services than we are now.

Chris Ham
There’s a real risk, donwnside, taking profits as extra income. Social HMO funding truly multidisciplinary.

Base on geographically determined groupings, or like-minded practices, which might cut across goegraphical area, allowing people to choose? Could be very attractive to a different government.