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Calls grow for radical clinician-led PBC overhaul

By Rebecca Norris

Calls are growing for a radical, clinician-led overhaul of practice-based commissioning.

Three separate ideas – from a GP, hospital consultant and academic – have all been proposed in the past three months.

They emerge as the latest Department of Health-commissioned survey shows GP uncertainty has grown (from 37% to 46%) about whether PBC has improved patient care.

In this month's Practical Commissioning, Dr Tim Richardson, executive member of the National Association of Primary Care and a GP in Epsom, Surrey, calls for practice-based commissioners to hold real budgets with which to commission integrated services delivered by GPs and specialists working alongside each other in modern-day cottage hospitals. (see page 12).

Last month, consultant paediatrician Dr Minoo Irani called for the introduction of ‘integrated provider organisations', based around PBC groups and comprising GPs, hospital specialists, nurses and other professionals, which would hold commissioning budgets and offer primary care, community and specialist services.

Dr Irani, who leads the NHS Alliance's specialists in primary care network, said: ‘Adversarial competition, resulting from practice-based commissioning and Payment by Results, has led to PCTs, NHS trusts and foundation trusts competing for organisational preservation, while clinicians have been polarised into professional self-preservation mode. The need for a seamless healthcare system risks being compromised unless something is done to address this "wrong sort of competition".'

He also proposed the creation of a new type of doctor – a community specialist or consultant – to be created with equal status to that of hospital specialists.

In December, academic Chris Ham called for collaboration between GPs and doctors and the introduction of ‘multi-specialty' commissioning, in a paper for the Nuffield Trust.

He said this could involve commissioning budgets jointly controlled by primary care teams and hospital-based specialists, with incentives for integrated teams to provide care in the most cost-effective way.

Such a model might initially focus on chronic disease areas such as diabetes and arthritis and over time could involve specialists moving out of hospitals to work alongside primary care teams, while retaining the right to admit patients to hospital where necessary.

Such models would create strong incentives to promote health rather than treat sickness, and also turn the hospital ‘into a cost centre whose use should be avoided except where necessary and appropriate', said Professor Ham, as opposed to the current approach where hospitals are seen as ‘profit centres' needing to attract patients.

The calls also come at a time when wide variations are exposed in PCT and strategic health authority attitudes to PBC (full details on page 34).

‘clinicians have been polarised into professional self-preservation mode'‘clinicians have been polarised into professional self-preservation mode' ‘clinicians have been polarised into professional self-preservation mode'

‘clinicians have been polarised into professional self-preservation mode'

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