May you live in interesting times

1

• May you live in interesting times!

2
Brave New NHS

• APMS
• Fund-holding
• PBC
• PCT
• SHA
• Purchaser provider split

• New contracts
• PMS
• GMS
• SPMS
• LHG

3
Brave New NHS

• 1990 New GP contract
• 1991 Internal Market
• 1992- Fundholding GPs control budgets
• 1996- Regional HA abolished 9 regional
  offices
• 1997 Labour elected 24hours to save the
  NHS
• 1998 PMS contracts started
• 2000- NHS plan to cut waiting lists.
• 2001 Hospital league tables introduced

4
Brave New NHS

• 2002 New funding announced
• - PCT take over commissioning of secondary care
• - 100 Health authorities replaced by 28 strategic
  HA
• 2003 New GP contract negotiated
• 2004 Foundation trust authorised
• 2005 - Payment by results starts
• Practice based commissioning announced
• 2005 Health Reform in England published
• 2006 PCT cut from 302 to 152 and SHA 28 10
• Hospital league tables abolished

5
Brave New NHS

• Purchasers
• Government ? DOH? SHAs? PCTs
• Providers
• (2ndary care)
• Hospital NHS Trusts/ Foundation trusts/
  Alternative Providers of medical services
• (Primary care)
• Contractors PCT Directly employed Staff
• GPs Physiotherapists
• Dentists Chirpodists
• Opticians D/N H/V
• Pharmacists Some salaried GPs etc
• Alternative Providers of Medical Services

6
Brave New NHS

• GP finance can be seen as split 3 ways
• GMS/PMS income money received from PCT for the
  provision of ordinary, additional and enhanced
  primary care services. From this all practice
  expenses are paid staff, building costs etc.
• Private income medicals, private patients, PMA
  reports etc.
• Commissioning budget held by PCT (for all other
  patient care including prescribing) who have to
  agree with the principles and method of spending.
  70 savings ploughed back into patient services
  for the practice population but NOT for the
  practice itself!

7
Brave New NHS

• PrimaryCareTrust (302 ?152) Body principally
  responsible for Purchasing of care for 300,000
  population
• Planning
• Commissioning
• Paying for Care
• Chief execs., finance directors, boards, non-exec
  directors appointed by NHS Appt. Commission
• SHA (28?10)Responsible for planning and
  oversight of Hospital trusts and PCTs serving
  2.5 7.4 million population

8
Brave New NHS

• Payment by results. Is a system for care
  providers that
• Pay service providers on the basis of a tariff/
  fixed price list
• Every procedure listed and costed
• Efficient providers work at less than tariff

9
Brave New NHS

• PMS
• A system that pre-dated the new GMS contract as
  an individually negotiated contract with the PCT
  aimed at reducing paperwork and allowing PMS
  practices to be rewarded for service development.
  (1st pot)
• Practice Based Commissioning. Practices that take
  part have
• Indicative (i.e. virtual) budget (PCT still holds
  money and is legally responsible for s,
  contracts strategy
• Commission care for their own patients
• 70 of savings go to practices for patient
  services
• (? 3rd Pot)

10
Brave New NHS

• Patient Choice
• 2006, England only
• Choice of 4 or more providers when referred by GP
  to hospital care
• Foundation Trusts (40 in England)
• Hospitals liberated form central control
• Financial and clinical independence
• Managed under local governance procedures
• Regulated by new body (Monitor)

11
The Government

• Is unable to continue funding NHS in its present
  form
• Has increased patient expectations without
  providing the resources
• Has a new found belief in private sector and
  wants to explore plurality of provision
• Wants increased control over spending
• Wants innovation and new ways of doing things

12
The Government.

• Believes PCT Commissioning has failed to deliver
  changes quickly enough
• Wants more competition in NHS
• Needs to make services cost efficient and so
  committed to payment by results
• Knows that GPs have a track record of
  entrepreneurial success
• Recognises fund-holding was a catalyst for change

13
All together PBC is

• Individual or groups of practices given an
  indicative budget
• Budget based initially on historical spending
• Use budget to commission (purchase) secondary
  care services but not tertiary services
• Can also commission primary care services and
  prescribing budget

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Practices.

• Can decide what aspects of the budget they take
  on
• Can move services from expensive secondary care
  to cheaper primary care settings
• Can be PROVIDERS of these services and make a
  PROFIT
• Can keep at least 70 of any savings (maybe????)

15
PCTs

• Retain overall control of the budget
• Must approve commissioning plans
• Agree the use of savings
• Contract for services
• Provide support for PbC
• Commission specialist services and those not
  commissioned by PbC

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Whats in it for GPs?

• Control over services where, how and how much
• Savings
• Profits from provision of services
• Inter-practice cooperation
• Perhaps protection from new threats to general
  practice

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What are the threats?

• Primary Care White Paper
• Increased private provision
• End of GP monopoly
• Better access to primary care
• Large multinational companies
• Alternative/Specialist Providers of Medical
  Services (APMS/SPMS)

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This is already happening!

• Vacant single handed practices put out to tender
• Private companies invited to bid
• Loss lead now for future profit
• Frequent changes in staff, loss of personal
  service
• Provide limited range of profitable services
• Increased opening hours

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How do we adjust to it?

• PbC allows us to draw in the wagons
• Mixture of
• locality or cluster small-scale service redesign
• Larger locality/ PCT-wide major service redesign
• Accept commercialism in primary care
• Form companies to win APMS contracts
• Persuade PCT that we are best
• Long-term relationships
• Proven quality of care
• Able to deliver on QOF, Access etc
• Can be flexible and adaptable
• Will deliver PCT targets
• Are cost effective and efficient

20
APMS

• Primary and Secondary Care Providers in the
  Community
• Or how to improve care for patients, Save the NHS
  money and get paid for doing it!!
• Allows groups of GPs and others to bid for
  traditionally secondary care services as well as
  primary care and PCT provider services
• Form a company partnership or limited by shares
• Profit making organisation
• Can raise capital from various sources

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What is the scope of an APMS company?

• Any healthcare service that could be provided
  safely in the community
• Essential and Additional services,
• Some outpatient services,
• Community nursing,
• Therapies,
• Diagnostics
• Intermediate care etc.

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What is the scope of an APMS company contd.?

• minor surgery.
• Non-emergency Urgent Care now provided by AE
• Prevention of acute admissions
• Provision of increased diagnostics in the
  comunity
• Intermediate Care perhaps employment of more
  cost-effective community nursing service with
  wider remit
• Mental Health Services (er probably NOT)
• Management Services (to other PCTs or
  commissioning groups)

23
Proposed Structure
General Practices
South Bham GP Ltd
Commercial provider
South Bham PCT
South Bham Health Ltd
APMS Contract
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Brave New NHS

• Is up to (individual, but more likely) groups of
  GPs to re-write patient care pathways as
  alternatives to the traditional models of care.
• Think for a minute about
• Cellulitis care
• Community acquired pneumonia
• Menorrhagia
• Cardiac failure
• Glaucoma
• Orthopaedics
• Minor ops
• Respiratory f/u

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Brave New NHS

• Could change our role as GPs but will
  physicians assistants/ nurse practitioners
  change this anyway..? RCGP sees our role in the
  future as advanced medical generalists,
  dealing with co-morbidity, diagnosis and
  coordination of care.