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Patient involvement and practice-based commissioning

Sally Brooks
BSc PgDip
Writer

Bev Bookless
RN RM MBA
Director

Sarah Walter
System Reform Project Manager

National Diabetes Support Team (NDST)

Practice-based commissioning (PBC) is a voluntary scheme that gives participating GP practices and professionals more freedom to develop local services that better meet the needs of their patients. Participating practices are given an indicative budget so local primary care staff can decide how best to use the money to meet the needs of their community.
Although primary care trusts (PCTs) retain ultimate accountability, PBC allows frontline clinicians, including nurses, to get involved with commissioning. It allows the people who know the community best to decide where the money goes. Delivering effective PBC is an essential part of creating a patient-led NHS.(1)
PCTs work together with practices to facilitate PBC. The Department of Health (DH) assigned PCTs to achieve universal coverage of PBC by the end of 2006.(2) Universal coverage means that all PCTs will need to create the right environment to facilitate and encourage practices to become practice-based commissioners. This involves:

  • All practices receiving information that will allow them to understand their clinical and financial activity in comparison with other practices in the PCT, and with the national average.
  • All practices receiving an indicative budget covering an agreed scope of services.
  • All practices receiving support from the PCT and the offer of an incentive payment to support PBC.
  • Governance and accountability arrangements for PBC to be put in place and agreed partnership between the practice and the PCT.(3)

Earlier this year it was confirmed that universal coverage had been achieved.(4)

Getting involved
Commissioning
Commissioning works best when people with diabetes are placed at the centre of the process. Commissioning a service means nothing unless it caters to the needs of the local diabetes community. The Department of Health (DH) document Commissioning a Patient-Led NHS identifies commissioning as the key tool for delivering choice to service users.(1) Effective commissioning, according to the article, is a prerequisite for making "real" patient choices.
In order for services to be commissioned a procedure must be followed. The National Diabetes Support Team (NDST) suggests the following:(2)

  • Assessing local need: this is how commissioners can assess the current and future needs of their local diabetes population. It assesses:
    • Prevalence and local breakdown of diabetes type.
    • Population demographic.
    • Risk factors, such as obesity levels.
    • Health inequalities.
    • Local health burden, such as the number of local deaths from diabetes and the number of complications.
    • Cost of the current diabetes service.
    • Local population and prevalence trends.
    • Comparative level of risk and need.
    • Designing a specification to meet local need.
    • Procuring services to deliver the specification.
    • Proactive monitoring.

It is essential that both people with diabetes and nurses are involved in assessing local need. Nurses come into close contact with service users and are best placed to identify needs, gaps and duplications.(5)
The Diabetes Commissioning Toolkit helps NHS commissioners and diabetes networks plan diabetes services.(6) It was developed by several organisations in response to the overwhelming need voiced by local services for support in the commissioning process.
The toolkit details how to carry out a needs assessment for a local diabetes population. It also contains generic requirements for diabetes care, setting out the core elements of quality care and signposting best practice quality markers, such as Diabetes National Service Framework Standards and NICE guidelines.(7) Commissioners are advised how to monitor the quality of their current local service and identify improvements that need to be made. Along with this, there are key outcomes that a commissioner could specify when commissioning diabetes care.

Service design
In order to be truly patient-led, people with diabetes should get involved in designing their service. The NDST has commissioned a project to promote user involvement, which is being carried out by Diabetes UK and the London Metropolitan University. The work aims to ensure that people with diabetes are involved in everything that impacts upon their healthcare. They will be able to contribute to policy development with the DH and also at a local level with diabetes networks. This will focus on engaging "hard to reach groups", such as ethnic minority communities, as well as children and young people and their parents or carers.
The project will, among other things, link with existing user involvement organisations, collate examples of good practice and work towards providing training for healthcare professionals.

Care planning
"Care planning" gives people with diabetes the opportunity to become more involved in their own care and treatment.(8) Care planning is underpinned by principles of patient-centredness and partnership. It is an ongoing process of two-way communication, negotiation and joint decision-making in which both the person with diabetes and the healthcare professional make an equal contribution to the consultation. It differs from the "paternalistic" or "healthcare professional-centred" model of consulting, traditionally applied in acute settings.
During a care planning consultation, a diabetes patient and their healthcare professional will raise and discuss their respective concerns, prioritise them, explore potential risks and available options and make mutually-agreed informed decisions about ongoing care. A consultation will produce action points for both the healthcare professional and the patient. These might be recorded in a patient-held record or a care plan.
Care planning in diabetes provides a model for effective care based on the vision set out in the Diabetes NSF and the report "good care planning for people with long-term conditions".(7-9) The model draws on research in clinical practice, psychology and education to set out a process of negotiation and shared decision-making between the healthcare professional and the diabetes patient. Where appropriate, family members or carers should be involved in this process.

Implications for primary and secondary care
There are several ways in which health services can be commissioned by primary care:(2)

  • PCT commissioning services.
  • Joint commissioning involving PCTs and local authorities to support better integration between healthcare, social care and other local government services.
  • Practice-based commissioning.

All healthcare professionals have a role to play in commissioning, and an increasing number of health communities are moving towards providing integrated services. In diabetes care, many services are now underpinned by a diabetes network, bringing together primary care professionals and specialists as well as users. These identify local needs and develop priorities; they enable primary and specialist care to work closer together than they might have done previously.
The aim of a diabetes network is to try and deliver more integrated care across organisational boundaries that reflect the whole spectrum of patient needs. Clinical networks tend to be nonhierarchical and involve many stakeholders. Their function is reliant on relationships, which take time to develop.(10)
Clinically-led, managed diabetes networks, involving people with diabetes, provide structure for service planning and delivery, promote seamless care and support staff by targeting resources where they are most needed. This results in:

  • Integrated care.
  • Improved clinical outcomes.
  • Cost-effective services.
  • Improved patient experience.
  • Equity of service provision.(10)

In Leicester, the diabetes network has used the Diabetes Commissioning Toolkit to undertake a full health needs assessment and create a detailed specification for a diabetes service that will meet the needs of the city. The network has set up many other projects, including a website which contains information useful for people with diabetes and healthcare professionals.

PBC in practice
PBC is still in its infancy across England, but there are areas where the approach is beginning to impact on diabetes care.
In Southport, groups of practices are working together to provide better diabetes facilities in the community. The PBC group decided to move annual reviews for people with type 2 diabetes into primary care in association with the Southport Diabetes Local Implementation Team. This has freed up secondary care enormously, and specialists are now able to book in appointments with just a four week wait. Patients have responded well, and appreciate the continuity of care they are offered. The PBC group is now looking towards commissioning services for people with diabetes.
The PBC picture will become clearer as practices begin to put it into practice. It has the potential to bring more tailored services to people with diabetes through intelligent commissioning.

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References

  1. DH. Commissioning a patient-led NHS. London: DH; 2005.
  2. NDST. Primary care commissioning factsheet. Leicester: NDST; 2006.
  3. DH. Practice-based commissioning: practical implementation. Available from: http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Commissioni...
  4. DH, Practice based commissioning. Available from: http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Commissioni...
  5. DH. Creating a patient-led NHS: delivering the NHS improvement plan. London: DH; 2005.
  6. DH. Diabetes commissioning toolkit. London: DH; 2006.
  7. DH. National service framework for diabetes: standards. London: DH; 2001.
  8. Department of Health. Care planning in diabetes: Report from the joint Department of Health and Diabetes UK Care Planning Working Group. London: DH; 2006.
  9. NHS Modernisation Agency and Matrix. Good care planning for people with long-term conditions: updated version. Leicester: NDST; 2005.
  10. NDST. Beyond boundaries: a guide to diabetes networks. Leicester: NDST; 2006.