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Hanging on in there

Dr Phil Yates describes how his enthusiasm for PBC is being stymied by deficits, meetings-overload and poor financial incentives

Dr Phil Yates describes how his enthusiasm for PBC is being stymied by deficits, meetings-overload and poor financial incentives

I'm not a cynic. I was a GP fundholder, moved my practice into PMS, and was involved in the primary care and the medicines management collaboratives. I steered my PCG to PCT status and chaired the professional executive committee (PEC). I believe in The NHS Plan and fiercely support the pivotal position of primary care to deliver services and health improvement. And no, I'm not ‘burnt out'. But what a mess it all has become.

Once elected, Labour dismantled GP fundholding for ideological reasons. Surprise, surprise, GPs disengaged from commissioning and referrals became divorced from finance. Services I'd developed, such as an in-house community psychiatric nurse and physio, were lost. Ironically, NICE now recommends wider access to cognitive behavioural therapy and orthopaedic referrals have risen.

We watch as various strategic health authorities transmogrify into regional offices and PCTs merge, often into the old health authority configurations. The term ‘primary care trust' now seems a misnomer.

Health care and finances have been destabilised, good clinicians have been demotivated and there is a planning blight of epic proportions as health institutions start over again.

The government wants to re-engage us in commissioning and promises full support from reconstituted PCTs. PBC will safeguard primary care's share of the cake against the ‘financial hoovering' effect of Payment by Results. But there's no software for practices to track activity, little chance of challenging the gaming of the acute sector by the upcoding bonanza and creative patient pathways (clinical decision units et al), and few staff left in PCTs to assist. Thankfully, there's the generous management DES, certain to incentivise us all to invest enough time to redesign care. I think not!

But I'm compliant. We formed our consortium. I even pressed my PCT into involvement in the first wave Improvement Foundation (IF) pilot. We're examining ideas that could transfer work to primary care, even if there isn't much profit in them.

We're basically altruistic at heart and work for the good of the NHS.

So we have to sit in PCT, IF, locality and consortium meetings where the same topics circulate interminably. There's no plan-do-study-act cycle; we must develop business cases that tick the right boxes for the PEC.

My local acute trust's deficit stands at more than £40m, so the SHA's only interest is financial balance, not in pump priming any innovations, however beneficial or cost-effective. And as acute trusts seek foundation status, they're realising they mustn't jeopardise future income streams so are threatening their clinicians with sanctions for working across the boundary.

Trojan horse

‘I like looking after my patients, but i have to employ ‘performers' to do my work at great expense'

The Department of Health has got its knickers in a twist about the purchaser-provider split and doesn't appreciate that at practice level we just identify what will benefit our patients and then work to deliver it. Now ‘any willing provider' can provide services that are extensions to primary care. But, for monopoly contracts, independent procurement means my big idea becomes the Trojan horse to allow the commercial sector to move in and cut the ground from under my feet. If the problem with fundholding was, in part, the transaction costs, imagine the finances of contract development, advertising, bidding and procurement here.

So Ms Hewitt, I'm a jobbing GP and I've only got one life. I like looking after my patients and creating beneficial changes for them. But all these meetings mean I'm having to employ ‘performers' to do my work at great expense, while I battle to create something from a flawed policy framework. My patience is wearing thin. Stop blaming the financial woes of the NHS on GPs and either sort out your unworkable, disjointed policies or make way for someone who can.

Dr Phil Yates is a GP in Bristol

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