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At the heart of general practice since 1960

GPs on message in Blair's backyard

From what I understand, practice-based commissioning has come about because of PCTs' inability to successfully commission services according to Government demands.

Assuming that PBC takes off and becomes a success, what future roles do the ever- expanding PCTs see for themselves? Can we look forward to a reduction in their number and size, or will new roles be invented for them to ensure their continued existence?

Dr Christopher Jones

Poole, Dorset

·In the discussions about practice-based commissioning one pivotal point seems to have been universally ignored ­ the problem of fixed costs. Many attempts have been made since 1990 to transfer work and resources from secondary to primary care. Remember 'money following the patient'? It didn't.

No one has yet managed to make it work and I suspect they will not now.

The essential difficulty is hospitals have very high fixed costs that cannot be reduced by moving modest amounts of activity elsewhere. If activity is moved out of hospitals and the fixed costs remain then the cost per activity for the remaining work will rise.

The variable costs that can safely be transferred will not support the activity in the alternative site. Thus, unless there is new money to support the transfers, either the hospital will go broke and collapse, thus prejudicing the continuing provision of any local secondary care, or the funds available will not support the transferred activity and it won't happen.

GPs must also remember that general practice is a 'for profit business' and thus any bid for new work needs to include all costs incurred plus a profit margin.

Many PCTs do not seem to understand this and while the Department of Health pays lip service to it, it usually manages to frustrate its application.

Dr Michael Blackmore

Ringwood, Hants

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