Review of GP locally commissioned services
What are GP locally commissioned services (LCS)?
Locally commissioned services (LCS) are negotiated and agreed locally and commissioned by integrated care boards (ICBs) from GP practices in addition to nationally negotiated primary medical services. LCS can also be referred to as local enhanced services, local incentive schemes or premium services, and are generally commissioned as part of a practice’s GMS/PMS/APMS contract, or via a Standard NHS Contract.
LCS services include add-ons to primary medical services (such as phlebotomy, wound care, shared care, proactive anticipatory care), and are often locally focussed to meet the needs of local care pathways and patient demographic and health profile.
Why should LCS be regularly reviewed?
LCS should be regularly reviewed for the following reasons:
o To avoid duplication of funding resulting from changes to the GMS contract, primary care network (PCN) DES/other commissioning routes realising potential to repurpose any released funding on alternative LCS services.
o Local needs and priorities may change, e.g. an LCS established to support GP contribution to part of a care pathway can become outdated.
o Practice uptake may be poor or activity low if the LCS is not priced correctly, or the specification is difficult to deliver.
o An LCS may be difficult for the ICB to monitor or for the practice to provide good outcomes data.
o Patient outcomes or the practices activity may not represent value for money.
o Patient experience of an LCS may be poor and/or service access may be inequitable, both within an ICB Place and across an ICB.
Every occasion we have supported ICBs to review their offered package of LCS has resulted in freeing up funding for reinvestment in new LCS services that represent better value for money and improved benefits to patients.
What are the barriers to ICBs conducting an LCS review?
In our experience, the primary reason that ICBs don’t regularly review LCS is that it is a resource-intensive process; it can sometimes take months to review a single service, negotiate changes and amend/produce a specification – and local politics often play a part too!
What lessons have we learned?
We have found the following to be the most productive ways of conducting an LCS review:
o Establish clear project management and appropriate project governance.
o Undertake an initial desktop review of the full LCS suite to establish ICB priorities, especially for service decommissioning to provide financial headroom to make price changes.
o Establish a small, dedicated working group of clinicians, practice managers, ICB and LMC representatives that can review LCS specifications in detail. Bring in clinical specialists as needed (e.g. diabetes, cardiology etc).
o Review each specification and capture the ‘Ask’ (ie the tasks that practices must complete to be paid). This should be done at a level of detail to allow the pricing of each task that forms the Ask.
o Test and agree any changes or additions to the Ask at the working group. Concentrating on the ‘Ask’ rather than the full specification keeps group discussions focused and more efficient.
o Agree who normally delivers each task of the Ask (e.g. GP, practice nurse, junior admin) and average time each task takes, and consider any non-staff resources, e.g. specialist equipment/training. This will allow the specification to be costed.
o Agree suitable clinical codes so that practices can record clinical activities and data can be easily extracted or submitted. Agree frequency of data collection/submission.
o Prepare the specification from the agreed Ask, adding the price (see Pricing services below), and get final amendments and sign-off from the working group. If possible, use a standard ICB service specification template; providing a standard structure makes it easier for commissioners and practices to find information in specifications.
o Sometimes the ICB will need to consider an incentive increment where the price established through costing activities is not sufficient to engage practices.
o Consider whether to commission LCS as Local Enhanced Service (i.e. being part of a GMS/PMS/APMS contract) or under a Standard NHS Contract. We favour the former as it is simpler for practices and commissioners.
o It is important to properly incorporate LCS into the chosen contract in order to be able to rely on some of the generic terms in that contract.
o Ensure that appropriate ICB governance procedures are followed to approve any changes recommended by the LCS working group
Pricing services
We suggest the following in pricing services:
o Determine each staff member type hourly rates that you will use to price an LCS before you start reviewing services.
o The hourly rate should include Employers NI and pension cost, and allow for practice overheads, clinical room utilisation (not rent/rates) and profit.
o Use a dedicated group to determine hourly rates, as the staff/expertise required will be different to those needed to review the clinical content of specifications.
o Once the who and how long is added to an Ask, apply the agreed hourly rates and cost of any non-staff resources to determine the price.
Financial modelling of impact of change
o Produce a financial model to establish the impact of any changes to LCS on overall practice income. NB. Even if all LCS funds are reinvested, any price change can still result in redistribution of funds between practices.
o If there is significant change to practice income, provide suitable notice of change and/or establish transitional arrangements.
Jonathan Weaver, PCC associate. PCC would be happy to support any commissioner who wishes to undertake an LCS review contact enquiries@pcc-cic.org.uk.