The Health and Social Care Act promised to transform the delivery of care to our patients and populations and the idea of a local, as well as a national, health service is at the heart of the NHS reforms. Of course, the new structures in the NHS will require more locally sensitive contractual processes to ensure that they deliver on the promise of a locally determined NHS.
PMS contracts have been around for some time, introduced to deliver more locally determined services to populations. The values and concepts in setting them up seem ideally suited to manage care in this new NHS, free of central, top-down control.
So why are they now subject to such systematic and, in many cases, ill judged attack?
Like many initiatives within the NHS, the implementation of PMS was not consistent. Many PMS contracts were indeed locally determined and aimed at delivering specific care to specific populations. But there were some that merely delivered GMS services without the added benefit being specified – or, indeed, monitored. It should come as no surprise that the outcomes emanating from PMS practices are thus mixed, with some showing excellent delivery of high-quality services and others unable to demonstrate health gain or focus.
The reactions of some PCT clusters to this situation have been interesting. Instead of considering why some of the PMS practices have not delivered health gains that the PCT itself failed to specify, clusters instead determined that the process itself was wrong and set out on wanton and ill-judged destruction of PMS contracts. This behaviour is not dissimilar to one deciding to ban the use of the telephone because it could be used for improper means, instead of introducing proportionate controls to ensure that it is available to enrich and better all our lives.
In this fiscal climate, it is right that PMS contracts should be reviewed and redefined. But it is not appropriate for practices that have worked hard to deliver the best for their population to be vilified. Practices have been subject to unfocused and indeterminate cuts to their overall budgets without review.
PMS contracts are also the ideal vehicle to tackle inequalities, as well as giving commissioners better control over particular local health needs. These contracts can be used to specify narrow outcomes for defined populations and to encourage the flair and inventiveness that is at the heart of general practice.
PCT clusters must consider where health outcomes from their local PMS practices have been poor and, if they have, redefine their key performance indicators to encourage practices to achieve them.
They should also introduce new initiatives for individual PMS practices to work on. It may well be the case that, in a few instances, the total budget associated with PMS needs to be redefined. But this decision needs to be taken after a wholesale examination of outcomes of each contract, not as a result of a crude calculation to reduce a contract by a chosen percentage.
Looking to the future, we need to remember that CCGs will have a duty to manage the totality of care within their budgetary constraints, and PMS local flexibilities offer distinct cost and value advantages over the present systems. This needs to be exploited, not extinguished.
We could seize the moment if general practice acts together on this. We could create an opportunity, through the values that saw the birth of the PMS process, to deliver QIPP in the way it was designed – by putting improved quality as well as cost reduction into every initiative. PMS contracts aid the process of disruptive innovation – and yet we seem to be rejecting the model.
The NHS can act very strangely on occasion. This situation reminds me of a gardener, uprooting every single plant in the garden and pouring weed killer over all the ground to ensure the whole garden grows the same. It will take the plants some years to recover, and the same could be said for the delivery of locally sensitive, locally determined services – the heart of the PMS contract.
Dr Charles Alessi is chair of the NAPC and a GP in Kingstonupon Thames
