Faint heart never won...
GPs will have to be bolder if they want to realise PBC’s potential to the full, argues primary care tsar Dr David Colin-Thome
GPs will have to be bolder if they want to realise PBC's potential to the full, argues primary care tsar Dr David Colin-Thome
With PBC set to play a vital role within the Department of Health's world-class commissioning programme, my personal view is that we are losing momentum in fulfilling PBC's potential.
GPs may have initially been sceptical about PBC's purpose, as it was a DH initiative, rather than the previous models of devolving budgets to practices, which were perceived as being more ‘bottom-up' (fundholding was divisive but did instantly appeal to clinical entrepreneurs).
Practices need to use the DH's supporting guidance on PBC and just go for it. The ‘it' being the chance to have more control of our working lives and develop or provide the range of services that our patients want and deserve. My hope is that practices in various guises become an acceptable and very English form of a managed care organisation (MCO), without slavishly following US examples.
Practices already have MCO attributes – providing what they can for their registered population and referring onwards what they cannot themselves provide – known in economic circles as ‘make or buy'. Referral is a commissioning act and therefore nails the erroneous comment that practices cannot be both provider and commissioner.
Now some boldness is required. If we need management, knowledge, public health advice or clinical expertise, we can make or buy depending on what talents are available. General practice must continue to focus on providing personal care, but this does not preclude extension of services.
If driven by entrepreneurial practices and supported by high-quality management, these can be comprehensive and could lead to a multispecialty organisation servicing a registered population's complete needs.
Practices don't need to be providers of all extended services, but they can facilitate their development by thinking of their premises as a venue where this care could take place – for example, using their practice as a base for consultant-run clinics.
The NHS spends as much money on outpatient care – seen by some as a relic of 19th-century medicine – as we do on general practice itself and there are huge variations in lengths of hospital stay. Is this the best way to spend resources when we know from international evidence that primary care is the most cost effective?
We need clinician-to-clinician relationships that focus on finding a win-win situation that does not put the financial stability of an acute trust under immediate threat. A hospital's clinical director for medicine and a practice-based commissioner should be able to acknowledge their mutual budgetary responsibilities, and talk about how they can pool their resources informally to get better care for patients.
Acute trusts will get smaller, and hospitals with good leaders already realise that some of their future business is in the community – not by taking over practices, but providing staff in community settings.
I disagree practice-based commissioners should hold actual budgets as it risks the kind of wasteful bureaucracy we saw under fundholding. Practices should focus on challenging the need for hospital referrals.
GPs have the influence but have not yet used it in sufficient numbers or scope. Now is their chance. Or is the reality, as Julian Tudor Hart said many years ago, that ‘GPs are always laying claim to ground they do not wish to occupy'?
Dr David Colin-Thome is national director of primary care and clinical adviser to the commissioning directorate at the DH. He retired as a GP in 2007 after 40 years' practiceDr David Colin-Thome: GPs and hospital doctors should talk about pooling budgets to improve care Dr David Colin-Thome