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Dispelling 10 PBC myths

PBC is a difficult policy to understand, so it’s inevitable there will be differences in interpretation. Our mythbuster, compiled by Emma Wilkinson, should help clear up the murkier points

PBC is a difficult policy to understand, so it's inevitable there will be differences in interpretation. Our mythbuster, compiled by Emma Wilkinson, should help clear up the murkier points

Myth 1: GPs cannot refer their patients to services they have set up through PBC

This is one of the most common misunderstandings about PBC, by both GPs and PCTs. There are, of course, guidelines to follow – the GMC recently updated its conflict-of-interest recommendations to take PBC into account – but there is nothing to stop GPs referring to their own service.

NAPC president Dr James Kingsland says this commissioning-provision ‘dilemma' often occurs because of a basic lack of understanding about what commissioning a service actually means.

‘First, there's no conflict whatsoever within registered lists,' he says. ‘If you boil it down, if a GP sees a patient and provides a service that is part of the primary care services contract – but if the GPs says you need to see someone else, I'll make a referral, they are commissioning a service. Whether you recognise it or not that is inherent within general practice.'

Where it gets difficult, he points out, is where the GP stands to gain financially from referring a patient to a service.

‘The test is, have you ensured choice by offering all the different services available? Then if the patient picks service A and that is your service, you say to the patient that's the service I provide and I have a financial stake in that.

‘If you don't do this, you may be in breach of your contract and the GMC guidance.'

Myth 2: The PCT must put PBC business plans out to tender

Not every single proposal must be put through a formal tendering process.

PBC consultant Scott McKenzie says the Department of Health was very clear on this in its 2007 document PBC – Practical Implementation.

This states that EU procurement directives are incorporated into UK law and set out the procedures to be followed by purchasers in the public sector, which includes healthcare.

But it adds: ‘Where the PCT is granting permission for "any willing provider" to operate in its area rather than purchasing an exclusive service from a single or limited number of providers, then these regulations do not apply and tendering is not required.'

This applies to routine elective services where the provider will not be guaranteed a particular volume of referrals – there's no block contract – and there are no guarantees on income.

‘PCTs and practices will need to ensure that value for money is secured in placing any contract, and that the process of contracting for a new service is fair, open and transparent,' says Mr McKenzie.

‘Additionally, it has been made clear by the Department of Health that tendering is not required when a PCT chooses to develop additional services through the extension of an existing GMS, PMS or APMS contract, including under local enhanced service arrangements.'

Formal tendering is required when the result is to create a monopoly by awarding a contract to a single provider.

Dr Kingsland explains: ‘When it becomes contestable is when you want to provide a new service not just to your registered list but to the whole area.'

Myth 3: PCTs do not have to give freed-up resources back to GPs

PCTs who are struggling to balance the books may think they are within their rights to withhold financial savings from PBC, but this is not the case.

The Department of Health has made it clear that it is vital that practices are allowed to use, as a minimum, 70% of freed-up resources – not as an income, but to be reinvested in services.

‘PCTs cannot simply withhold freed-up resources, and neither can they simply set unrealistic indicative budgets,' says Mr McKenzie. ‘The PCT can take between

3% and 5% as a risk-share top slice but it cannot top-slice simply to resolve PCT deficits,' he adds.

The key to avoiding arguments over who gets control of financial savings is to make it clear in any PBC business plan right from the start.

‘When you get two years down the road you do not want to be having a bunfight because you haven't made it clear in the business plan how the efficiency savings are going to be used,' says Dr Kingsland.

The Department of Health advice regarding a complete breakdown in negotiations around freed-up resources is that ‘in exceptional circumstances where local agreement cannot be reached, an

SHA may request permission from the department to modify locally the PBC guidance relating to budget-setting and use of freed-up resources'.

Myth 4: GPs and PCTs want different outcomes

There is a perception, sometimes grounded in reality, that GPs and PCTs are at polar opposites in their approach to PBC and rarely work well together.

But ask those who have been heavily involved in PBC and they will say that is not necessarily the case.

Mo Girach, a PBC consultant, says in his experience GPs and PCTs have a ‘symbiotic relationship' as long as the rights and roles of the parties are made clear from the start.

‘With clear boundaries, the relationship works in harmony,' he adds.

Mr McKenzie agrees: ‘The more advanced consortiums always have good relationships with their PCT and work very much in partnership, creating a win-win scenario.

‘They tend to focus on identifying the causes of any financial difficulty and then spend time on agreeing a joint strategy.'

Dr Nav Chana, executive board member of the NAPC, says the relationship between GPs and some PCTs has been difficult, mainly because of PCTs putting ‘ridiculous bureaucracy' in the way of decisions. But he concedes that's not the whole story.

‘There are ones who are very good and they are good because they have genuinely tried to redesign services and put GPs at the heart of services redesign,' he says.

Myth 5: Any service redesign has to be signed off by medical defence bodies and the GMC

PCTs can panic about clinical governance issues when they start seeing proposals coming to fruition.

According to Mr McKenzie, it appears to be ‘a stalling tactic designed to put consortiums off even trying' when in reality there is often no issue.

‘If this does come up, the consortium should ask for absolute clarity from the PCT as to why this is a requirement – ask if it is DH or NHS policy (which doesn't exist on this issue) or a local requirement,' he says.

Here's an example. A practice wants to extend a IUD-fitting service that it is already offering as an enhanced service. If it is already providing this service to patients, it must have already met the PCT's requirements for fitting IUDs. To then go on and extend this to be a local service provision within a GP-led provider company should not be a problem as long as all necessary patient medical information is shared and so on.

Mr McKenzie says: ‘This should be a case of the PCT sorting out its governance arrangements through extending the enhanced service rather than being a clinical governance issue.

‘The PCT would need to put the systems in place to allow interpractice referring.'

Myth 6: Information streams are accurate enough for PBC

According to the NHS Alliance, inadequate, late and sometimes inaccurate activity data is a perpetual problem, akin to expecting a major retailer to operate without knowing what their suppliers are delivering, how much it costs or where it is going.

Dr David Jenner, PBC lead at the NHS Alliance, says it is simply not true that information streams are accurate enough to get prompt, timely data at the practice level and it's not just PCTs to blame. ‘Often the problem getting data is from the acute trust,' he adds.

Dr Chana says having the right information enables commissioners to make sensible decisions – but unfortunately it tends to be ‘lousy'.

‘Nobody has the data to understand their population,' he says.

Myth 7: PBC must be done in PCT-defined consortiums

In his experience, Mr McKenzie says the most common major obstacle in moving PBC forward is PCTs dictating the clusters that GPs must work together in.

‘The premise for PBC was likeminded healthcare professionals coming together to drive forward the agenda.

‘Where PCTs have imposed a top-down approach, this normally stifles the consortium and leaves the motivated individuals fighting uphill battles with the less enthusiastic.'

He says the better developed consortiums have two things in common – they have been developed by a group of likeminded healthcare professionals who share a common vision for PBC and what they want to achieve, with a strong interpractice agreement in place holding people and practices accountable for what they deliver; and they have a strong relationship with the PCT based around a foundation of mutual trust.

He adds: ‘They are also likely to be following a staged approach where they start small and grow – "earned autonomy" as described by Lord Darzi's review in July – where they move forward together, working at the same pace.

‘Consortiums that set up of their own volition also tend to expand rapidly as the practices who sit outside see what is being achieved and want to join in.'

Myth 8: Each PBC consortium can set up its own service pathway

Being local and flexible is the key to PBC but it does not mean all groups in the PCT can just commission their own pathway.

‘Quite a common misconception is GPs believe each commissioning group can develop a service pathway but the PCT can only commission one pathway,' says Mr McKenzie.

‘The groups have to influence each other to commission the care pathway.

‘There is an example in Leeds where they agreed on the diabetes pathway but in one district they needed an interpretation service so they provided that locally.'

Dr Chana agrees: ‘With the example of diabetes, the pathway to hospital might be the same but elements of that can differ depending on the needs of the area.'

Myth 9: The sole impetus for PBC was to improve patient care

Too many people talk about PBC improving care, forgetting that it was originally set up to make efficiency savings, says Dr Kingsland.

‘A tool – whether that's a piece of policy or a thing to mend your car with – will only do what it was designed to do.

‘It started as a tool for demand management, the next stage is hopefully you have a more efficient system and you improve quality but people forget the history of it.

‘PBC is a vehicle to more efficiently manage the internal market.'

Myth 10 PBC is enshrined in impenetrable legislation

Dr Jenner believes there should be legislation on setting budgets but, although many people may be surprised to hear it, this is not the case.

‘The great myth of PBC is that it's enshrined in legislation but there is not a single bit of legislation around PBC.'

But NAPC chair Dr Johnny Marshall says: ‘All the necessary legislation already exists for clinicians to get involved in commissioning and there isn't the need for any more – it just needs to be put together. We want things to be as flexible as possible.'

Emma Wilkinson is a freelance journalist

Dr David Jenner Dr David Jenner

The great myth of PBC is that it's enshrined in legislation but there is not a single bit of legislation around PBC.'

The key to avoiding rows over who gets control over the savings is to make it clear in the business plan

There are many myths that have grown up around PBC

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