Setting realistic budgets and forecasts in the evolving market is challenging. Can you tell us how you approach this?
Dr Nav Chana, Chair of the National Association of Primary Care, looks at the challenges of setting budgets for GP organisations.
Budget setting in the NHS is a real challenge and a lot of people have found that over many years and it will continue to be a challenge because as our population grows and demographics change particularly we get a more elderly population the requirements on a state-funded system become increasingly challenging and we’re beginning to see a lot of that. The actual setting of budgets is also a problem because we have different incentives within the system, so we have some bits of the system arguably such as general practice which is funded through a capitated-type funding model and we’ve got other bits of the system, say an acute trust, which is often paid on a payment-by-results tariff and you can see that sometimes the non alignment of that budget setting and the behaviours that creates becomes a challenge. So, in certain Clinical Commissioning Group areas where there is great leadership around this some of those problems are addressed, but we know in others that becomes a real problem. And if we’re really interested in improving population health outcomes, we’ve got to actually try and think about how we help address some of the broader determinants of health as well as some of the determinants that we know that health alone is responsible for. And that requires in my view a multi-agency response to the challenges that we see within the context of a population health approach. So communities if that’s what were interested in have particular health needs, a lot of those are often governed by the environment in which they live, so having a job, having a house, having a family as we know are quite significant factors that can impact on health. And I’m not for a moment saying that all of that is delivered through general practice but it is about general practice being part of a system which works together that helps to address some of those issues. So in order to do that some of the responsibility sits with how do we control and influence the budgets around the resources we need to improve the health of a population. Currently the Clinical Commissioning Groups are responsible for commissioning services on behalf of the member GP practices and that might involve care provided in acute trusts, or community services, or mental health and so on. I guess what we’d be looking for, and that’s beginning to happen within the context of the Five Year Forward View and the new care models programme, is how some that budgetary responsibility might transfer down to provider organisations at a much more local level and so that those provider organisations which might be groups of GP practices or community pharmacies a community service provider or mental health provider, working collaboratively together, take responsibility for improving the health of their population, working with other agencies such as the voluntary and charitable sector organisations and social services and local government. So in terms of budget setting and making that approach work, the National Association of Primary Care is part of a new care model programme which is implementing a model of care which we’re calling the Primary Care Home which is the opportunity to take responsibility for the health resources for a population at the level of a defined population of around 30 to 50,000 people which requires a collaboration between providers - general practices, community pharmacy, mental health, community services, volunteer and charitable sector organisations and acute trusts - coming together in a way that actually supports the health and wellbeing of a population and not just trying to address individual disease –based approaches as and when they arise. And this is early stages for us at the moment, and early stages for a whole new care models programme, but we’re beginning to see some positive effects at least from people collaborating and talking in a collaborative way rather than the traditional winners and losers arguments that we get within the healthcare system. Budget setting within that kind of arrangement is actually quite difficult to do as I said at the beginning of this, were beginning to see approaches that are essentially working out the cost per patient in each of these populations and if you then aggregate that up to whatever population size you’re talking about you’re getting a sense of the type of budget you need based on the demographics as well as how much we traditionally spend for those patients over a period of time. Then the next stage which is often more difficult, is how we have some really pragmatic discussions about how we prioritise and where we prioritise the care that people need and in which setting. And we’re beginning to see some great results from the new care models programme more widely but also from the Primary Care Home. Element of that as to how this might work in the next couple of years.