Website of the Department of Health

Question

2. 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

3. 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

4. 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.

PBC financial guidance

Question

5. 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

6. 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

7. 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

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

Answer

The new toolkit should be published on the website by the end of February.  PCTs who wish to request the updated data files should email pbc@dh.gsi.gov.uk from 1 March

Question

9. 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

10. 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

11. 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

12. Is there a fixed period of time for a practice to achieve financial balance, and what happens if they don’t?

Answer

Practices and PCTs will work together throughout the year to ensure resources are properly controlled and that resources which are freed up within the year are effectively redeployed to benefit patients in a sustainable way.  The PCT will retain its responsibility for the allocation and the statutory financial duty to break even.  The PCT and practices will work together to ensure the PCT achieves financial balance, or runs a small surplus.  

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.

Question

13. 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 should 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.

Support for practices and incentive schemes

Question

14. 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

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

Answer

The “tools and templates” 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

• PBC guidance and resources
• Improvement Foundation: Practice-based commissioning development programme (opens new window)
• Primary care contracting (opens new window)
• NHS Alliance (opens new window)
• National Association for Primary Care (opens new window)
• BMA General Practitioners' Committee (opens new window)
• Royal College of General Practitioners (opens new window)

Question

16. Do PCTs have to offer an incentive scheme?

Answer

There is an expectation that PCTs will offer an incentive scheme, in order to facilitate practices’ engagement in PBC.  With the offer of the DES incentive scheme ending at the end of March 2007, PCTs should now focus on locally agreed incentive schemes.

Question

17. 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: Achieving universal coverage).  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

18. Should the practice treat any incentive payment as income?

Answer

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

Information for PBC

Question

19. 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

20. 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

21. 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.

Question

22. 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.

Indicators

Question

23. How will PBC be 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 the guidance) to challenge the NHS to implement PBC policy, present a national picture to Parliament and to influence future policy direction.

Question

24. 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

25. How will the practice survey work?

Answer

A practice survey will take place quarterly.  It will be commissioned
by the Department of Health and will be carried out by an independent company.  Practices in each PCT will be surveyed and results shared with the PCT and SHA.  Individual practices will not be identified.  The first survey will take place in April.  PCTs should encourage their practices to participate, and this might be included in any local incentive scheme that is developed.

Patient choice

Question

26. 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.

Health inequalities

Question

27. How will PBC tackle health inequalities?

Answer

PBC gives practices real power to redesign services to meet local needs and tackle health inequalities.

PBC will tackle health inequalities in the following ways:

- The move from historical to ‘fair share’ budgets.
- A more appropriate range of services commissioned, including a focus on prevention, early intervention and cooperation with partners in social care. 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 need to understand those issues which have the biggest impact on health locally, and what they can do to tackle them, as well as the views of the patients and public they serve.
- 70% of freed-up resources can be used by practices to commission more and better services as agreed with their PCT and in line with their PBC plan.
- 30% of freed-up resources can be used by the PCT to improve services in those areas in most need in order to tackle health inequalities.
- Health inequalities will be tackled best by the targeting of resources to those areas which need them most, rather than sharing them equally across the patch.

PBC and secondary dental care

Question

28 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)
• sean.fenelon@pcc.nhs.uk (opens new window)