NT/NHSA - Beyond practice-based commissioning: The local clinical partnership - 30 November 2009

Source

Joint Nuffield Trust and NHS Alliance Paper...

Practice-based commissioning (PBC) has been a cornerstone of the government’s health service reforms in England since it was introduced in 2005, but it has so far had limited success. With the NHS about to enter a period in which growth in its budget will be severely constrained, it is vital that clinicians, especially doctors, are engaged in decisions about how patient services are designed and delivered and how NHS money is spent.

With the future of PbC in the balance, this joint paper by the Nuffield Trust and the NHS Alliance examines how PBC can be developed. While there may be many ways this could happen, this paper considers one broad model – that of multi-specialty groups of clinicians – for example GPs as well as hospital-based specialists – taking responsibility for the provision and commissioning of local healthcare.

A ‘local clinical partnership’ (LCP), with full responsibility for a population’s health outcomes and funding, is examined as a means of bringing together the known benefits of involving clinicians in NHS resource management, with an incentive structure that could engage them in local service redesign. Its aim would be to improve quality of care and secure greater efficiency of service provision. LCPs would be handed real budgets and would have responsibility for the health outcomes of their local communities. The paper proposes that this model holds real promise as a way of developing more efficient and higher-quality care beyond PBC.

This paper has been informed by a series of interviews and two workshops held with clinicians and managers active within PBC, academics, and policy-makers expert in this area. In these interviews, people were asked about their views of the role and potential for groups of clinicians to assume responsibility for health provision and commissioning in the NHS. As context to the study, a review of the research and policy literature on physician groups, multi-specialty groups and primary care organisations was undertaken, including material from the UK, USA, Australia and New Zealand.

Beyond Practice-based Commissioning: the local clinical partnership will be important reading for health care leaders, policy-makers, practitioners and academics interested in this crucial area of health care reform.

• Local Copy of Paper

Executive Summary
Significant challenges face the NHS. In the short to medium term, funding levels will be severely constrained. Pressure on health services to be far more responsive to, and engaging of, the individuals using them will grow. Traditional providers of healthcare, hospitals and general practices will be forced to improve the efficiency and quality of care, as well as offer new forms of care that are more convenient for the public.  These pressures are seen universally across the developed world.

Those responsible for commissioning care using tax funds must become more skilled and proactive in helping to shape desired forms of  care that offer greater value. If not, the quality and availability of care, and along with it public support for the NHS, will diminish.

Yet commissioning in the NHS by primary care trusts (PCTs) has not delivered nearly as much impact as expected (Smith and others, forthcoming). Practice-based commissioning (PBC), a policy designed to engage doctors, in particular, to be more conscious of cost, quality and patient choice in commissioning hospital and community care, has not in many cases been able to bring about the significant change nor widespread clinical engagement that was anticipated in policy.

There is little appetite, politically or within the NHS, for further large-scale policy upheavals. Yet with PBC apparently unfit for purpose in its present form, and PCT commissioning frequently cautious and tentative, further thought is urgently needed as to how to boost commissioning, and specifically how to nudge or evolve clinically-led commissioning into life.

How commissioning has developed to date, and what might be the appropriate next steps in its evolution, are the subjects for discussion in two forthcoming joint monographs by The Nuffield Trust and The King’s Fund (Smith and others, forthcoming; Lewis and others, forthcoming). This paper focuses specifically on how practice based commissioning can be developed to help face some of the challenges outlined above. While there may be many ways that practice-based commissioning could be developed (see Lewis and others, forthcoming), this paper considers one broad model – that of multi-specialty groups of clinicians – for example general practitioners (GPs) as well as hospital-based specialists – taking responsibility for the provision and commissioning of local healthcare. A ‘local clinical partnership’ (LCP) is examined as a means of bringing together the known benefits of involving clinicians in NHS resource management, with an incentive ,structure that could engage them in local service redesign aimed at improving the quality of care, and securing greater efficiency of service provision.

The report has been informed by a series of interviews and two workshops held with clinicians and nanagers active within practice-based commissioning, academics, and policy-makers expert in this area. In these interviews, people were asked about their views of the role and potential for groups of clinicians to assume responsibility for health provision and commissioning in the NHS. As context to the study, a review of the research and policy literature on physician groups, multi-specialty groups and primary care organizations was undertaken, including material from the UK, USA, Australia and New Zealand. A presentation of the draft conclusions from the report were delivered at a workshop session at the NHS Alliance annual conference in October 2009, and the feedback was used to inform this final report.

In a number of international health systems, clinicians form themselves into organisations to manage and develop the provision of local health services and/or the commissioning of healthcare. These groups are variously known as physician groups, independent practitioner associations, divisions of general practice, or primary health organisations. For the purposes of this study, the authors considered such groups as ‘clinical collectives’ that bring together mainly (but not exclusively) doctors into organisations that take responsibility for the funding and provision of a range of local health services, and are accountable for local health outcomes. The report uses the term ‘local clinical partnership’ (LCP) to describe how these groups could operate within the NHS in England.

Key features of a local clinical partnership might include:

• Responsibility – for the provision and commissioning of a range of local primary, community health and ‘office medicine’ services.
• Clinical involvement – the LCP would comprise a group of clinicians, and in most cases would be doctor-led, although it would have the active involvement of nurses from primary and community care, pharmacists and allied health professionals. As well as generalists, it would include specialists who would be contracted to the organisation from local foundation trusts/other acute trusts or community provider agencies, employed by the LCP, or engaged in the organisation as partners.
• Geography – an LCP would ideally be based on a geographical community, thereby enabling it to assume a population-based budget and focus on delivering health outcomes for that population. However, a strict geographical focus should not override the need for LCPs to develop ‘bottomup’ as independent collectives of clinicians who are committed to working together in managing budgets and sharing the associated risk.
• Size – evidence suggests that to maintain a sense of ‘localness’ for the clinicians forming the group, whilst having sufficient critical mass for managing clinical and financial risk, organisations need to have a population base of at least 100,000. LCPs will need to be of sufficient scale to keep management and transaction costs under control and be effective commissioners.
• Ownership – the organisational form of an LCP would be determined by local clinicians. The precise nature of ‘ownership’ would vary according to the history and context of the particular collective of clinicians. Factors to be considered would include whether they want to be purely provider organisations, entities that assume both provider and commissioning responsibilities, and how ‘multi-specialty’ they intend to be.
• Budget – LCPs would have a population-based, real, capitated and risk-adjusted budget, assumed on the basis of taking responsibility and accountability for local health outcomes, patient experience, and financial performance. The LCP should be able to take ‘make or buy’ decisions.
• Accountability – LCPs would be accountable to PCTs and regulators for health outcomes, patient experience and financial performance.

It is clear that if clinician groups with real budgets and responsibility for population health outcomes are to play a key role in the next phase of development of the NHS, a phase that entails possibly the greatest management and financial challenges known to the NHS for a generation, then radical change will be necessary. The report outlines  the potential role of multi-specialty groups of clinicians in taking responsibility for and leading such change at a local level. The main changes needed are:

• enabling LCPs to adopt an organisational form relevant to their scope, size, and organizational history – foundation trust, social enterprise models, and multi-professional partnerships show particular promise
• the crafting of a sophisticated set of incentives for GPs engaging in an LCP, including a renewal of the General/Personal Medical Services (GMS/PMS) contracts 
• the development of an incentive package for specialists becoming part of an LCP – the portability of the NHS pension is a key issue
• the use of robust methodology in allocating population-based and risk-adjusted budgets
• development of a framework for assessing the outcomes of LCPs
• finding ways of ensuring public accountability within LCPs, through public membership or other advisory and consultative arrangements
• examining the potential of offering people a choice of LCP
• a reshaping of the role of the PCT, towards one focused on being the steward and governor of a (probably larger) health community.

A migration path is suggested for the move from current PBC consortia towards becoming an LCP. This is set out as a series of possible models that different local groups might adopt, depending on the willingness and readiness of local clinicians to assume certain levels of
financial and service commissioning responsibility.

The paper concludes by outlining the essential requirements for putting in place an LCP, as viewed from the perspective of local clinicians, and the PCT. This ‘deal’ is suggested as a checklist of critical issues
that might guide the further development of policy for multi-specialty clinician-led organisations beyond PBC. The key elements of the ‘deal’ could be:

• budgets must be real, with financial risk handed over and assumed
• savings could be kept by the organisation and used in a not-for-profit way
• LCPs must be developed and owned by clinicians
• experimentation and innovation must be encouraged
• ‘make or buy’ decisions must be possible
• governance must be robust and proportionate, and accountability clear
• responsibility for health outcomes must be taken
• radical service improvements must be possible.

As the NHS enters a time of financial challenge that calls for significant changes to the delivery of care in primary, community and hospital settings, clinical leadership and engagement will be needed as never before. Experience of primary care-led commissioning, service line management and other approaches to involving clinicians in resource management and service change highlight the potential of harnessing clinical knowledge and enthusiasm with strategic service change. We suggest that a multi-speciality local clinical partnership, with full responsibility for a population’s health outcomes and funding, holds real promise as a way of developing more efficient and higher-quality care beyond practice-based commissioning.

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