Media Archive 2005

I am also very pleased to be here and to launch the NAPC’s website on practice based commissioning – which I will do in due course. But first, my two questions.

Why is practice based commissioning essential?

Let me start by putting practice based commissioning in some kind of context.
We stand half way through a ten-year improvement plan. A plan based upon both investment and reform. As you know, spending in the NHS is rising rapidly - from £33 billion in 1997/98 to over £90 billion in 2007/08. By the time we get to 2007/8, health will be consuming some 9.5% of our national wealth a year, up from about 6.5% 10 years before. And that shows significant investment into healthcare in this country and raises questions about how well managed it is in some parts of the country.  Thanks to this investment, the enormous hard work of NHS staff,  and changes we have already made, the NHS is greatly improved. But it is still not good enough. Further reform is necessary. An NHS that is performance managed and driven from Whitehall will always I would suggest face inwards towards Ministers and the Department of Health, not outwards towards its patients and users.

So, as we said in Creating a Patient-Led NHS, the NHS needs a change of culture as well as a change of systems.

We need an NHS where:

• Everything is measured by its impact on patients
• The NHS is as concerned with health promotion and prevention – looking after the whole person – as well as with sickness and injury
• The staff directly looking after patients have more authority and more autonomy, supporting the patient better.

In other words, we are shifting, fundamentally, from a central and politician-led system – and let’s be honest; a provider-led system  to one that is  a patient-led service. And improving patient care and experiences are going to be at the heart of our reforms.

Coupled to this is the “Your Health, Your Care, Your Say” White Paper which will be coming out in January probably on healthcare outside the traditional acute hospital.  Our aim was to engage the public in how they would like to see their health services developed as society and lifestyles change. Through one national summit, four regional events, 150 local events, and 36,000 questionnaires returned, we believe we have achieved this and learned a great deal.

We heard that patients want to see more local services that can better respond to local needs, that are more integrated, more convenient and involve less travel - particularly for the elderly. We heard patients want better care for those with ongoing needs – and those the people with long–term conditions.  They have provided us as Ministers with much to think about and reflect in the White Paper but they may have delivered some strong messages for the NHS and health professionals and some may be uncomfortable for many NHS deliverers.

Practice Based Commissioning as a means to a patient led NHS

Practice based commissioning is essential as a means to attaining this different level and type of service that patients want. 

Improving patient experience involves making sure decisions are taken as close to patients as possible. GPs and other primary care professionals are to be at the heart of the new commissioning process. They are the clinicians that are in daily contact with patients. And just a few figures - there are over 300 million consultations in general practice every year.  In hospitals there are just 13.4 million first outpatients and only around 10 million in- patients are actually admitted to hospitals each year. The scale and proportion is fundamentally different from the scale of contact in acute and general hospitals. We need to ensure that we give frontline staff outside hospital the means to respond more to the needs of their patients without unnecessary or avoidable referral to hospital. Primary care has to become much more than a gateway into secondary care.

Payment by Results and patient choice are part of this. Patients in discussion with their clinicians will choose where they want to go for treatment. Given the levels of public trust in GPs who better I would suggest to help them with those decisions? Payment by Results ensures the money follows the patient to pay for their care. Once established, the payment by results tariff offers the opportunity for adaptation to encourage alternatives to hospital referral. Offering care out of hospital is a key development in many healthcare systems. Indeed, in France, Sweden, Spain and Australia, all, or an increasing proportion of specialist outpatient care is based in the community.

Where a patient can be treated within primary care and thus preventing a referral to hospital - rather than the money flowing to the hospital regardless in a block contract, it will be freed up to be invested in other services. Practice based commissioning allows practices to keep these savings made against its hospital budget to invest in alternative services, further improving patient care. Practice based commissioning is a key part of changing the direction of travel for the NHS for the future – more prevention, more community-based service reponses, more integrated health and social care, more self-care, carers support and use of expert patients.  A health service more fit to cope with an aging population. And that is what the White Paper will be about.

How can we effectively achieve practice based commissioning?

Practice based commissioning will help us  deliver a health service we all want to see. A health service where patients receive care which is closer to home, more convenient, and more tailored to individual needs.  All of us here today  have a role in trying to fulfil this vision.

Let me now turn to the role of GPs and clinicians.
Practice based commissioning itself enables GPs and primary care clinicians to become integral to the commissioning of services for their patients. The case for PBC is overwhelmingly I would suggest a clinical one. It is not a system dreamed up by bureaucrats, but it is an opportunity for GPs and their clinical teams to have better information about their practice, and to respond better to their patients' needs. 

We want to encourage clinicians to see practice based commissioning as in three points really:
• A chance to thoroughly examine which  services their patients are using;
• A chance to consider how services could be redesigned to the patient’s advantage; and
• A chance to implement this change.

You are the people who see more patients day in and day out than any other part of the NHS.  You are in pole position to do a better job for them and I suggest also to improve job satisfaction in the primary care teams.  Not only do your patients trust you , we trust you to make these changes.

Already there are many examples of success across the NHS.
• We know that Musculo-Skeletal services providing specialist assessment and treatment from physiotherapy to pain management can reduce referrals to hospitals and provide faster access to more appropriate care, closer to home.

• A group of GPs in Kent have found that as many as seven in eight ENT hospital referrals do not end in surgery and could be dealt with in primary care by an ENT specialist. They have identified a local GP with a special interest who will run a clinic in a local practice.

• In Uttlesford, practices are employing a respiratory nurse specialist to reduce the number of hospital admissions caused by respiratory conditions. They estimate that just 17 emergency admissions, around 5% of the total in the area, need to be avoided to cover the cost of the post.

• Langbaurgh PCT does not have an acute hospital in its area and so diabetes care is predominantly through specialist GP-led clinics.

• A consortium of 25 practices in South Manchester have redesigned services so as to treat up to 55% of ENT outpatient referrals and up to 60% of gynaecology outpatient referrals within primary care. I was very pleased to note from the recent NAPC survey that clinical engagement has brought ‘the buzz back’ to these practices.

We must ensure that these are not just islands of success. We need to take this to scale.  The potential there is considerable.

We must not forget that the ethos of primary care is all encompassing. NHS primary care is envied around the world for its continuity of care. This must not stop at the surgery door. Practice based commissioning enables primary care clinicians to stretch the envelope of primary care beyond traditional appointments into what happens to patients next.  We want you to blur the age-old artificial and sometimes rather mysterious boundary as far as patients are concerned between primary and secondary care.

Practice based commissioning strengthens the gold standard values of primary care. It does not undermine them.

Role of Practice Managers
And now a few words about practice managers.  Practice Managers too have a fundamental part to play - both inside and outside the practice – in improving patient care.

Inside the practice, practice managers can play a crucial role in enabling doctors and clinicians to focus on their clinical work. Writing business cases, validating commissioning data, and identifying areas where savings could be made and turned to patient advantage, are all jobs which are highly necessary for effective practice based commissioning.

Outside the practice, practice managers have a key role in communicating and linking with their PCT, as well as other practices. They can be essential in promoting good clinical engagement and organisational understanding.

• In particular, I am aware of an example in North Somerset. Through meetings focusing on the benefits to patients of practice based commissioning, a practice manager has been able to shift several practices from general scepticism to being raring to go. I wish I could sometimes achieve the same in the Department of Health!

Role of PCTs
It is worth saying  a few words about PCTs informed from my travels around the country. PCTs have to play in practice based commissioning. I understand that many of you have been frustrated in your dealings with PCTs over this area. I can sympathise with your frustrations but let me try to explain the role  PCTs have to legitimate role to play.

Fundamentally PCTs are publicly accountable for achieving value for money through their wider commissioning role, which includes commissioniong effective primary care.  It is true; in some parts of the country primary care is not effective .  The more deprived areas can be ineffective. In discharging these responsibilities, as I like to describe this, as custodians of tax payers money they must ensure that the practice based commissioning in their area is effective. We will hold them to account for that but it doesn’t mean they should thwart the development and expanding of practice based commissioning. Their role, I suggest, can be split into three components.

Firstly, PCTs need to assist practices in managing practice based commissioning. This initially includes providing practices with a budget, which will move as quickly as possible from reflecting activity levels to being based on population need. They will need to agree budgets with practices or groups of practices and ensure that they have - and use - good information about their referral patterns. Those who haven’t moved in this direction need to do so smartly.

In addition, the PCT will  retain responsibility for dealing with all contracts and bureaucracy. This is a marked contrast, I would suggset, to the arrangements under GP fund holding, when practices were left having to manage contracts on their own. We want PCTs to minimise the bureaucracy associated with PBC and to make it as painless as possible, after the initial start-up effort.

Secondly, it is for the PCT to carry out needs analyses of their local population. This analysis will help support decisions on how best to meet local needs. At the heart of this is tackling health inequalities, particularly as the resources allocated to each PCT are largely determined on the basis of health needs.

• An excellent example of good practice comes from Vale of Aylesbury PCT. To help implement practice based commissioning, the PCT has set up a database that enables commissioners to identify health inequalities on a street by street basis. Because of this, commissioners in Vale of Aylesbury are able to target services and resources to where they are most needed

Thirdly, there are some areas of specialist commissioning which PCTs will continue to have a key role in, coming together in groups with a lead commissioner for the 30 or more specialist areas. I have commissioned a review of this area by an expert group under the Chairmanship of Sir David Carter, former Chief Medical Officer of Scotland, to make this area fit for purpose for the future. They will be reporting on specialist commissioning by next Spring.

PCTs, I would suggest, remain vital to the operation of the NHS. And that is why we are going to lot of trouble to reconfigure them and will engage with a devleopment programme to make their Boards – executives and non-executives fit for purpose. I wish those here today from PCTs success in carrying out their functions. For doubters let me say that to any PCTs who say they cannot afford PBC my response will be you cannot afford not to pursue PBC.

PCTs must be viewed as a partner. Not as a problem.

Only by working together PCTs and primary care groups will practice based commissioning be able to be effective, and subsequentally improve services for patients. These partnerships need to strengthen in the interests of patients and to embrace social care as well, as we will make absolutely clear in the White Paper.

Role of the Department

Finally we come to the role of the Department of Health in ensuring effective practice based commissioning. I know that many of you will want to see the fine print on practice based commissioning as soon as possible. I also understand that you will want reassurances over support being there  if and when you need it. Let me address briefly both of these points.

We shall shortly be publishing a document on the over-arching framework of system reform showing how commissioning and PBC fit into this framwork and that crucial role in the future NHS. We will be publishing practice based commissioning rules of engagement for the year 2006/07 in January. We want to see every GP involved in some way by the end of 2006 and for the rights and responsibilities for this involvement to be clear. We shall be working closely with all the professional and NHS interests involved in primary care with the aim of guidance for 2006/7 that is being agreed and commended by all of those key stakeholders. I particularly don't just want to see the DH logo on this, I want to see as many logos from the key stakeholders as possible and so there is professional buy-in and engagement. That is why it will take a lot longer than might have been ideal but hopefully the document will have a wide degree of acceptability across the sector. Around the same time a White Paper should appear.

We have also put in place a number of support programmes to help those involved in practice based commissioning.  The range of this support is continously increasing.

And I will have great pleasure to show this increase in action, by launching the NAPC practice based commissioning  website in a few moments.

The Department is very pleased to have commissioned the NAPC to provide support to practices for practice based commissioning. One of the many things the NAPC has been doing is collecting examples of best practice in practice based commissioning. When you go home and type in www.napc.co.uk you will find these on this website. In addition to this, there is a dedicated helpline which has helped many NAPC members with some of the more knotty issues- a really key support mechanism as practice based commissioning progresses. We need to move from aspiration to how this made to work.

The support of the professional organisations such as the NAPC is absolutely vital for the implementation of PBC. It is one of a range of bodies we have given funding to, to support the roll out of PBC.

The National Primary Care Development Team will be working with every PCT and SHA in the country to deliver a national support programme so that in a years time, every PCT will be working with its practices to deliver practice based commissioning.

The NHS Alliance, NHS Confederation and the Primary Care Contracting Team are all supporting different parts of the NHS to deliver practice based commissioning.

There is a rich source of support available which I would encourage you to make full use of. Special thanks must go to the NAPC for this invaluable website they have created, for organising this conference today, and for their tireless efforts to improve primary care.

Conclusion

Let me conclude by saying that we are all on the same side. We are all involved in creating a NHS better that’s positioned to provide the services people want.

The message is clear I think – patients want high quality services in local and convenient settings. Practice based commissioning is essential because it enables us to move in this direction.