Meetings

Practice-based commissioning

Last week, groups of local pharmaceutical committee members and contractors got together to formulate a business case and to pitch their ideas to two primary care trust commissioners in a Dragons’ Den style session. Dawn Connelly (on the staff of The Journal) reports

“Practice-based commissioning Dragons’ den” was organised by Hampshire and Isle of Wight Local Pharmaceutical Committee and took place at Donnington Valley Golf Club, Newbury, on 28 January

Practice-based commissioning: tips for preparing and pitching a proposal

Practice-based commissioning has been the focus of several recent pieces of guidance for pharmacists in England as well as the subject of an awareness week last year organised by national pharmacy bodies (PJ, 22 September 2007, p317).

The aim of a Dragons’ Den style meeting, organised by Hampshire and Isle of Wight Local Pharmaceutical Committee last week, was to gain some practical experience of preparing a business case and pitching for a service.

“We want to get beyond the talk and into the realms of the practical reality of bidding for services,” said Mike Holden, chief officer of the LPC as he welcomed a group of LPC members and contractors from the south of England.

The first step in the commissioning cycle is to assess need, said Mr Holden. Once a need is identified, current service provision can be reviewed and redesigned. “It is important for LPCs to be driving this agenda for pharmacy, making sure we are at the table in those redesign pathways,” he said.

Several companies have developed “budget impact models”, which calculate the costs of service redesign based on local data, he explained.

Participants then heard from Wyn Tingley, health outcomes consultant at GlaxoSmithKline, who demonstrated the SPIRO model, a tool that can assist with redesign of services for patients with chronic obstructive pulmonary disease.

The SPIRO model enables the user to calculate accurate costs of the current COPD service and to compare these costs with alternative ways of delivering services over three years, said Mr Tingley. It uses the latest available hospital episode data, with real referral and admission data. Population and prevalence figures are obtained from the Quality and Outcome Framework and are available at both a PCT and an individual practice level, he explained.

The model also allows the user to obtain accurate information on the number of staff needed to run the current and alternative service and gives an insight into future training and development needs, Mr Tingley added.

The pitches

Participants at the meeting then split into two groups and each was asked to come up with a business case for a chronic obstructive pulmonary disease service change. The groups pitched their proposals to two commissioners (see Panels), who acted as the “dragons” — Tim Jones, a freelance commissioner, and Kate Hovenden, head of medicines management at Portsmouth City Teaching PCT.

Both commissioners were impressed with the groups’ pitches, given the lack of time and data available to them. The commissioners offered the following advice to the groups:

• Identify and influence the key opinion leaders

• Offer either an innovative service or a more cost-effective or clinically effective version of an existing service (do not just offer to remove the responsibility from someone else)

• Know the figures, for example, the number of patients, the total cost of the service and the likely value of freed resources

• Link the proposal to key PCT/commissioning consortia targets and other national or local initiatives

• Provide evidence of the effectiveness of the proposed intervention, eg, that early intervention affects outcomes in COPD patients

• Show that the service will be performance managed, ie, plans for auditing the service

• Show that you have a good track record of delivering services

• Be realistic about what you can achieve

Mr Jones advised that pharmacy scores highly when it comes to tackling health inequalities because commissioners can see its potential to reach people who do not see themselves as ill.

However, he added: “For an area as complicated as [COPD] it is likely to be a multidisciplinary team [effort], which means that you not having a seat at the table on practice-based commissioning makes your life quite challenging.”

He said that, somehow, pharmacy contractors have to secure a place at the table talking about what they can add clinically, then eventually they can talk about what they can add as providers.

One possible way to gain a seat at the table might be to use medicines use reviews, Ms Hovenden suggested. “Use MURs as a stepping stone,” she advised. If you can get one thing working then that is a way to influence the key opinion leaders, she added.

Mr Holden suggested that, particularly for an area like COPD, it could be advantageous for pharmacists to bid as part of a collaborative with other healthcare professionals.

Mr Jones recommended that contractors should not underestimate how much intensity and effort is involved when preparing a business case. “I would estimate between five and 10 days to do a proper, good quality written business case … you need to submit a lot of evidence,” he said.

He also warned that standards would get higher as the Government’s vision of “world class commissioning” is implemented.

Pitch A: screen and support

The first proposal was an innovative case finding and case support service for patients with undiagnosed COPD provided by 30 pharmacies.

Patients would be targeted for spirometry screening according to an agreed local protocol. Those suspected of having COPD would be referred to their GP for confirmation of the diagnosis. Diagnosed patients would then be referred back into the pharmacy service for education and support. A structured programme was suggested, with consultations at months 1, 3, 6 and 12.

The group proposed a charge of £50 per patient referred (target 450 patients) plus £25 per consultation. The final consultation would be a full medicines use review. The aim of the service was to increase compliance and therefore reduce exacerbations, prevent hospital admissions and reduce medicines wastage.

Pitch B: targeted MURs

The second proposal was a service aimed at patients who are often admitted to hospital and are known to be of significant cost to the PCT. It was based on the existing medicines use review service but targeted COPD patients recently discharged from hospital.

Within two weeks of discharge an MUR would be conducted in the patient’s home or in a community pharmacy. The aim would be to improve compliance and therefore health outcomes and reduce admissions to hospital.

The service was offered at £100 per year per patient (target 500 patients), and was estimated to save the PCT £100,000 by preventing 10 per cent of hospital admissions.

The service could also be of benefit to other COPD patients and could be extended to include GP or nurse referrals, said the team.