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Reinvigorating PBC - will it happen? The experts' verdict

PBC has struggled to get off the ground for a variety of reasons. But all is not lost, with a new Government document – Clinical commissioning: our vision for PBC – aiming to breathe life into the policy. Here, five experts share their thoughts on whether the latest initiative will work and what needs to happen next

PBC has struggled to get off the ground for a variety of reasons. But all is not lost, with a new Government document – Clinical commissioning: our vision for PBC – aiming to breathe life into the policy. Here, five experts share their thoughts on whether the latest initiative will work and what needs to happen next

Dr Stewart Findlay, PBC chair, Durham Dales Cluster

The latest document is a bit too woolly. It is saying that everything we said about PBC is still true – people should have budgets, information, a management allowance and delegated responsibility to be able to take advantage of savings.

But it depends on whether SHAs take it forward and use it to performance-manage in a robust way – we could just continue as we have done. We know PBC is key to World Class Commissioning (WCC) and that has given it a bit more importance with PCTs – these are the national pushes we need.

At a local level, we need people to delegate more decision-making responsibility to PBC clusters and they need dedicated budgets. We need to make the business-planning process slicker so GPs with innovative ideas can get on with delivering them.

We need to make sure PCTs adopt the ‘any willing provider' model as the way services are commissioned, which will allow GPs to offer or commission alternative provider services. And trusts need to make sure the requirements needed for a business case are in proportion to the business case itself.

It is a matter of building up trust and GPs are desperate to get on with it.

Chris Naylor, Health policy researcher, The King's Fund

The guidance contains a realistic diagnosis of the problem and a clear account of what support GPs are entitled to. There is little detail on how PCTs and practice-based commissioners might overcome the various barriers they face, but the guidance at least provides a welcome reaffirmation of the Government's commitment to PBC.

Reinvigorating PBC will be no small task. Our recent report set out several minimum requirements to make PBC happen, including making resources available. It will be a huge challenge just to meet these minimum requirements around governance issues and data quality, but our research suggests the problem goes deeper still.

PBC has been paralysed by the tensions emerging from the inevitable differences in perspective between PCT-based commissioners thinking strategically and practice-based commissioners thinking locally and entrepreneurially.

The only way to overcome these tensions is to recognise that different types of commissioning activity are best done at different levels.

Strategic commissioning is best reserved for the PCT (with clinical input), whereas the commissioning of primary- and community-based care should be devolved to fully autonomous PBC groups.

Simply re-energising PBC under existing arrangements will not be sufficient to overcome the paralysis.

Gerald McLean, PBC consultant

Although in my experience PCTs and PBC groups do work well together, the new guidance has proved invaluable in developing the relationship between WCC and PBC – for a while people thought WCC was here to replace PBC. The clear intention to expand WCC and PBC and to cement the shift of commissioning towards local clinicians is very useful.

The main issues are around the culture of the relationship between PCTs and PBC. There are still some areas where PCTs appear to have a belief that freed-up resources once earned are the property of the PCT and can be withdrawn from clusters to meet deficit problems, rather than working in partnership to address the deficit problems together. The response to the removal of savings without agreement is an area in which I spend a lot of time, mainly undoing the damage to relationships such decisions cause.

There is also some sense in which consortiums feel like subcommittees of the PCT – in other words ‘having PBC done to them', so the issues of trust, confidence and the requirement not to impose but engage in mutual negotiation still needs working on. This has been somewhat addressed in section 4 of the new guidance.

The section on entitlements I think will be valuable to both PCTs and PBC groups alike while they sort out their roles and responsibilities. I work with about 36 PBC consortiums. One of the problems I'm coming across is the lack of real understanding on behalf of PCTs about what the PBC agenda is about and a real sense of confusion about the terminology around commissioning and provision.

And the data that PCTs provide is often inadequate. PCTs need to let GPs take their rightful place within the PBC agenda.

But sometimes the GPs themselves don't fully understand the magnitude of the task they are undertaking and the organisational requirements.

Dr Mike Dixon, NHS Alliance chair

The document says all we could have hoped and it's very good. The only problem is, will it produce changes? I suspect it may have been read by PBC leads but not by your average GP. It can only achieve so much. There has to be an invigorated campaign to make sure practice-based commissioners really do feel supported. When WCC results come out, we need to make sure it is absolutely clear where PBC is working and where it isn't, and we need to put resources into where it isn't working. I hope the framework will help in that respect.

PBC groups need to make sure they have an identity. Too many are just a loose group of practices. And that's a cultural change.

There is a final issue about making it come to fruition and that is creating a primary care-led NHS. Primary care needs to be a priority but at the moment it is a secondary care-led NHS. When 90% of activity and 50% of doctors are in primary care it is a downright scandal that primary care is still being ignored.

Dr Shane Gordon, National co-lead for the NHS Alliance PBC federation and chief executive of the Colchester PBC Group

The document is an effective narrative about how to overcome the issues. It essentially says stop messing around with conflict of interest and get on with it – find an appropriate strategy. The key message is that clinical engagement in commissioning won't spring out of nothing – you're investing in WCC and PBC is a key part of that, so you need to invest in it.

There are several practical steps that can be taken to reinvigorate PBC.

• Sign a service-level agreement with the PBC clusters setting out clearly what the PCT will do, including the ‘rights and entitlements' from the primary care strategy, budgets and data with a timetable, management support, funding of clinical time and what is expected in return.

• Invest in education and training to develop commissioning skills for PBC, for example through FESC or the PBC development framework.

• Stimulate commissioning with some innovation funds – or FUR if you have it.

• Allow clusters to appoint or directly employ managers to support their work.

• Take clinical involvement seriously and show that by professionalising those roles with salaries, terms and conditions and so on. And streamline governance processes and standing financial instructions to allow proper (and proportionate) devolution of commissioning authority.

Dr Michael Dixon Dr Mike Dixon Dr Stewart Findlay Dr Stewart Findlay Chris Naylor Chris Naylor Gerald McLean Gerald McLean The most successful PBC groups will inform, influence and complement the strategic direction of the PCT and be an integral part of World Class Commissioning.

• All PBC consortiums are entitled to:

– accurate, timely data and analysis, in particularWhat the new Government document says

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