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What now after the Darzi review?

Lord Darzi’s Next Stage Review has been hailed as a new chapter for practice-based commissioning. We asked NAPC chief executive Mike Ramsden for his views on what it means for PBC

Lord Darzi's Next Stage Review has been hailed as a new chapter for practice-based commissioning. We asked NAPC chief executive Mike Ramsden for his views on what it means for PBC

What implications does the Next Stage Review have for PBC?

There's nothing to indicate the Government's commitment to PBC has diminished.

Some, including the NAPC, were disappointed that certain aspects haven't gone further and faster (notably real budgets), but PBC is here and I sense the Department of Health is keen to take it forward in a proactive way.

I think ministers recognise that GPs and those at practice level are responsible for setting the ball rolling in accessing further elements of care and so need to be engaged in the process and be accountable for those decisions.

It's about taking the gatekeeper role further by encouraging more direct responsibility for the actions that GPs take. PBC is, in part, about trying to make people take on such accountability.

There is a strongly held recognition that fundholding, although it had its problems, unleashed a wave of creativity in the health service that hasn't been seen before or since. PBC goes some way to bringing that back in a more structured way.

I am a great believer in financial responsibility and I think real budgets are the way to go. That means taking everything that goes with it.

Fundholding was limited in this because if overspends occurred they were someone else's problem.

People should recognise that there are financial consequences in every decision they take, just as in their home and business lives and that it has to be the same in the NHS. I would have liked to have seen this financial accountability in the Next Stage Review.

Integrated care organisations (ICOs) are a clear demonstration of the DH's willingness to take some radical decisions and do things that are very different.

Do you feel ministers are still fully behind PBC?

I think they're absolutely keen to see it work and I've not heard or read anything that suggests otherwise.

There's a receptiveness to new ideas and practices and this will continue. But that's not to say everything we want will happen tomorrow. However, the DH has just asked for expressions of interest for the supply of capability development services for PBC so this is a further signal that the DH wants to sell PBC work.

How do you think GPs feel about PBC at the moment?

There's a gulf the size of the Pacific Ocean in the difference between what ministers and civil servants expect with PBC and what's happening on the ground.

There's a handful of GPs who have done really great things with PBC and there's a good number that haven't engaged with it at all. And then there's a rump in the middle who are frustrated and don't feel it's happening.

Some PCTs have been much more supportive than others but it's very easy to blame others. If GPs really believe in this approach they need to stay with it and be tenacious and develop the persuasive abilities to make it work.

But there is a need to see it from other perspectives as well. If PCTs are faced with a large number of practices trying to develop business cases and they are relatively small scale to the PCT, then it's easy to see why they haven't given these plans much attention.

I'm not making excuses for PCTs, but at the end of the day it's public money and it's entirely right and proper that the use of it is appropriately scrutinised – and that's a role PCTs have.

Do you think one model of PBC might now become stronger than others? (Social enterprise vs cluster vs limited company)

I don't think that's the case. I think there's a willingness at the centre to look at different models. What's suited to one area won't be the case for another and that has to be a good thing.

People have argued against top-down decisions and we have got an opportunity now to drive things from the bottom up and create models that suit local circumstances.

Social enterprises have clearly come to the fore in recent times and there appears to be a will to see that take off, but I don't believe that will be at the expense of other models.

What do you think will be the biggest influence on PBC over the next 12 months?

The ICO opportunities are the most exciting thing that we will see in the next 12 months.

I give credit to the DH for its approach with this. It has been very clear that it is looking for a range of different ideas and opportunities to come forward and it appears not to be fixed on the number of pilots.

If we asked you to look into your crystal ball, where do you think PBC will be in a year's time – and five years' time?

I don't see a large amount of difference between now and next year, though there are some good things happening. But I think we will still broadly be in the same position we are in now where some PBC groups have leapt forward, some that have not done anything and the bulk are in the middle striving to do things. But things are inching forwards with more people making progress incrementally and breaking through the frustrations.

For five years' time there are a lot of unknowns. I would like to think that the potential exists for practice-based commissioners to hold budgets and be accountable for their spending as part of an overall managed system, but there are a lot of things that could stop that – political will, Government change, attitude of ministers, attitude of GPs and NHS managers.

If more GPs get frustrated and drop out then it could easily stall.

The NHS history is one of restructuring so there is no guarantee that PCTs will exist in five years' time.

It's entirely likely that if PBC grows, it will be taking on more responsibility and so perhaps the role of PCTs will become one of more overall assurance of the use of public money.

What advice do you have for GPs interested in putting a bid together for an ICO?

ICOs are a great opportunity, but that doesn't mean they're right for everyone.

It will be different in each area and there will be some potential partners who have different attitudes from others, but I think that if GPs want it they should go for it and look very carefully at the opportunities that this offers.

GPs shouldn't be afraid to put forward different ideas and different options. They should be bold, be brave and see this as an opportunity for radical thinking.

Every healthcare system in the world is facing the same challenges as the NHS and if one of them had the answer we would go and copy it. There's no guarantee that bringing in ICOs will make things significantly better but we have to keep trying.

Mike Ramsden is chief executive of the NAPC

Dr Mike Ramsden, chief executive of the National Association for Primary Care Dr Mike Ramsden Ramsden's views at a glance

If more GPs get frustrated with PBC and drop out things could easily stall in the next 5 years.

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