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Let’s take a mature approach

Dr Chaand Nagpaul argues that a strict purchaser-provider split is not essential for PBC success

Dr Chaand Nagpaul argues that a strict purchaser-provider split is not essential for PBC success

An emergency motion passed at the BMA's annual representative meeting in 2006 opposed the Government's health reforms in England. In particular the motion's proponents were unhappy with the market-based policy of increased commercialisation, competition and use of the private sector. The BMA was tasked with producing an alternative vision of healthcare, underpinned by the principles of collaboration and integration, which resulted in the publication of A rational way forward for the NHS in England in May this year. This document

is out for consultation, and a further paper will be published later this year.

When it was published, the part that grabbed the headlines was our proposal the NHS be run by an independent board, free from political interference.

The paper also proposed restricting use of the private sector to only where there is no local NHS capacity.

With regards to practice-based commissioning, it called for a ‘mature form of commissioning' that ‘would diminish the need for a purchaser-provider split'.

This has understandably caused concern among many GPs, who believe the purchaser-provider split is integral to PBC success. We are already seeing evidence

of PBC successfully redirecting resources into primary care, through service redesign, development of community-based services and referral management systems. Naturally as GPs we would not wish to see this lost, nor a return to the old days of block contracts locking funding into hospitals, with no leverage on quality or productivity, and an inability to liberate resources for reinvestment in primary care.

However we need to be realistic and admit the current system is not without its problems. For example, payment by results perversely incentivises hospitals to increase activity to generate income – with increased costs to the NHS – and militates against hospitals collaborating with the ‘care closer to home' agenda. There are already examples of trusts preventing consultants from working with GPs to develop practice-based commissioning, concerned it would reduce hospital income.

It would be far more cost-effective if resources were pooled so that there was a single diabetic or rheumatology service for a local population – one that is community based and primary care focused. There are examples of successful integrated health systems without a purchaser-provider divide – for example, the Kaiser Permanente model in the US incentivises GPs and specialists to work collaboratively, yet it is a cost-effective and community-focused system with reduced lengths of hospital stays compared with the UK.

We need a system that will encourage hospitals and specialists to work with the PBC agenda rather than be polarised against it, and harness the skills of clinicians in both primary and secondary care. Clearly in any such system there must be payment for delivery – such as the current quality and outcomes framework. We also need chronic care co-ordinated and planned with a public health perspective rather than leaving it to the vagaries of market forces.

It is vital that GPs contribute their views to the development of this BMA policy,

to ensure that general practice and primary care remains at the heart of any future proposed model of PBC.

Dr Chaand Nagpaul is a GPC negotiator and a GP in Stanmore, Middlesex

we need to encourage hospitals to work with pbc rather than against itwe need to encourage hospitals to work with pbc rather than against it we need

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