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Practice-based commissioning: making change happen

Debra Sprague
Advanced Nurse Practitioner
Handsworth Wood Medical Practice Heart of Birmingham Primary Care Trust
Member of Department of Health National PBC Improvement Team

Practice nurses are ideally placed to understand the challenges patients face in managing their health. Being on the frontline of patient care gives nurses a good understanding of how patients cope with acute and long-term conditions; how they feel about their treatment; and the challenges and difficulties they can face in everyday life.

This insight into patients' lives is invaluable in identifying potential improvements in the safety, speed and delivery of care, and practice nurses can use this knowledge as a springboard for creativity in devising new or extended services – services that can be implemented for their local population through practice-based commissioning (PBC).

PBC is a way in which those working in primary care, such as GPs and practice nurses, can influence priorities for health improvement at a primary care trust (PCT) level and have an active role in redesigning or developing new services for patients. Often, this is about shifting care into more convenient settings by providing treatment for patients in GP surgeries, local clinics, community pharmacies and in people's own homes.

PBC aims to be flexible enough to improve care options, whether to change things for just a few individuals or to bring about the large-scale redesign of a service for the local community. Within PBC, those working in smaller practices shouldn't be limited in their ambition, since services can be commissioned to work across the needs of a number of practices within a local "consortium". Members of a consortium will have agreed to work together under PBC to promote local healthcare, deliver increased efficiency and make a strong business case for new services to a PCT.

Improving quality of care for patients by making more services accessible within the surgery is a change many practices have made. These changes might be relatively simple, such as undertaking warfarin testing or having specialist gynaecology clinics in the surgery to avoid the need to refer a patient to hospital, which, in some cases, may be many miles away.

At our practice in Birmingham, we are about to launch an on-site X-ray service, which we've set up through PBC. We were able to make the case that it would be more cost-effective and more convenient, that it would reduce infection control risks and the carbon footprint for patients to access an X-ray service locally rather than travelling to the hospital. If a patient requires an X-ray we will be able to perform this on the premises; the patient can then view the results digitally on screen alongside the GP and can be reassured and sent home more quickly if no issue is found.

What's more, for patients with transport problems or with language, learning or communication difficulties, the ability to access this service within the familiar and easy-to-access primary care setting is much more satisfactory.

Another change we have made locally to improve patient care through PBC is in improving rates of diagnosis of chronic obstructive pulmonary disease (COPD). We noticed that although we had a low recorded prevalence of COPD (0.69%), we were seeing high rates of hospital admission for respiratory conditions, including COPD. It appeared that, locally, we were not diagnosing the condition early enough to keep patients well, and that some practices did not have access to high-quality diagnostic spirometry. Through PBC we have been able to divert funding to support earlier diagnosis and keep patients in good health, by getting in diagnostic equipment and, for many practices, increasing numbers of practice staff who are accredited in performing spirometry and in clinically managing COPD.

PBC gives nurses the opportunity to make their views for change heard. Practice nurses have some of the greatest insights to offer both in terms of understanding the key needs of patients and suggesting practical, clinically and cost-effective ways that healthcare can be improved. A drive for helping patients is, after all, the reason we chose the nursing profession, and through PBC we have the opportunity to direct our drive and enthusiasm into identifying and implementing improvements that make a real difference to the communities and local populations we serve.

A new guide for GPs, Practice-based commissioning in action: a guide for GPs, developed by the Department of Health, was sent to every practice in June. Ask your GP or practice manager to see your practice's copy or visit to view the guide online.1

To speak to Debra about how to get involved in PBC, contact her by email at:

[[Box 1 practice]]

1. Department of Health. Practice-based commissioning in action: a guide for GPs. London: DH; 2009.