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Healthcare commissioning is the process by which the health needs of a population are assessed, the responsibility is taken for ensuring that appropriate services are available to meet these needs, and the accountability for the associated health outcomes is established.
The NHS and its local bodies have commissioned services from various providers (e.g. hospitals, GPs and pharmacies) for a great many years. Since the publication of The NHS Plan in 2000, there has been a shift of power from central government to local NHS organisations and with this change has come an increase in commissioning responsibilities.
Local Pharmaceutical Committees (LPCs) have for many years worked collaboratively with Primary Care Organisations (PCOs) to facilitate the commissioning of local services from community pharmacies. The changes in the approach to commissioning that Practice Based Commissioning is bringing about presents LPCs and local pharmacies with new opportunities to develop service provision, however in order to maximise these opportunities it is essential for local pharmacy leaders to get involved in the PBC process at an early stage.
Commissioning Pharmacy Services
Support and advice on the commissioning of local pharmacy services can be obtained from PSNC's Aylesbury office (01296 432823). General guidance and background information can be found in the following publications:
PSNC Sources of Funding 2005 (PDF format)
This updated guide replaces the previously published 2003 document. It sets out sources of funding that could be available to community pharmacists for the development of pharmaceutical services and aims to make sure that community pharmacists are able to enter into negotiations with primary care organisations from an informed position.
NPA Commissioning Resource Pack (PDF format)
A resource for PCTs to support understanding of the key commissioning routes for Primary Care Services in England and how to utilise these to commission services from community pharmacy.
Two jointly badged publications from pharmacy organisations CCA, NPA, RPSGB, PSNC and AIMp were published in May 2009. The documents, which were produced in collaboration with the NHS Alliance, are part of a strategy to promote the role of pharmacists to commissioners, managers, general practitioners and others in primary care. The documents also seek to influence the commissioning of pharmacy services by PCTs under World Class Commissioning and the integration of pharmacy into Practice Based Commissioning (PBC).
The guides - ‘10 High Impact Changes in PCT Commissioning Practice' and ‘5 High Impact Changes for SHAs' - have been produced as a provider perspective on commissioning. They provide PCTs and SHAs with suggestions of how to work with pharmacists in order to maximise their contribution to the development of PBC and commissioning.
Five High Impact Changes for SHAs
10 High Impact Changes in PCT Commissioning Practice
Background to PBC
Practice based commissioning transfers these responsibilities, along with the associated budget from the PCT, to primary care clinicians, including nurses, with the PCT acting as their agent to undertake any required procurement and administrative tasks to underpin these processes.
PBC was first announced in The NHS Plan:
‘...PCTs will extend indicative budgets to individual practices for the full range of services’
The concept was further developed in The NHS Improvement Plan which stated that:
‘from April 2005, GP practices that wish to do so will be given indicative commissioning budgets’
PBC is seen to be a key part of improving the NHS and the expectation is that every PCT will encourage their practices to take it on and maximise the potential of the policy as far as possible.
All practices will receive annual information on their use of health services and this will be one of the factors by which PCT competency in commissioning will be measured.
The development of PBC is expected to evolve over time, potentially with other primary care clinicians holding indicative budgets.
The Department of Health has published a series of documents on PBC which are available on the DH website:
Department of Health PBC website
Guidance and Publications
Practice Based Commissioning – A practical guide for Pharmacy Contractors
This briefing document aims to provide Pharmacy Contractors with the knowledge to enable them to effectively engage with Practice Based Commissioning (PBC) and builds on the guide for LPCs (see below)
Practice Based Commissioning: A Guide for Community Pharmacists
Practice based commissioning: A guide for community pharmacists provides LPCs, contractors and community pharmacists with the knowledge to effectively engage with Practice Based Commissioning (PBC). The guide was developed jointly by PSNC, RPSGB, NPA, CCA and PCC and outlines the benefits in introducing PBC and the potential risks associated with failure to engage with the programme. The aim of the guide is to influence the development of community pharmacy to play a more inclusive part in healthcare, public care and social care.
Practice Based Commissioning – A practical guide for LPCsThis PSNC briefing document aims to provide LPCs with the knowledge to enable them to effectively engage with Practice Based Commissioning (PBC). As well as providing background information on the place of PBC in current health policy, it provides practical suggestions for action.
The document covers several major areas including:
1. A description of commissioning and practice based commissioning, including the commissioning cycle;
2. Key issues in the implementation of PBC and the impact of recent PCT re-organisation on commissioning;
3. Opportunities for community pharmacy considered within the three areas of preventing hospital admissions, effective prescribing and redesign of care pathways;
4. The role of the LPC in engaging with practice based commissioners; and
5. Advice on the development of robust business cases to PBC commissioners.
Making commissioning effective in the reformed NHS in England (Full Report/2007)
The Health Policy Forum, a new collaborative venture between PSNC, NPA, CCA and RPSGB, published a report on Effective Commissioning in the NHS in England. The research, conducted by primary care policy experts from The Health Services Management Centre (HSMC) at The University of Birmingham and The King’s Fund, sought to identify the components of effective commissioning. It pinpoints key elements that make a critical difference, and suggests actions that primary care organisations might take, based on these findings, to develop successful commissioning policy and practice.
The report concluded that there are four key elements to effective commissioning. These are:
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The identification of need and demand, which will require PCTs to take a more sophisticated approach to research and data analysis in the future;
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Market shaping, which will require PCTs to balance the need to provide choice with market management to ensure that services are provided in a sustainable way;
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Holding the market to account, which requires PCTs to act as local stewards of NHS funding and ensure they achieve value for money from providers; and
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Holding commissioners to account, which is crucial to ensuring that all stakeholders, not least the general public can be satisfied that PCTs are doing a good job.
NHS Primary Care Contracting PBC bulletin 5 - Pharmacy & PBC (June 06)
One of a series of PBC bulletins produced for PCTs and Commissioning Groups by NHS PCC.
Practice based commissioning: early wins and top tips (DH)
A clinically focused document highlighting how Practice based Commissioning can be used to improve services for patients. (Published 8th February 2006).
Practice based commissioning: achieving universal coverage (DH) contains the guidance published on the 26th January 2006, along with its accompanying budget setting toolkit.
Commissioning e-Book - An open access, online facility to help people who are commissioners of community-based health, social care and housing services.
Practice Based Commissioning (2005)
This PSNC document explains the background to PBC, details of relevant DH documents and lists useful websites, along with action points for LPCs:
Advice and Actions for LPCs
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Make sure you are aware of local developments and are actively involved in the initial discussions.
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Make sure that your members are familiar with PBC developments.
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Find out what services are to be commissioned and consider the implications for local community pharmacy service development.
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As the PEC will oversee the development of PBC, it is important to have good links with your PEC pharmacists, or identify a PEC member to work with if a pharmacist has not been appointed.
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Continue to lobby for the appointment of PEC pharmacists.
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Work closely with LMCs – they have had guidance from the GPC on how to take PBC forward.
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Feed back to PSNC any information from early implementers so that it can be used to inform other LPCs.
FAQs
What is practice based commissioning?
Practice based commissioning (PBC) is a key part of the overall NHS reforms to improve local services and health. By devolving money to local level, PBC provides engagement of primary care clinicians in commissioning decisions and redesign of services to better meet patient needs, and make better use of health resources.
PBC is a system whereby all practices or group of practices will be allocated an indicative budget, enabling them to operate as commissioners of services. Budgets will be allocated on a ‘fair share basis’ equivalent to their historic use enabling practices to purchase a range of services with PCT agreement. Currently there is no actual transfer of funds and overall responsibility and accountability, as well as all funds, resides with the PCT with the PCT holding the contract with service providers.
Since the introduction of practice based commissioning in 2005, the Department of Health (DH) set a target of achieving universal coverage of practice based commissioning, and this was met at the end of 2006.
What is ‘universal coverage’?
Universal coverage is a measurement set and monitored by DH to show PCT progress towards implementing PBC and provides a minimum framework for practices.
In order to achieve universal coverage to meet the deadline of the end of December 2006, a number of arrangements had to be put in place –
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All practices had to receive information that would allow them to understand their clinical and financial activity compared with local and national indicators
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All practices had to receive an indicative budget covering an agreed scope of service
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All practices had to receive support from PCT and the offer of an incentive payment (the Directed Enhanced Service (DES) or locally agreed payment) to support practice based commissioning
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Governance and accountability arrangements for practice based commissioning had to be put into place and agreed in partnership between the practice and PCT
PCTs now have arrangements in place to support PBC and practices have taken up their incentive payments. The next step in 2007/8 is to improve the quality of this framework to facilitate practice engagement and service redesign.
How does practice based commissioning work?
Firstly practices and PBC consortia have to agree detailed PBC plans with their PCT, which set out their commissioning objectives. Underpinning these plans are complex assessments of the needs of the local population, which are undertaken together with relevant clinical professionals. The PBC plans are then approved by the PCT and form the basis of overall PCT commissioning plans which will be reviewed regularly.
New services will be developed through PBC and may be commissioned from a range of providers including community pharmacy. Contracts will set out quality standards, but will give no income or activity guarantees.
PCTs are responsible for providing practice based commissioners with information, analysis, management and HR support either directly, or failing that through support arrangements using a PCT managed budget. Any management costs for service provision through PBC are provided separately by the PCT and should be included within service costs.
PCTs are encouraged to commission from a wide variety of providers, to ensure innovation, quality and value. Service users will also therefore have a wide choice of options. Any willing provider is free to compete, and may include providers from the public, private and the third sector. PCTs are able to challenge the service ideas of practices and will not necessarily allow all ideas to proceed. There must be evidence to show that commissioning of these services is necessary.
What is a ‘willing provider’?
A ‘willing provider’ can include providers from the public, private and third sectors. The Department of Health believes that it is by including as many groups as possible that the greatest innovation and variety will be encouraged. In turn more service providers will also increase levels of competition resulting in improved efficiency and service. The PCT also needs to be satisfied that the service provider can deliver the service and is compliant with quality standards, before a contract or agreement is awarded. Tendering for services will not always be required if the process is open to any willing provider, and will only be needed in order to avoid creation of a service monopoly which would serve to inhibit choice and contestability
How does practice based commissioning fit into the NHS structure?
The concept of service commissioning was initially introduced in the 1990s and was intended to enable those responsible for spending money on service users to have a greater input into, and to take responsibility for, the way that the money was spent. Initially the system worked through fundholding, this system was held to have a number of faults - arguably that it forced GPs to decide between treatments with money being the principle concern rather than patient welfare. Practice based commissioning is a method to put the patient first and enable greater choice and options. There is emphasis on prevention and finding new and better ways to help patients.
In 2006 the Government stated that its vision was……’to develop a patient-led NHS that uses available resources as effectively and fairly as possible to promote health, reduce health inequalities and deliver the best and safest possible healthcare’
Health Reform in England: update and commissioning framework (July 2006)
Practice based commissioning is part of the overall NHS reforms which aim to improve local services and health. It offers the possibility of creating savings in a number of ways, either by providing the service in the same way but more efficiently or by changing clinical behaviour and care pathways to provide a service differently and more cost effectively. 70% of any funds that are saved will be available for practices to reinvest in further developing patient care.
What are the opportunities for pharmacy and pharmacists?
Much of the philosophy behind practice based commissioning is an attempt to look at new, more efficient and cost effective ways of doing things. This includes a strong emphasis on preventative measures. There is also a desire to use funds more effectively and enable patients to have choice. There are potentially many opportunities for pharmacists to become actively engaged in practice based commissioning.
These include:
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Screening
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Monitoring including anticoagulation, blood pressure, and blood-glucose
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Medicines management
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Immunisation
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Patient education
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Community pharmacy services such as minor ailments, stop smoking or weight management schemes
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Practice or pharmacy based services such as pharmacist-run clinics
Examples include:
In Hillingdon community pharmacists deliver a primary care diabetes management service, available to all adults taking medication for the condition. Each patient has a consultation with the pharmacist at least six times a year. The initiative focused on improving patients’ understanding of their condition and treatment in order to improve the clinical indicators associated with diabetes. Pharmacists agree the referral criteria with GPs for problems, such as intolerable side effects, that cannot be resolved in the pharmacy. The initiative was developed following a case-management audit, which showed that the management of some patients with diabetes was without local guidelines.
In the North East of England a pharmacy-based anti-coagulant clinic has been running for many years. The programme means that patients do not have to travel to the general hospital. Previously patients had to spend half a day of their time on what is now just a ten-minute appointment.
In 22 pharmacies in Manchester the “High Street Testing” pilot provides clinical services and point of care diagnostic blood tests for diabetes and cardiovascular disease.
In Sutton & Merton PCT community pharmacists run a holistic lifestyle health care management programme for individual clients. The pharmacists provide a range of services including screening, lifestyle advice (including smoking cessation advice) and support to improve compliance with medicines.
How can pharmacy and pharmacists get involved in the process behind practice based commissioning and create opportunities?
Practice based commissioning provides many opportunities for primary care professionals to engage, influence and take action to innovate and challenge current practice.
In order to maximise the opportunities for pharmacy it is important that pharmacists get involved throughout the commissioning process - this includes working behind the scenes.
There are many such opportunities for contributing such as:
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Identifying and establishing contact with your local PBC locality or practice lead
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Lobbying for inclusion of a community pharmacy representative in locality PBC groups and local improvement teams
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Encouraging the appointment of PEC pharmacists – PEC members will be involved in service development and commissioning decisions
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Establishing good links with your PEC pharmacists, or identifying a PEC member to work with if a pharmacist has not been appointed, as the PEC will oversee the development of PBC
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Initiating and supporting the identification of gaps in service provision – use customer and patient input to identify new services
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Establishing good links with your local GPs and discussing their plans for PBC
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Finding out what services are to be commissioned and considering the implications for local community pharmacy service development
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Getting involved in the design of care pathways
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Keeping abreast of local developments, playing an active role in initial discussions
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Making contact with the Improvement Foundation regional leads (see Key PBC websites)
Key PBC Websites
Department of Health – Practice Based Commissioning Mini-Site
Department of Health – Practice Based Commissioning Frequently Asked Questions
National Association of Primary Care (NAPC) Website
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