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Time is running out for PCTs to make the necessary cultural changes to support PBC, warns Dr James Kingsland, chair of the National Association of Primary Care

Time is running out for PCTs to make the necessary cultural changes to support PBC, warns Dr James Kingsland, chair of the National Association of Primary Care

There are three keys factors governing the development of practice-based commissaioning – namely the culture of individual PCTs, the quality of clinical leadership, and having the right tools to make it happen. While there is a growing number of success stories relating to the implementation of PBC, a recent internal Government review has identified a number of barriers that remain, preventing its ‘universal coverage' in primary care.

Some PCTs need to improve their analytical skills to support practice-based commissioners; mutual accountability between practices and PCTs needs to be improved, with PCTs receiving feedback from practices in a similar way to 360° workplace appraisals; and PBC must not be viewed as a tick-box exercise. What is clear is that PBC flourishes where PCTs provide appropriate support and falters where PCT enthusiasm, particularly at chief executive level, is low.

PCTs have undergone a huge upheaval and restructuring in the past 12 months which has in many cases, understandably, diverted their attention from PBC. In the past year, PCTs have also faced the requirement for financial balance, which has led them into many inappropriate and unsustainable actions to achieve this, such as rationing, top-slicing budgets and withdrawal of some services. Although there are some pockets of good practice where GPs and PCTs are beginning to work together to deliver improvements to patient services through PBC, this is still all too rare.

What hasn't happened during this time of restructuring is the expected concomitant change in function and culture in PCTs to create a new environment in which clinicians will engage not only in PBC but the wider NHS reform agenda.

PCTs and SHAs now need to give priority to PBC and rapidly develop substantial financial and non-financial incentives. Service redesign through PBC cannot commence without devolved indicative budgets and regular clinical and financial information to practices. Bureaucracy needs to be kept to a minimum, for example by fast tracking PBC business cases. Surely a PCT can give willing and enthusiastic GPs an indication within two weeks that plans for a new service may need some tweaking but will be given the go-ahead, rather than having to wait two months?

PCTs need to understand and develop improved capability in their new commissioning role. PCTs should be commissioning primary care services and then facilitating those primary carers to assess the need, and secure the necessary services that they themselves cannot provide for their registered population.

PCTs should be encouraging collaboration between primary and secondary care to help determine how these services are designed. There needs to be an improvement in PCTs' contracting skills so they can act as the ‘agents' for their clinical colleagues, who are redesigning clinical services.

GPs' interest in the aims of PBC remains high, but progress needs to be made quickly to sustain this. PBC has been live for two years now and GPs will not wait another year or even months for PCTs to make the necessary cultural changes. I would contend that PCTs have only a matter of weeks to get it right – starting with the agreement of decent local incentive schemes – otherwise they risk widespread disengagement by GPs from this policy.

Dr James Kingsland is a GP in Merseyside and chair of the NAPC

GPs will not wait another year or even months for the necessary changes

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