Person-based Resource Allocation: a clinician's perspective

NAPC chairman Dr Johnny Marshall explains on why shifting resource allocation to practice level is the right thing to do, but must be treated with caution.

I have to confess that it was with some trepidation that I stepped into the Nuffield Trust one November morning to hear first-hand of the progress on Person-based Resource Allocations (PBRA), designed to allocate about one third of the total budget that will be available to clinical commissioning groups (CCGs).

The thought of trying to keep pace with Martin Bardsley’s technical wizardry around such a key issue was always likely to move me out of my comfort zone in the familiar thought patterns embedded in my basal ganglia and deliver a full frontal assault on my cortex, inevitably resulting in brain ache!

Yet I was drawn to it like a moth to a flame. My hope was that such an experience might merely result in a dull throb but my fear, figuratively speaking, was a full blown hemiplegic migraine!

So what action could I take to mitigate against this? I chose my prophylaxis carefully, adopting a clear focus on what CCGs are expected to deliver and how any method of resource allocation might support just that.

CCGs have a key role in a collective responsibility for delivering the best possible outcomes for the population from the available resources, both in terms of delivering on their commissioning function and leading cultural change across the whole care system.

To date the design of health services by primary care trusts (PCTs) has been too distant from the decisions that are made that determine their use, by people and clinicians. CCGs should redress that imbalance but this will require new cultures, attitudes and behaviours to ensure that the constituent practices are the CCG, and vice versa.

Only through the highest levels of practice involvement will it be possible to fully deliver clinical interventions around the needs of individuals within a population and design a system of care that supports joining up those interventions in a way that provides the greatest value. Any resource allocation would need to contribute to just this movement.

Therefore, in my mind, resource allocation to CCGs would need to be applicable at practice level to engage and inform individual practices in carrying out their commissioning and providing roles as part of the local care system.

Fairness would need to be achieved through allocations based on health need rather than historical supply, which in turn would provide an incentive to innovate and to achieve greater productivity rather than fossilising present services by moving resources from the most productive to the least productive parts of the system, as has all too often in the past been the NHS way.

So how did PBRA stack up against this? Well, with respect to practice level health care budgets it does rather well predicting up to 85 per cent of the variation in next year’s costs at practice level. The addition of additional data from community and primary care datasets would probably improve this even further and it would be in the interests of both patients and practices to facilitate such a move in the pursuit of an even fairer funding formula.

In addition, by excluding the level of previous hospital activity, it ensures that those who have designed new models of care that are not reliant on hospital services will continue to be funded at the level of need and therefore encouraged to continue to innovate and invest in improving outcomes for their population.

However, there are some inherent problems within an allocation formula based on practice list size as a result of the uneven distribution of list inflation within England. This potentially shifts resources away from those with the most accurate data to those with the least accurate.

At face value this might build unintended bias into the system at practice level so it will be important to understand whether this is indeed the case and if so how to reduce its impact.

The whole process also highlights important aspects around financial risk, with size of population being the overriding factor in managing such risk, but effective at population sizes as low as 100,000.

There is more to come from the Nuffield Trust on this and I will continue to use a focus on our collective responsibility as future prophylaxis against brain ache. On the evidence so far it seems to work!

This article has also been published on The Nuffield Trust website.

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