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What next for freed-up resources?

With many PBC consortiums looking set to miss out on the freed-up resources owed this year, we asked five experts what this means for the bigger PBC picture

With many PBC consortiums looking set to miss out on the freed-up resources owed this year, we asked five experts what this means for the bigger PBC picture

Dr Nav Chana, GP in Mitcham, Surrey, and executive committee member of the NAPC

I'm not surprised to hear GPs aren't getting freed up resources. Getting FURs can depend on the PCT's financial position and with the new HRG4 coming in, a number of PCTs have been left with a financial imbalance. But it represents a significant disincentive to get people engaged in PBC and as long as the system is based on freed-up resources, this will be a difficulty.

This is the problem of redesigning things in little pieces. You redesign service X but it has a knock-on effect and causes a problem in a different area.

The real difference is made when you have an understanding of cost across the whole pathway and greater understanding of savings in areas other than your tiny redesign. You say ‘We have done this wonderful thing, we're saving money and we should have these resources' – but it may be that your service had a knock-on effect elsewhere.

This all goes back to the point that we're talking about indicative budgets and really the money is held by the PCT. So no matter what you do, it's still the PCT that calls the shots and the only way around that is for the money to be real and for commissioners to hold the budget.

I'd like to think clinicians are in it for altruistic, rather than financial, reasons so I still think there's the opportunity for people to use the framework to improve services for patients. But the reality is that if there isn't some sort of tangible reward, a lot of people find that rather demotivating and will say ‘why bother?'

Dr Shane Gordon, national co-lead of the NHS Alliance PBC Federation and chief executive, Colchester PBC Group

Failure to deliver freed-up resources will break the PBC ‘contract'. It will disenchant GPs who have given their time and interest in good faith to help the PCT achieve its strategic aims. Further, it will deprive PBC clusters of any opportunity to innovate by investing in new services.

This could set back service reform by several years and create a loss of trust between PCTs and primary care, which would create great problems for the coming financial challenges. Only by working closely with primary care will PCTs be able to manage demand.

Confrontation is unlikely to build co-operation and trust. PBC clusters must act maturely and seek to develop a close partnership relationship with their PCT, especially when times are difficult. Likewise PCTs must continue to develop their investment in PBC to deliver sensitive local commissioning and full engagement of primary care in the commissioning process.

Taking steps to develop internal governance and robust processes within PBC clusters will enable PCTs to place more trust, and therefore more resources, at the disposal of PBC clusters.

A mature approach might include a clear statement that PBC clusters are working to support the PCT through a difficult time, but will expect a reciprocal expression of trust on the part of the PCT.

The key to making PBC work is a ‘transfer of power', as set out in the recent Department of Health vision for the policy. This means, inevitably, some direct control of resources to reform services.

Dr James Kingsland, national lead on PBC for the Department of Health and NAPC president

In the current financial climate, the fact people are not getting their freed-up resources does not surprise me but there's only two ways that can happen – either you didn't have a business case in the first place and it was based on crossing your fingers, or you did have a business case but the PCT reneged on it.

The problem with many service redesigns is they're conversations and loose arrangements, or there is a business case but the expected financial savings haven't been identified. When you haven't got a clearly identified business case and it is a time of financial difficulty, it is easy for the PCT to renege on an informal agreement.

So it's important not to work solely on trust.

If a contract is in place, then it's black and white, end of story. If you have the document that proves you're entitled to the freed-up resource, it was down to real work and not just a windfall, and you have been refused it, you need to go to the SHA and say the PCT hasn't managed the system properly.

If you do one area such as dermatology, there's always the risk of saving in dermatology and overspending elsewhere, but that is not a problem for the consortium that has got a business case. The guidance is absolutely crystal clear about negotiating this at the start of the financial year.

If you agree you can keep 70% of the freed-up resources, the PCT signs up to that in the knowledge it may have problems in other areas. If it doesn't want that risk then it doesn't have to sign up to it.

A PCT can say at the outset: ‘You are focusing on this area and you expect to save £1m but we should have some risk built in and you can only keep a proportion of the overall savings because you are overspent in areas that you are not focusing on.'

It's just a case of following the instructions, the guidelines are out there.

Dr Johnny Marshall, NAPC chair

What should be happening is that commissioners should be involved in redesigning care services and then freed-up resources can be reinvested in further service redesign.

Under fundholding that was a successful model – not that I'm saying we should go back to fundholding. But unfortunately PCTs haven't worked to achieve the potential benefits of PBC.

With fundholding, it was very much the practices' responsibility – they had budgets that they managed properly and were accountable for, and they had every incentive to make sure they were getting value for money.

Because PBC works on indicative budgets, it has removed that sense of ownership and getting engaged in the first place. And when you are engaged and you deliver services but you don't get freed-up resources, it's frustrating.

I don't think the policy of freed-up resources is wrong but we need to move beyond indicative budgets to explore the possibility of real budgets.

We need to look at what we're trying to achieve overall, looking at the whole issue of financial risk within PBC. We need to give people the skills to manage that risk appropriately and we also need to look at PCTs and how they're managing PBC and commissioning and service redesign. There are some PCTs that are fantastic but as a whole they are focused on bureaucracy rather than management – and they're not taking risks.

It's a culture of acting safely and doing things the way we have always done them. We need to be looking at a more commercial culture but that's very foreign to PCTs and they get no thanks if they fail. We need to give primary care the capability and capacity to take a financial risk.

Dr Stewart Findlay, Chair of Durham Dales PBC cluster

Of course not getting freed-up resources will demotivate GPs and it's important to remember this is not money GPs can directly benefit from; it's money they want to control to reinvest in patient care.

It makes a mockery of PBC. What is the point of it if you can't make decisions that benefit the patient?

There is a particular issue about how fair the budgets are – how do you know the practice hasn't been overfunded in the first place? To address that we have been trying to move to fair-share budgets but progress with that has been pretty slow.

It's very difficult for PCTs to balance the books but if some areas are underspent and some are overspent, that's something that should be open for negotiation.

PCTs need to give practice-based commissioners some simple targets and the ability to make decisions and let them get on with it. At the moment it's a tickbox culture; there is no responsibility and GPs don't feel engaged.

They have got to give PBC clusters the responsibility and the ability to make decisions and get over their worries about conflict of interest and the huge amounts of bureaucracy which stifle the NHS.

There are two options. The PCT could choose to give the cluster the whole budget and give them the problem of how to share out the resources and the savings.

Or the cluster focuses on an area such as dermatology, but then they should get those savings and it's up to the PCT to balance the rest of the budget.

I believe a mature PBC cluster should be able to work on the entire budget. If you don't align clinical and financial responsibility you're going to get a disaster. Up until last year we had access to freed-up resources but certainly didn't get the 70% that we were due.

Then it was agreed for last year and this coming year that we would replace freed-up resources with a reward scheme centred around obesity and COPD and if practices hit a number of public health targets and also became involved in PBC, they would get a considerable incentive from the PCT.

The question is, is this PBC? I would argue that it's not – it's a QOF-plus scheme. It doesn't align clinical and financial responsibility. We have to move to real budgets because we know that's the only way it can be done properly, but PCTs are reluctant to do that.

"No matter what you do, the PCT calls the shots - real budgets are the only answer." Dr Nav Chana This could set back service reform by several years and create a loss of trust. Dr Shane Gordon If a contract is in place and it's black and white, then end of story. Dr James Kingsland Unfortunately PCTs haven't worked to achieve the potential benefits of PBC. Dr Johnny Marshall What is the point of PBC if you can't make decisions that benefit the patient? Dr Stewart Findlay

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