Managing scarcity in the NHS: a PCT perspective

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Managing scarcity in the NHS a PCT perspective
Dr Peter Brambleby Director of Public Health,
Norwich PCT Honorary Senior Lecturer,
UEA peter.brambleby_at_norfolk.nhs.uk 1 December
2005
Committed to improving the health of Norwich
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Introductory thought

• The defining purpose and role of PCTs is postcode
  rationing.
• PCTs are responsible for a defined geographical
  population (postcode)
• for whom they have to secure services from a
  fixed budget (rationing).

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Commissioning a Patient-led NHS

• What do we mean by commissioning? Is
  it transactional or transformational?

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Transformational commissioninggetting the best
possible balance between need, demand and
supply in local health care
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Need, demand and supply in the NHS
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What is need for NHS services?
The ability to benefit from healthcare, ie a
measurable change in health status attributable
to the intervention. Need for NHS services is
often defined by expert consensus, eg NICE
appraisals, flu vaccination, diabetes test strips.
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Health needs assessment is

• a systematic method for reviewing the health
  issues facing a population, leading to agreed
  priorities and resource allocation that will
  improve health and reduce inequalities.
• NICE, 2005, Health needs assessment a practical
  guide.
• This fits neatly with programme budgeting and
  marginal analysis.

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What is demand ?
Demand is what people ask for. It is not
necessarily what they need, ie they may not
benefit or may not meet NHS eligibility
criteria. Question are choice and
patient-led synonyms for demand?
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What is supply ?
Supply is what is made available by the NHS (what
is funded in the programme budgets).
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Each section poses challenges
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Where we want to be
Need
Demand
Supply
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For example

• Diabetes test strips budget in 2003/04 for
  Norfolk and Waveney was 2,272,300 (Norwich PCT
  249,300)
• A consensus statement recommended need to be 2
  strips per week for patients with stable type 2
  diabetes
• Owens D et al, Blood glucose self-monitoring in
  type 1 and type 2 diabetes reaching a
  multidisciplinary consensus. Diabetes and Primary
  Care 2004 vol 6 no 1
• 4 Norfolk PCTs adopted this as their policy

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The inch-long strips cost 14p each, and patients
say they often need 10 or more per week, but
several PCTs limit patients with type 2 diabetes
to only two.
Vital testing strips being rationed due to cost
Diabetes consultant I think PCTs are taking the
health economics approach and trying to reduce
expenditure whereas they should take a more
humanitarian position
13 April 2004
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Tough choices on spending
16 April 2004
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22 April 4 May 2004
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Diabetes can be a killer Diabetes Consultant
3 May 2004
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6 May 2004
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Diabetes test strips
Need
Demand
Supply (Budget 2,272,300)
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Transformational commissioning

• Commissioning involves change management and new
  behaviours, not just writing a new specification
  and altering a few budgets.
• It involves patient education and support,
  professional education, case-finding, chronic
  disease register management, provision of
  services to dependant older people, elimination
  of wastage, understanding budgets so as to use
  them in new ways, etc
• ie full involvement of front line staff.

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Transformation starts with reframing the questions

• By regarding test strips as part of a diabetes
  budget rather than a prescribing budget we
  were able to change the disinvestment/re-investmen
  t decision.
• Unless we change the questions we are likely to
  get the same answers.
• If we keep doing what we always did we are likely
  to keep getting the same results.

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Programme budgeting and marginal analysis helps
us reframe the questions

• What are our main programmes? (DH ICD10
  chapters)
• What are the programme objectives?
• How much do we spend at present?
• What activity do we see?
• What outcomes are we getting?
• How do all these compare with our peers?
• What do the public, partners and professions
  want?
• Is there a better way to match resources to
  objectives?

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PBMA is an ideal framework for

• PCT public health reports
• PCT local delivery plans
• Public and patient involvement
• Bridging the gap between doctors and managers, or
  doctors as managers (practice-based
  commissioning)
• Re-engineering patient care within the discipline
  of set budgets (transformational commissioning)
• Performance monitoring and reporting
• Setting a context for national policy, national
  service frameworks, NICE guidance

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Transformational commissioning

• Requires specific competencies
• Requires training and learning
• Requires accreditation and revalidation
• Requires experimentation, research and evaluation
• Requires a degree of organisational stability
  (reforming without re-forming!)

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Transactional commissioning

• is an oxymoron

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• Commissioning should be a long-term relationship
  between interdependent primary and secondary
  health care partners who have shaped patient
  pathways to local needs within a finite budget.
  The local service-level agreement imposes
  constraints on both parties to deliver their part
  of the pathway. Clinical governance is shared.
  Results are gauged by health gain, reduced
  inequalities and enhanced patient satisfaction.
  (HSJ 21 July 2005, pp18-19)

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• Purchasing is a less sophisticated model, where
  the holder of funds negotiates a volume of
  activity at a certain cost from a range of
  providers take it or leave it. Think of the
  difference between commissioning a picture and
  purchasing a picture.
• (HSJ 21 July 2005, pp18-19)

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• Payment, as in Payment by Results, is the most
  crude of all. It is a post-hoc settlement for
  some-one elses clinical practice and referral
  decisions
• (HSJ 21 July 2005, pp18-19)

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Contracting

• making smaller or shrinking
• Oxford English Dictionary
• . acquiring a disease
• Blacks medical dictionary