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Should GPs profit from PBC?

With commissioners increasingly moving into the provider role, NAPC chair Dr Johnny Marshall and Dr Amit Bhargava, NHS Alliance PBC co-lead for South Coast SHA, debate whether GPs should profit from this

With commissioners increasingly moving into the provider role, NAPC chair Dr Johnny Marshall and Dr Amit Bhargava, NHS Alliance PBC co-lead for South Coast SHA, debate whether GPs should profit from this

Dear Amit

It seems clear to me that engaging clinicians through practice-based commissioning was never intended to simply be about giving clinicians a stronger commissioning voice but also to engage them in leading the transformation of local health services as both commissioners and providers.

The opportunity to contribute to the redesign of service delivery and the reshaping of primary care provision within the wider local health economy was always going to be the greater prize.

GPs' understanding of local health needs and how primary care could better provide both existing and new services within the community means GPs are inevitably better placed to deliver the services that the patients and PCT commissioners demand. This would invariably facilitate investment in primary care with the desired movement of services from an acute setting into the community. So while GPs should not profit directly from PBC simply by commissioning, it is wholly reasonable that they benefit from alternative provider opportunities that might arise from the commissioning process by being well-placed to respond to the locally defined service requirements. Through this process financial gain acts as an important lever to GPs in delivering the transformational change that PBC is intended to unlock.

Kind regards, Johnny

Dear Johnny

Good to hear from you. I agree with a lot of what you say – GPs have a unique understanding of what our patients' needs are, we have usually been around for decades and have local credibility. GPs are also likely to be the only ones who have

any local organisational memory. This gives them an important place at the table when systems for design, delivery, commissioning and procurement of services are discussed. Our views will only be seen as valuable if we are believed to be at the table for the gain of the population we serve. As soon as there is evidence that we are engaging only for personal gain our credibility and value to the discussions will be lost and would be detrimental to commissioning and ourselves.

For all the well known and rehearsed reasons the brand, unique selling points and status of the local GP has been diluted in the past few years.

To restore our real value in the centre of the community from which we have made a good living, and would like to for many years to come, it is in GPs' interest to be seen to be above personal gain and engage with community partners for the good of the entire population, especially the vulnerable and disadvantaged. It is only then that the general practice we all treasure will be safe. There are bigger and better business beasts set to profit more than us who are likely to have no local knowledge or long-term interest.

So it is in our business interests to put our population first and then when folk want to commission services from us because only we are unique and the best, and we know they will, we will all continue to evolve and thrive together in an environment of trust.

I believe PBC is for the improvement of the health of the community and practices would be wise to engage in commissioning for that purpose. We will then all profit.


Dear Amit

I agree that general practice is most valuable when it serves the needs of its local population in partnership with both the public and other partners. I recognise the type of general practice you describe but do not share your view that this is to be treasured or saved. General practice in its current state has served the NHS extremely well. But the world around us is changing and general practice needs to continue to adapt to meet the challenges presented by the increasing burden of long-term conditions, spiralling healthcare costs in the midst of a deep recession and increasing patient expectation.

This response must start with the transformation of health services in partnership with patients and other partners that addresses quality of services, value for money and patient satisfaction. We need to be investing in new services fit for the future and challenge ourselves as to what the future role of general practice will be. Current financial incentives within general practice do not necessarily support this change.

We need to move to a position where a commissioner is clear about what health outcomes it requires for its population so that it can procure them. That this should provide a financial incentive for general practice to match its provision to what the commissioner requires for its population sounds far more likely to deliver the high quality, patient-responsive services required than the maintenance of existing practices.

Rather than being protectionist, we have to raise our game to meet the private sector challenge, adopting the best practices we can find without compromising our existing values. Only if we demonstrate delivery would we continue as providers – a far cry from the complacency existing primary care contracts may be perceived to have engendered.

Time and time again over the years general practice has demonstrated its ability to transform service delivery where additional resources support investment in alternative delivery. That they might now be able to contribute to the development of those improvements in partnership with the PCT as commissioners should serve to increase the value of investment in primary care for both patients and taxpayers. This puts the interests of our patients right at the centre of our business interests – if we do not meet them our businesses will fail. Commissioners will contract from us not because they trust we will deliver but because we will have to deliver to survive.


Dear Johnny

There is much we are agreeing on.

We agree on the adaptive, expansionist and responsive model of general practice as a business. Working in a commissioning environment where the drivers are the needs assessment of the population, with the providers responding by designing services for those needs, then being performance-managed on delivery of outcomes and customer experience. We are also in agreement that any gain for general practices from PBC is because of the increased opportunities – not by right.

I agree we should not be protectionist of all things in current general practice, but we must protect what works and is uniquely valuable. General practices are essentially highly functional and continually evolving social businesses that have a shared fate with their communities. The practices you and I joined many years back are very different in terms of systems and technology, but the philosophy of care, humanity and local responsiveness are likely to be the same.

It is a fact there is much the current general practice could, should and will do better. As it is a fact that there is generally a great satisfaction with practitioners and practices from their registered populations. People want and usually demand continuity of relationships and professionals who look after them – that is what we do best.

There is a very small minority who bring the profession to disrepute and this very small tail seems to be wagging the policy dog. Breaking anything is much easier than creating, of course. People who wish to shake up and break up general practice must reflect long and hard on the intended and unintended consequences and costs in this economic downturn.

My favourite restaurants are family- owned, where I am recognised and welcomed, served great food altered to my taste, in a comfortable and warm environment by people who care about me and want me back. I only go to the international chains when I have a stomach to fill, not really bothered about the eating or staff experience and largely unimpressed by the limp ‘have a nice day' said with a synthetic smile. It is the British general practice that has the evidence of delivery beyond expectations for all the targets that have been set for us. There are too many to list, but QOF would be one, and we are improving on patient satisfaction. As a QOF assessor for West Sussex, I am amazed how hard practices work on the things they are less good at even when the standard of practices is high. We do a lot of what the family-owned local restaurant does. Our general practice needs support, a clear narrative and wise counsel to evolve and it will continue to be the cost efficient heart of the NHS, as it has been for decades.

What does need fixing is the continually changing narrative, moving goal posts and contracts and the gap between what people in power say and do. This has confused GPs and made us go into protectionist fortress mode and dampened innovation and engagement. I think there are many financial incentives and opportunities for GPs to improve our falling incomes through care outside of hospital policies by delivering the right outcomes on contracts the commissioners want. We know we can add real value to the volumes because we have local knowledge and presence.

What would really help is a sensible and proportionate procurement process.

I realise there are European and other rules we have to follow. But are we interpreting these rules as flexibly and wisely as we can, so that small businesses such as general practice and the third sector can compete on equal footing with the corporate giants that have large and expensive back offices?

In summary, I believe our type of general practice that is rooted in its community, which is showing that it is improving the health of its population and is accredited by assessment, should be treated honourably and fairly as it has provided good service to the NHS.

We should reflect long and hard before we allow ourselves to be seduced by a vision that seems so attractive from this side of the pond; on the other side they seem to have the same rose-tinted glasses focused on us. On a level playing field I am sure we will outperform any private sector multinational on important measurables, but more importantly, on things our patients value most. Delivery of these will give us the sustainable profitable and valued businesses.


Dear Amit

While I share your concern that we should not be seduced by international experience, we already have British examples of practices sharing back-room functions and service delivery to mutual benefit. Indeed, I often hear, as I'm sure you do, that practice-based commissioners lack the detailed information necessary to be more effective commissioners that perhaps a more effective back office might deliver, regardless of its origin. We should retain an open mind as to how this might develop in the future while retaining the values of local leadership within general practice to ensure we do not miss out on the opportunity to bring further benefit to patients and commissioners, and develop health services that might genuinely be the envy of the world.

I think in your last email you make an eloquent argument as to why GPs should profit from practice-based commissioning through providing a service valued by commissioners and patients alike, alongside shaping future service delivery based on what we all value in general practice. How could I but not agree with you!


Dear Johnny

You are right that a federated model of general practice where we share intelligence, learning and back-room functions, would accelerate our growth and also make us much stronger and viable. I think the pressure on general practice as individual businesses is going to be unremitting for the next few years and outward-looking and joined-up general practices are most likely to thrive. There is much to learn from international examples which would add to our already strong base. Also, keeping an eye on the macro-economic and health drivers would be valuable to us when we do our practice business planning.

I am all for a profitable general practice, I have three expensive girls to maintain!

It's been a really worthwhile discussion, we are fundamentally in agreement – a rare treat for me.


Dr Johnny Marshall is NAPC chair and a GP in Buckinghamshire

Dr Amit Bhargava is NHS Alliance PBC lead for the south east and a GP in Crawley, Sussex

"GPs are inevitably better placed to deliver services" Dr Johnny Marshall "GPs have to restore their real value in the community" Dr Amit Bhargava Dr Johnny Marshall

Rather than being protectionist we have to raise our game to meet the private sector challenge

Dr Amit Bhargava

As soon as there is evidence that we are engaging only for personal gain our credibility and value to the discussions will be lost

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