Website of the Department of Health

What are the benefits of PBC?

Answer

Better clinical engagement:

PBC gives practices and primary care professionals the freedom to develop innovative, high-quality services for their patients.  Using information on current health service usage, primary care professionals can understand how resources are used, and identify areas that will benefit from redesign.

Better services for patients:

PBC enables primary care professionals, working across boundaries with secondary care clinicians and others, to redesign services that better meet the needs of their patients.  Patients can benefit from a greater variety of services from a larger number of providers in settings that are closer to home or more convenient for them.  Patients will also benefit from reduced waiting times when they do need to go to hospital.

Better use of resources:

By giving practices the ability to develop new services for patients within a framework of accountability and support, PBC will improve access, extend patient choice and help restore financial balance.

Can all GP practices get involved in PBC?

Answer

PBC remains voluntary for practices. As PBC contains numerous benefits to patients –a greater range of services, more services provided closer to home, increased investment in primary care – we expect GP practices will want to get involved in PBC.

By ensuring the right environment exists for PBC, we are removing the obstacles for GP practices to get involved.

It is important to remember that recent health reforms have changed the way that healthcare is commissioned.  Under reforms such as payment by results and patient choice, clinical decisions are now direct drivers of financial resources.

Primary care professionals commit NHS resources as a matter of course through their clinical decisions.  In this way, all practices are already in some form, such as in their decision to refer patients, engaging in commissioning.

Question

How can I get information about which practices in my area are engaged with PBC?

Answer

National data on the number of practices taking on an incentive payment to get involved in PBC is available here. For specific details on individual practices, you should contact the practice or the local PCT.

Question

Can practices engage in PBC on their own?

Answer

Yes. GPs cannot be forced into locality or other commissioning groups. However, we would encourage practices to consider the benefits of working with others. For example, working with other practices will create a larger pool of resources for reinvestment in services, which can then be accessed by a larger number of patients across the practices involved (eg. diagnostic services provided to a number of practices).

Question

Can GPs engage in PBC with other like-minded GPs?

Answer

Yes. There are a number of benefits of GPs working together to resolve similar issues. There are also benefits in GPs offering clinical leadership to other practices who are facing particular challenges.

Question

Will becoming a member of a Limited Liability Partnership (LLP) affect the amount of tax I pay in a year?

Answer

The decision to form an LLP is entirely up to the practice consortium. The Department of Health does not expect consortia to form formal legal entities for commissioning purposes and will treat individual practices as the recognised legal entity as far as setting indicative budgets is concerned.

The Department understands that some consortia are considering or have already decided to join a more formal legal entity for Practice Based Commissioning. There may be legal and/or tax implications that go with joining formal legal entities and that practice groups should seek professional advice before formalising, as they would before entering any other contractual agreement. The National Association of Primary Care has sought the advice of its accountants on this matter for its members and has posted the advice in the members' section of its website.

Question

Isn’t PBC too focused on GPs?

Answer

No. PBC is about those in the best place to make commissioning decisions, making those decisions. Often this is likely to be GPs, but it can also include other primary care professionals such as nurses, pharmacists, optometrists amongst others.

What does PBC mean PCTs have to do?

Answer

PCTs are responsible for ensuring that, as a minimum, the following arrangements are in place. This is laid out in Practice based commissioning implementation.

1. All practices are receiving information that will allow them to understand their clinical and financial activity compared with local and national indicators.

2. All practices have received an indicative budget covering an agreed scope of services.

3. All practices are receiving support from the PCT and the offer of an incentive scheme to support practice based commissioning.

4. Governance arrangements for practice based commissioning are in place.  These will have been agreed in partnership between the practice and the PCT.

• Practice based commissioning: implementation

Question

Are there targets for practices to engage in practice based commissioning?

Answer

There are no "targets" for practices, practice based commissioning is voluntary, however the Department aspires to most practices getting involved due to the benefits: a greater range of services, more services provided closer to home, increased clinical involvement in commissioning, and an investment in primary care to better meet the needs of patients.

Budget setting and financial management

Question

How is an indicative budget set?

Answer

The first step in agreeing an indicative budget is to set out the practice share of the entire PCT unified allocation. It is not intended that practices manage this entire budget, but rather this is to illustrate to practices how the PCT's resources are deployed across practices for their patients. It also helps to ensure transparency in the budget setting process. Different parts of the PCT budget should be attributed to practices in different ways. GMS/PMS and prescribing budgets will be attributed using current formulae. Where historic activity for services is available, this should be converted to spend and attributed to practices - as a minimum this will be activity covered by the national tariff under Payment by Results. Other areas of the PCT budget should be attributed to practices using weighted capitation. The next step is to agree the scope of the indicative budget - the budget that the practice will have influence over and be able to access freed up resources from. As a minimum, this will cover prescribing and PbR activity - those budgets where a PCT can accurately ascribe historic activity and so spend to a practice. Practices and PCTs can agree to cover a wider range of services in the indicative budget.

Question

Should funding for secondary dental care be included in indicative practice budgets?

Answer

Secondary dental care forms part of a range of specialised dental services that span primary and secondary care.  These services include oral surgery, orthodontics, paediatric dentistry, restorative dentistry, periodontics and prosthodontics.  Most of the referrals for these services are made by dentists but other referral routes include GPs, consultant-to-consultant, self-referral and A&E.

Both secondary and primary dental care services fall outside the scope of PBC.  They should be commissioned by PCTs, in order to ensure an integrated approach to commissioning and referral management for dentistry (which considers the total budget across primary care dentistry, primary care-based specialist services and secondary care services).  PCTs should engage both primary care dentists (who make most of the referrals) and secondary care clinicians in assessing needs, developing care pathways and managing referrals.

These services should be included when the breakdown of the entire PCT budget is shared with practices but, as is the case with funding for specialised services and central management costs, it should be blocked back to the PCT and not included in the indicative budget taken on by the practice.

NHS Primary Care Contracting (PCC) are producing a briefing paper to share learning on effective commissioning in this area.  PCTs working on redesign of these pathways can contact the NHS PCC team by emailing:

• barbara.dingley@pcc.nhs.uk (opens new window)
• contact sean.fenelon@pcc.nhs.uk (opens new window)

Question

What is a 'fair share' for practices and how is it calculated?

Answer

A 'fair share' allocation for practices is where the amount of resource allocated to the practice is based on the relative needs of the their populations. The current system of allocation to practices is based on historical spending which does not fairly reflect the needs of their current populations. The Department of Health has produced a toolkit that allows PCTs to determine a 'fair share' allocation for practices, based on the relative needs of their populations. This toolkit uses the same formulae as is used to inform PCT allocations. For 2006/07, practice indicative budgets should continue to be based on historic activity, and practices will not be moved straight to their 'fair share' allocation. Rather, the 'fair share' allocation sets a target that practices should move to over time. The Department of Health has not stipulated a pace-of-change policy, and as such PCTs will need to determine this locally taking into account both the merits and risks of different paces in line with local circumstances and distance from target.

Question

Won’t moving to fair-shares give some practices substantially less funding?

Answer

DH policy is moving towards a fair-share allocation and it is appropriate that progress is made in 2007/08 to move towards indicative practice budgets where the practice is a long way from its fair share (+/- 10%).  Where this is the case, PCTs should undertake a simple utilisation review with the practice, with the purpose of understanding why the practice is spending more or less than fair-share.  This is an opportunity to test prevalence data for robustness and to ensure that all need is met.  The move to fair-shares is capped for 2007/08 at 1% of the indicative practice budget, which will ensure that the pace of change is not overly aggressive.

Question

When will the Department update the tool which calculates 'fair share' budgets?

Answer

The new toolkit was published on the website at the end of February.  PCTs who wish to request the updated data files should email pbc@dh.gsi.gov.uk.

Question

The DH fair-shares tool doesn’t seem to be very fair to some of my practices, such as those that have a number of nursing homes in their catchment area. What can I do?

Answer

The DH tool is designed to provide an indication of fair-shares allocation based on weighted capitation.  However, such a national tool will be inflexible to local variation.  PCTs have discretion in the application of the tool when calculating fair-shares when there are particular local populations involved (e.g. students).  Any budget should be understood by and agreed with the practice, in the context of the total PCT allocation.

Question

How should central management costs be devolved and blocked back by PCTs?

Answer

PCTs should share transparently funding for central management costs with practices, as part of helping practices understand how their budget is made up and how much resource they have available.  It would be appropriate for PCTs to label management costs on the indicative budget, and indicate that these will be blocked back.  Management costs for practices, required to set up a new service, should be covered by the business case submitted to the PCT.

Question

Should funding for specialised services be blocked back to the PCT after the PCT's budget has been devolved to practices?

Answer

Yes. Funding for specialised services should be blocked back to the PCT in the same manner as funding for the central management team, because specialised commissioning groups (SCGs) are responsible for commissioning these services.

Question

What happens if a PCT cannot set a budget in line with the guidance?

Answer

A PCT in special circumstances will be expected to identify the causes of the financial difficulty, and to agree how to resolve it.  In exceptional cases, where local agreement cannot be reached, the SHA can seek agreement from the Department to modify locally the PBC guidance.  Where the PCT is struggling to set practice budgets in line with the guidance, agreement should be sought with the SHA, and then permission to follow an alternative route should be sought from the Department.  Where PCTs are struggling to share freed-up resources with practices in line with the principles set out in the guidance, agreement on a different approach must be reached with practices.  The SHA will act as an arbiter, and the Department should be informed of the final decision.

Question

How should PCTs in deficit implement PBC?

Answer

PBC policy was developed to improve services for patients, by engaging clinicians more in commissioning.  This process will involve PCTs operating to ‘invest to save’, and we appreciate that this may be more challenging for those in a financial deficit position.

The PCT has a statutory responsibility to achieve financial balance.  PBC can make a contribution to this through freeing up resources and producing savings, and incentivising GPs to engage in PBC is a key route to achieving financial balance.  However, for PBC to be successful it is imperative that practices are allowed to use a minimum of 70 percent of freed-up resources for reinvestment in patient care.  It is not acceptable to withhold freed-up resources and practices must always be provided with fair and realistic indicative budgets, which should not be allocated with elements top-sliced to resolve PCT deficits.  We expect that all freed up resources would be reinvested in line with the overall strategic vision for PBC.

PCTs and practices have a shared responsibility to achieve financial balance.  Practices in PCT areas subject to special circumstances must use the 70 percent of resources freed up to address specific national (such as 18 Weeks) or local priorities as determined by mutual agreement between practice and PCT.  In addition, when a health economy is in special circumstances, PCTs and practices will be expected to agree how financial balance should be achieved.  A particular focus should be on identifying the causes of the financial difficulty and agreeing a joint strategy for resolving deficits. PBC plans should reflect the contribution from practice based commissioners to the PCT recovery plan.

In exceptional circumstances where local agreement cannot be reached, a SHA may request permission from the Department to modify locally the PBC guidance relating to budget setting and use of freed up resources.

Question

What happens if a practice has overspent their indicative budget at year-end?

Answer

PCTs and practices should work together during the year to ensure that practice spend is regularly monitored. Regular monitoring will highlight potential problems early and a course of action should be agreed. Financial management must be seen as a year-round and not a year-end process. Any local incentive award should be dependent on practices not overspending their indicative budgets.  Where practices persist in overspending, the PCT will wish to consider the practice contract to ensure that they are making the most effective use of health service resources. Where a practice is overspent at year-end then there should be a dialogue between PCT and practice to determine the reasons. In some cases it may simply be due to natural variation in demand for healthcare; overspends for this should be managed through risk management arrangements. In some cases, however, it may be appropriate to review the commissioning responsibilities that the practice have and the PCT may wish to offer the practice more support in future years.

Question

Why do I have to share my savings with the PCT?

Answer

Not all service improvements can be organised by one practice on its own, and as such it may be appropriate for freed-up resources to be shared with the PCT to benefit a wider group of patients. We have therefore suggested that a maximum of 30 percent of a practice's freed-up resources is shared with the PCT for the PCT to spend on the wider health needs of its population. Where a PCT is in deficit at year-end, the first call on this 30 percent will be to cover such overspends. This should, however, be seen as a last resort.

Question

Do practices still have the right to balance their books over a three-year period?

Answer

Where a practice puts forward a plan to spend more in one year to free up resources in future years, PCTs must consider this as part of their wider financial responsibilities. In some cases, there may be the flexibility to do so, but for some PCTs in financial difficulties, the first priority must be to ensure balance at year-end.

Question

Do budgets for 2007/08 have to be set using 2005/06 activity?

Answer

PCTs should calculate indicative budgets on the basis of actual activity for the last 6 months of 2005/06 and the first 6 months of 2006/07 converted into 2007/08 prices.

Question

Can practices spend freed up resources on premises development?

Answer

Yes, but only with the specific approval of the PCT board.

Accountability and governance

Question

Will GPs contract directly with providers for new services?

Answer

No. Current legislation does not allow general practitioners to contract directly with providers of services. However, if GPs identify new services which will benefit their patients and meet the business case criteria set out by the PCT, we would expect the PCT to carry out the procurement on behalf of the practice.

Question

What do you expect the governance arrangements to look like?

Answer

We expect PCTs to set out clearly the details of the PBC scheme locally. This would cover the following and will be agreed by the practices involved: information - timing and content of information to support PBC at practice level; budget setting - methodology for setting the budget; services included; arrangements for risk management; support and incentives - expectations for practices eg. monthly meetings; details of the incentive scheme; practice based commissioning plans - format & sign off; business cases - format, criteria for assessment, sign off.

Question

Why are there no references to the PEC (professional executive committee)?

Answer

Fit for the Future, new guidance for PECs sets out how the role of the PEC in relation to PBC.

• Guidance for the PCT Professional Executive Committee (PEC)

Question

Where localities/clusters of GPs span PCT boundaries which organisation holds the ring over the PBC governance arrangements?

Answer

It will be for PCTs to agree locally how to support PBC across geographical boundaries. We are keen to promote locality approaches, however, each PCT will need to remain accountable for their own resources.

Question

Do practices have to work with stakeholders?

Answer

PCTs and practices must work with other stakeholders in PBC redesign of services. PBC involves frontline clinicians to commission services that better meet the needs of patients. When designing a new service, PCTs should ensure that relevant partners have been consulted appropriately. This would sensibly include consideration of the views of providers of new or existing services even if these individuals were not on the smaller focused PBC group. The business case proforma for new services suggest this criteria is considered before the PCT accept the business case.

Question

How will the quality and safety of new services be assured?

Answer

PCTs retain responsibility for assuring that the services with which they contract are of high quality and safe for patients and users. The Healthcare Commission also has a role in accrediting and inspecting all providers of health services. The National Patient Safety Agency are producing a toolkit which practices and PCTs can use to assess service changes. This will be available on their website.

• National Patient Safety Agency resources for health professionals (opens new window)

PBC Plans and Business Cases

Question

When should a practice submit a PBC Plan?

Answer

Practices should integrate PBC with the commissioning cycle, and although a practice can submit a PBC plan at any time in the year, it would be most helpful if the practice can develop its PBC plan alongside the development of the PCT’s commissioning plans, so that they can be aligned.  PBC plans should form the basis of overall PCT commissioning plans, and the plans should be included in the annual PCT prospectus.

The timing of incentive payments for approved and delivered PBC plans are for local agreement between PCTs and practices and need not be linked to the financial year.

Question

How does the PBC plan link to the local area agreement?

Answer

LAAs contain public service targets appropriate to the locality, agreed between local partners including local government and the PCT.  The PCT has a role to ensure that PBC plans are in line with local targets, including, but not limited to, those in the LAA and LDP.  PCTs should provide their practices with advice on local objectives and help them to tackle priority areas within the PBC plan that fit with the wider strategies on health and wellbeing.

Question

What support is there to help me write a PBC plan?

Answer

The “Guidance and Resources” section of the PBC website is a good place to start.  Other organisations also offer supporting tools, including the Improvement Foundation, the Primary Care Contracting Team, the NHS Alliance, the National Association for Primary Care, the BMA General Practitioners’ Committee and the Royal College of General Practitioners.  See support section of webiste.

Question

Must clinicians exclude themselves from decisions on any PBC business cases that prpopose to provide a service commissioned through PBC, which directly rival services in which they have an interest?

Answer

Yes, in order to avoid any conflict of interest.  Clinicians must exclude themselves from the group making the decision about a service, that would rival a current service, that they themselves are proposing to provide.  The PCT should ensure that robust governance procedures are in place to prevent a conflict of interest between GPs as commissioners and as providers.

Question

Are practices expected to follow the decisions of SHA arbitration groups?

Answer

Yes, both practices and PCTS are expected to follow any decision by an arbitration group.

Question

Why are arbitration decisions on a pendulum basis rather than compromise?

Answer

Fewer cases result in formal arbitration if either party faces the potential to lose. We expect arbitration to be the last resort, with most issues being resolved through dialogue between practices and the PCT.

Question

Why are there two business case proforma included on the website?

Answer

Use of the business case proforma are optional and where local processes are in place, these may be used. The two proforma recognise that some service redesign may be straightforward, take place within the practice and require little or no financial investment. Other redesign may cover a wider population than one practice and may require upfront investment. The two proforma provide different levels of detail required for the redesigned services.

Incentive Schemes

Answer

2006/07 DES Scheme:
To encourage practices to engage with practice based commissioning, a Directed Enhanced Service (DES) for 2006/7 was agreed with the BMA's GP Committee. The DES was payable in two parts. Component one entitled practices to 95p per registered patient in recognition of the engagement (particularly clinical) required of practice staff to develop and implement a locally agreed plan. Component two was payable on achievement of the plan.

Question

Who was eligible for the DES?

Answer

The DES was available to all general practices, not just GMS practices. For further details, please see:

• Guidance on non-GMS contracting arrangements for 2006/07

Question

What was in the locally agreed plan that qualified for component one of the DES?

Answer

The locally agreed plan set out the ways in which the practice would redesign care - how the current patterns of care would be changed, and where the freed up resources would be reinvested to the benefit of patients. The plan was agreed between the practice and the PCT. This agreement triggered the award of component one.

Question

How did practices qualify for component two?

Answer

If practices delivered the objectives set out in the locally agreed plan, they were entitled to component two. Component two was a minimum of 95p per registered patient. It needed to be reinvested in practice activity for the benefit of patients locally. Where practices and the PCT agreed that practices could access freed-up resources above the value of component two for reinvestment in practice activity, this agreement superseded the resources available for component two.

Question

Where can I find more information on the DES?

Answer

Further information is available on the NHS Employers website.

• Directed Enhanced Services on the NHS Employers website (opens new window)

Question

When were DES funds made available?

Answer

Component one was payable on agreement of the plan, (end of June 2006). Component two is payable on delivery of the plan. We would expect this to be at the end of the financial year.

Question

My PCT offers an alternative local scheme to the DES. Will this continue?

Answer

Many PCTs and practices have already agreed arrangements for introducing practice based commissioning and handling the resources freed up. Where these agreements went beyond the specification of the 2006/7 DES, the DES was not intended to override these. The DES guaranteed a minimum level of investment and PCTs needed to consider whether any supplementary resources were required.

Question

What was component two intended to cover?

Answer

Component two must be spent on 'patient care'. Freed-up resources similarly must be reinvested in patient care. The DES allows for component two to be reinvested in 'practice activity to support the continued achievement of the objectives in the PBC plan' and so allows for investment in activity that ensures patient care is delivered. PCTs should be clear through the PBC plan how component two or freed up resources will be reinvested.

Question

Where does the funding from component two come from?

Answer

Funding for component two comes from resources freed up through service redesign. In the event that no resources are freed up, PCTs must find the resources for component two as the minimum where practices achieve the objectives agreed in the PBC plan.

Question

Where does the funding from component two come from?

Answer

Funding for component two comes from resources freed up through service redesign. In the event that no resources are freed up, PCTs must find the resources for component two as the minimum where practices achieve the objectives agreed in the PBC plan.

Question

Can practices access both the 95 pence per patient available under component two of the DES and also have access to the resources freed up through redesign of services?

Answer

No. Practices can access either the 95 pence per patient or the freed-up resources. Access to either resource is dependent on achievement of the objectives set out in the PBC plan.

Question

Does the Directed Enhanced Service under the GMS contract fall part of core GMS/PMS and are therefore excluded from the PBC budget setting process?

Answer

The first step in setting practice budgets is to set out a practice's share of the entire PCT allocation. The practice and PCT will then agree which parts will form the practice's indicative budget. Although the PBC DES falls outside of core primary medical services allocations, it does constitute practice income and as such is appropriate to be excluded from an indicative budget. A similar area would be notional rent payments.

Question

Is the DES plan the same as the PBC plan?

Answer

Yes. The DH template for the plan is more explicit that the template plan attached to the DES. Where the DES plan discusses objectives, the DH plan specifies that these should cover estimates of the value of freed-up resources and how those resources might be reinvested.

Question

If practices work together in a consortia, then how does the DES apply? What happens when one practice in the consortia meets the plan objectives, but another practices does not?

Answer

The DES payment is to individual practices. Where practices work together in a cluster, the cluster will need to ensure that they have governance arrangements in place to cover the arrangements for payment of the DES. The governance agreement will need to ensure that practices have agreed the process where one or more practices do not deliver on the PBC plan objectives.

Question

The DES arrangements were available for 06/07 only. What about incentive schemes for 07/08 onwards?

Answer

The offer of the DES incentive scheme ended in March 2007.  PCTs should now focus on locally agreed incentive schemes as set out in PBC practical implementation.

Question

What should the incentive scheme cover?

Answer

The provisions within the DES arrangement represent the minimum requirements for local incentive schemes (see Practice based commissioning: practical implementation).  PCTs should consider focusing local incentive schemes on encouraging activity that supports delivery of the national 18 Weeks priority and the ten High Impact Changes identified by the NHS Modernisation Agency.

Question

Should the practice treat any incentive payment as income?

Answer

Yes, any incentive payment should be regarded by practices as income.

Information Requirements

Question

What information should PCTs provide to their practices?

Answer

Information on a practice’s utilisation of health resources (including benchmarking) as well as local intelligence on needs assessment must be made available to practices.  The minimum requirement on information is set out in para 5.6 of PBC Practical Implementation.

Question

Where are PCTs expected to get the information from?

Answer

We anticipate that much of the information that PCTs are expected to provide will be easily accessible to PCTs.

Question

What will happen if PCTs do not provide the information to practices?

Answer

Two things. Firstly it will be impossible for practice based commissioning to be implemented properly. Secondly PCTs will be performance managed by Strategic Health Authorities against the four criteria on PBC, one of which is to provide information to practices.

Question

Is there a national system for information management? How will it be developed?

Answer

An information template is available on the website via the link below. This is a first iteration and we are considering how it will be developed. In addition, we are auditing the local arrangements currently in place to support PBC which will inform the development of the tool.

• Management information template
• Feedback on the tool would be helpful, to pbc@dh.gsi.gov.uk (opens new window)

Question

Do PCTs have to use the template?

Answer

No - the important thing is that the information is provided to practices and that they can interpret it . The template is there to help PCTs and practices where arrangements do not already exist for sharing this information.

Question

What if a PCT is already providing information to practices?

Answer

So long as practices are receiving sufficient information for them to support practice based commissioning , there is no need for PCTs and practices to change the arrangements they may already have in place.

Question

What help will be available for practices to interpret data?

Answer

PCTs are expected to ensure that practices have sufficient support to implement practice based commissioning, including support to analyse or interpret data. How this is done is for PCTs and practices to agree locally.

Question

Where will the national data come from?

Answer

The national data that will pre-populate the template that the Department provides, will be taken from the NHS-wide Clearing Service.

Question

Who is responsible for checking the data that practices need?

Answer

The PCT has a responsibility to check the data that it provides to practices is accurate. PCTs may wish to involve their practices in the checking of data which will help drive up the quality of future management information. This two-pronged approach should ensure that practices have the most accurate and up-to-date data.

Question

How is confidentiality of practitioner-specific data ensured when using the information template?

Answer

As stated in the guidance accompanying the information template, PCTs should formally notify their practices that their practices’ information is being included in the PBC information template. This is to avoid any problems with data protection. The template does not ensure absolute confidentiality as there is no facility to anonymise the data. PCTs will need to consider this when disseminating the data locally. This might be through the use of codes for practices rather than names and then sending the relevant identifiers to each practice.

Question

What happens if a PCT is unable to meet the minimum requirements for providing information to practices?

Answer

The minimum information requirement is set out in paragraph 5.6 of the guidance. The PCT may have difficulty meeting the requirements because some of the data is not yet available. Nevertheless, the PCT must develop as rapidly as possible to meet the requirements. It may wish to consider buying in support from an external provider.

Question

How can a PCT use its contracts with secondary care to help it meet the minimum requirements for providing information to practices?

Answer

The PCT’s contracts with secondary care providers should include requirements to provide data that is timely and accurate. This is the best lever to develop more and better data. Schedule 5 of the model contract published alongside the Operating Framework for 2007/08 sets out guidance for including national and local information requirements in contracts with secondary care.

Question

How should a PCT present the required information to practices?

Answer

As part of the support that PCTs provide to practices, we expect PCTs to offer information to their practices that is timely and in a form that practices find most helpful. PCTs also need to offer support to practices with analysis and interpretation of management information to help with commissioning and service redesign decisions.

Indicators

Question

How is PBC being performance managed?

Answer

SHAs have a direct role in challenging PCT performance on PBC.  This includes ensuring the PBC framework is enabling and that practices are engaging with PBC. The Department will maintain a close interest in PBC implementation as part of the wider health reform programme, and will use the three-pronged system of indicators (described in section 6 of PBC Practical implementation) to challenge the NHS to implement PBC policy, present a national picture to Parliament and to influence future policy direction.

Question

What should the annual SHA report include?

Answer

The report should not be extensive, but should include:
- Five case study examples of service redesign initiated through PBC, including financial information on each.
- Summary activity trends indicating the range of specialities affected by service redesign, including the number of patients accessing these new services
- Financial summary, taken from PCT approved PBC business cases, including resources freed up and resources reinvested
- Total number of business cases submitted to the PCT, and the total number of these approved.

Question

How does practice survey work?

Answer

A practice survey is taking place quarterly.  It has been commissioned by the Department of Health and is being carried out by IPSOS MORI.  Practices in each PCT are being surveyed and results shared with the PCT and SHA.  Individual practices will not be identified.  The first survey took place in May/June.  PCTs should encourage their practices to participate, and this might be included in any local incentive scheme that is developed.

Support for practices

Question

What sort of support can practices expect from their PCT?

Answer

PBC Practical Implementation states that tailored support should be provided to practices by PCTs. This will depend on the progress that practices are making with PBC. The exact nature will be for local agreement between the practice and PCT.

Question

If the PCT’s support to a practice does not meet the standards defined in the guidance, what can the practice do?

Answer

We expect PCTs to provide the levels of support necessary to allow practices to fully engage with PBC and allow its full benefits to be realised.  The precise support necessary will vary from practice to practice and we have not sought to be prescriptive, but the recent guidance explains the sorts of budgetary, analytical and IT expertise involved.

It is important that PCTs provide the necessary support functions to practice based commissioners, so we expect that such a situation where this does not occur will be very unusual. If it does arise, practices will be able to negotiate an indicative budget to procure these services for themselves. It is expected that such negotiations will be resolved locally, with cases referred to the SHA if agreement is not reached. The budget will be proportionate to the scope of the practice’s PBC plan and, if applicable, the size of the practice consortium. The budget itself will be held by the PCT with practices arranging for invoices for agreed management support to be submitted to the PCT for payment.

Question

What support is there nationally to help PCTs and practices to get going with PBC?

Answer

Nationally, the Improvement Foundation runs a support programme for PCTs.

• The Improvement Foundation, incorporating NPDT (opens new window)

Question

Do I have to pay to take part in the programme?

Answer

No, it is free for PCTs and practices to take part.

Question

Why is the Improvement Foundation running the support programme?

Answer

With its network of regional offices and experience of working with PCTs to deliver a new way of working, the Improvement Foundation is in an excellent position to provide a tailor made service for PCTs and practices to support delivery of PBC.

Question

Does my PCT have to take part in the Improvement Foundation programme?

Answer

We can't force PCTs to take part - but every PCT will have the option to participate. PCTs will be performance managed against the arrangements they have put in place to enable practices to undertake practice based commissioning and taking part in the programme will help PCTs meet these criteria.

Question

But my PCT and the practices in it, are already implementing PBC.

Answer

There is still value in taking part in the Improvement Foundation programme to share your experiences and to learn from the experiences of others as well.

Question

The PBC guidance mentions promoting peer support and clinical leadership, what does this mean?

Answer

How this is done locally is for PCTs and practices to decide. We are keen for local PBC champions to act as local leaders supporting their colleagues who may not be so advanced with PBC, and to promote and share best practice and their experiences. The Improvement Foundation programme will help with this process.

Practice based commissioning and procurement

Question

How does PBC affect existing rules on procurement?

Answer

Practice based commissioning provides practices with the incentives and opportunities to get involved in the provision of care. Under practice based commissioning, PCTs remain responsible for the decisions and contracting arrangements for new services agreed. They must therefore balance the requirement to follow rules on procurement with the need to foster innovation and avoid an unduly bureaucratic or lengthy process. The following brief guidance has been agreed with the NHS Purchasing and Supply Agency. We intend to produce more complete guidance in due course, and are working with the NHS Primary Care Contracting Team to produce this.

• Download guidance note on PBC and procurement (PDF, 27K)

Question

When is tendering for new services required?

Answer

Formal tendering will normally only be required where the result is to create a monopoly by awarding a contract to a single provider i.e. where an unavoidable service monopoly would be created.
For routine elective services, the ‘any willing provider’ model can be used.  Under this model, there are no guarantees of volume or payment in any contract given.  PCTs through contracts, give permission for the provider to supply services to their population without any promises regarding income.

In addition, tendering is not required when a PCT chooses to develop additional services through the extension of an existing GMS, PMS, APMS contract, including under local enhanced service arrangements.

PCTs and practices have a responsibility to ensure that value for money is secured, and that the process of contracting for a new service is fair and transparent.  Paragraphs 3.40 – 3.42 in the practical implementation guidance set out how this can be achieved.  In addition, some PCTs are ensuring they have undertaken a risk assessment around the need to tender, to ensure that they have an audit trail for their decisions.

General questions

Question

How is PBC different to GP fund-holding?

Answer

PBC is not fund-holding. The 1997 NHS White Paper made it clear that we wanted to "extend to all patients, the benefits, but not the disadvantages of GP fund-holding."

Subsequently, there are key differences between PBC and fund holding:

i. PBC is less bureaucratic. Fund-holding was bureaucratic.  PCTs will continue to deal with the administration ie. contracting, payments etc which should mean limited additional bureaucracy.

ii. PBC is centred on improving patient care. Savings from fund-holding did not have to be spent directly on patient care.  Under PBC all proposals for savings must be agreed at the outset and must be spend on patient services.

iii. PBC is more equitable. Fund-holding practices received more funding than non-fund-holding practices, leading to an inequitable distribution of resources. Under PBC, practices not taking up PBC will not receive proportionally less funds.

iv. PBC is focused on quality, not price. Fund-holding GPs could negotiate the cheapest price for acute services.  With tariffs there is no longer any incentive to bargain on price.

Question

Patient choice: The guidance refers to the principle of offering patients a choice of provider in primary care. Is this principle set out in formal guidance?

Answer

No. Formal guidance has only been issued concerning patient choice in secondary care, and this does not currently cover instances where primary care provides similar services. At the moment the principle of offering patient choice in primary care is only a direction of travel in which PCTs should be heading.

Question

Health inequalities: How does PBC fit with health inequalities?

Answer

PBC offers opportunities for tackling health inequalities and for investment in prevention services Resources freed up can be reinvested in services that will aim to prevent ill health and tackle health inequality. There will be a need for practices to engage with other partners in provision of services - often outside the health arena. This may be difficult and frustrating, but long term goals of better health will be the driver. In the future, local targets will be delivered through LAAs and other local agreements and there will be a need for services to be joined up in their approach. Practices will need to understand the drivers behind local health issues. Practices can tackle ill health through a more coherent approach, but in return, they will be expected to direct more of their resource in to tackling the issues that rest behind health-relevant agendas - such as crime and education. Clustering of practices to map on to local authority boundaries can only enhance this service planning and commissioning.

Question

Joined up working between health and social care: How does PBC apply to social care?

Answer

PBC delegates indicative budgets to practices in order that they can commission services for their patients. These delegated budgets cover health resource. However, there is a need to engage with other partners when redesigning health services, and those services provided by social care will be amongst those that will be relevant. The DES states that practices will be expected to work with other relevant local stakeholders, especially community staff and social services in the development and implementation of their plans.

Question

How does PBC fit with commissioning of children's services?

Answer

Children's trusts arrangements bring together planners and commissioners in children's services. Joint commissioning arrangements are developing well and are offering opportunities to tackle some of the health inequalities in children's services and to support care pathways. These developments are further supported by increased inter-agency and inter-professional working in children's centres, extended schools and other sites. PBC has the potential to build on this. By ensuring that PBC is consistent with local children's trusts arrangements, services can be commissioned at the appropriate level, responsive to local need and demand, and integrated where integration will lead to better outcomes for children and young people.