There’s still time to keep PBC alive
Dr Chaand Nagpaul argues that PBC can have a long life if it’s given the right treatment
Dr Chaand Nagpaul argues that PBC can have a long life if it's given the right treatment
Evangelical fanfare accompanied the introduction of PBC back in 2004. It promised wholesale improvements in the quality and design of services, while freeing up resources and engaging all GPs as part of ‘universal coverage'. Five years on, lamentably, these aspirations have not been realised. Indeed, the most recent Department of Health PBC quarterly survey revealed only 68% of practices were even aware of being given an indicative budget – a fundamental prerequisite to commissioning. More than 30% of practices reported PCT support as ‘poor' and only 51% believed PBC had improved patient care. These results are a far cry from the original lofty vision and the formidable political importance given to PBC as a policy initiative.
The problem has been largely caused by variable implementation at PCT level, since we do have examples of PBC operating effectively in some PCTs, with high levels of GP engagement. In many PCTs there have been problems from the outset, including being dogged with interpretation of Government guidance on such issues as freed-up resources (FURs), a central driver for PBC. With some PCTs reneging on making FURs available on the back of financial deficits, this has naturally demotivated GPs who had made considerable effort to commission and refer cost-effectively. For many GPs, PBC has been a process of debt management and referral obstruction schemes rather than any form of commissioning.
Centrally, there have been mixed messages regarding the role of PBC with the advent of World-Class Commissioning, which emphasised PCT-led commissioning and promoted the use of commercial commissioning support to PCTs via the Framework for External Support to Commissioners (FESC) – rather than focusing on GPs and practices leading PCT commissioning. Furthermore, we have seen political imperatives dictate the use of local resources such as for Darzi centres, ISTCs and secondary care targets that have stopped PBC meeting local needs.
It is noteworthy that PBC remains a firm commitment of shadow health policy, albeit with the vexed issue of what real budgets may mean. I believe that for PBC to survive, we need the following list of ingredients, drawing upon the experience of PCTs where PBC is operating successfully:
• a move from PCT-led to practice-led commissioning – PCTs need to ‘let go'
• motives for practices to be involved – this has to go beyond crude referral vetting schemes that appear as sticks not carrots
• GPs need to be ‘enabled' to become clinical leaders shaping service redesign, with resources for protected time and locum backfill
• adequate practice-level resources for PBC work such as data analysis
• competent PCT-level management support for PBC
• longer-term budgetary cycles to allow investment in service redesign that will accrue savings in future years.
If GPs and practices can be enabled, empowered and supported, even at this late stage, I believe that PBC still has a fighting chance of being resuscitated from its current semi-conscious state, to achieve some of its original aspirations.
Dr Chaand Nagpaul is GPC negotiator with lead on commissioning and a GP in Stanmore, MiddlesexDr Chaand Nagpaul Dr Chaand Nagpaul