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Sabotage and apathy

PBC might more accurately be termed practice-based decommissioning, writes Dr Julian Spinks

PBC might more accurately be termed practice-based decommissioning, writes Dr Julian Spinks

A few months after the first announcement of Department of Health plans to introduce PBC, I was invited with a small number of doctors to meet a senior Government representative to discuss the scheme.

Although he would not admit scrapping fundholding was a mistake, he did say they realised they had lost some of the drive to innovate and the entrepreneurial spirit that fundholding had created in primary care. PBC was not to be a reintroduction of fundholding but it was hoped to be the major driver to system reform.

Now, years later, I think this has proven to be hopelessly optimistic. I had previously worked in NHS management when a public health approach dominated NHS planning. Individual patient needs were submerged in that of the population and new services were a nightmare to introduce as they involved multiple meetings and reams of paperwork.

Fundholding came as a breath of fresh air. We were given the money and power to make changes at a practice level. It was possible to make significant changes relatively quickly, services moved into primary care and personalised patient care became commonplace.

But there were disadvantages: fundholding fragmented the planning of care and there was no mechanism to ensure that access to services was equitable. We also had no reliable way to set budgets and hospital activity data was very poor.

Joint commissioning, and later primary care groups, addressed some of these problems. There was no doubt that some of the flexibility had gone but, at least in my PCG, we made attempts to level up services so that the advances made by fundholding practices were made available to all patients.

By contrast, PBC should have been able to offer so much but it appears to have delivered so little.

Dodgy budget setting

Much of the failure lies outside the influence of GPs and practices. The scheme itself is complicated by the setting in which it works. Payment by Results limits its ability to make deals. Multiple Government targets and national schemes restrict its ability to produce a service truly responsive to local needs.

There are also some familiar problems including dodgy budget setting and poor data that you would have thought to have been sorted by now.

But the biggest blame has to lie with PCTs that seem to treat PBC as an irritant. In the early days I was willing to accept they were being distracted by reorganisation but now I wonder whether they are actively trying to sabotage the process to retain control. In my locality, possible ‘quick' wins such as access to imaging and counselling were deemed ‘outside PBC'. Saving money seems more important than improving patient care.

The only proposals that seem to be met with any enthusiasm are those that restrict patient choice and access to secondary care (practice-based decommissioning might be a better name for the policy).

We're also back to multiple meetings and mountains of paperwork to make insignificant progress. It's like trying to cross a swamp on stilettos and my initial enthusiasm has all but vanished.

It's all summed up by our local achievements. In terms of new services, so far, we have commissioned... nothing.

Dr Julian Spinks is a GP and member of the locality PBC group in Strood, Kent

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