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Keep pace with NHS changes in the year ahead

New NHS rules and guidance affecting PBC take effect from April. We asked national PBC expert Dr James Kingsland and grassroots GP Dr Gerard Bulger to offer their interpretations.

New NHS rules and guidance affecting PBC take effect from April. We asked national PBC expert Dr James Kingsland and grassroots GP Dr Gerard Bulger to offer their interpretations.

Practice-based commissioning is here to stay

The NHS Operating Framework for 2008/9 states on page 27 that PBC is here to stay, is central to world-class commissioning and that it is up to PCTs to ensure it succeeds.

Dr Gerard Bulger: If true, then the statement would never have been made. The inclusion of this is a clue that there is a debate going on somewhere, either to scrap the purchaser-provider roles, or to develop PBC into practice-based contracting.



Dr James Kingsland
: The statement has been included because the National Association of Primary Care [which Dr Kingsland chairs] and the NHS Alliance have been saying to the Department of Health that that's what GPs need to hear. As a result, we've heard the same statement made in recent months from ministers Alan Johnson and Ben Bradshaw as well as Mark Britnell [DH director of commissioning]. If GPs still don't believe it, then maybe nothing the department, or the NAPC, says will change their minds, sadly.

The 18-week referral-to-treatment target has changed

By the end of 2008, 90% of pathways involving hospital admissions and 95% of pathways not involving admissions should be completed in 18 weeks, to allow for factors such as patients choosing to wait longer or clinical complexity (page 13 of the framework). Previously the target was 100%. A new patient survey will be rolled out to provide feedback on the target.

Dr Bulger: Allowing patients to choose to wait longer will stop a lot of aggravation. But PCTs are still allowed to count the referral data from when their CAS [clinical assessment service] or CAT [clinical assessment and treatment service] refers on to the hospital, rather than from when the GP actually referred. The new survey, focusing on patient satisfaction, may help undermine these kinds of delays.

PCTs are expected to work with providers on pathway redesign, but they do not exist in many areas. Are they expected for every clinical condition? This would be a huge undertaking. It has taken our PBC groups two years to set up a COPD pathway and it is still not running.

Dr Kingsland: This target seems, unfortunately, much like that first set for PBC. A target was set for universal coverage by December 2005, by when we expected all practices to receive a budget and PBC data. It changed to PCTs reporting they had systems in place to support PBC development. So although PCTs reported universal coverage, we then found through a subsequent Government-commissioned MORI poll less than 20% of practices had useable budgets.

The 18-week target is a relatively arbitrary one, with limited evidence, but quite rightly we need to improve the time from routine referral to treatment in hospital. The explanation on www.18weeks.nhs.uk is that ‘feedback from patients and other evidence suggests 18 weeks is a length of time patients find acceptable'. In relation to the robust evidence we use to treat patients, the evidence behind the 18-week target is, at best, thin.

If you're not going to reach the target, you shouldn't start manipulating it later on. Waiting and access are vitally important, but let's be honest about how we will achieve it.

Dermatology outpatients activity can be locally negotiated

Page six of the 37-page document on the Payment by Results tariff for 2008/9 announces this surprise change, which will mean PCTs no longer need to pay a mandatory, nationally set price for this activity and can instead enter into local negotiations with trusts.

Dr Bulger: The national tariff is wobbling. This line seems to have been inserted as dermatology is in danger of no longer being a hospital speciality. It could undermine services set up by PBC provider groups, CAS, CATS and private provision. We could see a similar tariff rule change for other ‘at-risk' hospital specialities such as rheumatology and ophthalmology.

Dr Kingsland: Starting to signal you can undercut the national tariff destabilises the whole principle of a health service that contracts on quality, not costs. I'm going to ask the PbR reference group to clarify if there has been a change in policy.

Some areas of the country are seeing PBC provider consortiums setting up services that have a basic business plan of moving hospital outpatient services into the community and providing the same service, only cheaper. The focus shouldn't be on providing a cheaper service, it's about whether you offer better quality, better access, shorter waits and also challenging whether some services should be provided in hospital in the first place, or could be routinely delivered by a primary care team.

Take paediatric eczema. Some GPs are saying if it costs £180 in outpatients, we'll do it for £100, but then in other areas of the country GPs say they do it anyway as part of their core practice service and don't need to refer anywhere else.

A competitive healthcare marketplace continues to be encouraged

From April, patients should be offered a free choice of which provider they go to for all routine elective services and commissioners should not constrain the opportunities of any willing provider to do so, other than for exceptional reasons such as concerns about clinical quality, according to annex D of the operating framework.

PCT provider arms that deliver community services could be allowed to gain foundation status in the coming year (page 31 of the framework).

Private companies will advise the DH through a new independent sector procurement forum on policies designed to ensure a ‘fair playing field', and a new competition panel will advise SHAs on competition disputes after all local resolution efforts have been exhausted (page 35 of the framework).

Dr Bulger: Patients will assume that choice means they can choose the latest, most expensive chemotherapy, or that they can have atorvastatin and not simvastatin. Choice of provider is not much of a consideration in patients' minds, because their choice is their local district general hospital, and that their DGH should look and behave like a hospital in France.

Somehow the extent of private provision in the acute sector will be patient led. But who gives the private sector contracts in the first place?

The competition panel could be interesting for PBC groups. PBC has often been equated with practice-based providing – usually by PCTs that expected provision by practices. The conflict of interest inherent in that has not been tackled.

And are GPs invited to the independent sector forum? To achieve a level playing field, GPs will need to be able to trade the goodwill in their contracts, as the private sector does.

Dr Kingsland: I welcome competition – it drives up quality. Historically, if there was poor performance in primary or secondary care, they were given more resources, and if you were efficient, your budgets got squeezed. That was unfair. I'm an advocate of decommissioning services that are inefficient, poor and continue to be poor, despite encouragement and investment.

A conflict of interest persists in PCTs – who are now aiming to be world-class commissioners but at the same time most are continuing as provider organisations – especially if they decide independently to introduce services. I believe they should be divesting their provider functions – unless they continue to do so by default because other providers cannot be commissioned.

Much less of a problem, I believe, are any conflicts of interest within PBC, and these can be clarified in local governance arrangements. GPs, whether we've had a budget or not, have always been commissioners and providers, potentially on a daily basis.

If I write a referral, I'm commissioning a service for my patient elsewhere, but if I continue to look after the patient, I'm providing. Whether I've got the budget or not, money follows that decision. PBC is trying to align and identify that clinical decisions on a day-to-day basis have financial consequences.

Other changes in brief:

Acute trusts should provide GPs with patient discharge summaries within three days, and within a day by 2010.

Outlined in Annex E of the framework (the standard NHS acute contract for acute hospital services); however, rules don't apply to foundation trusts on pre-existing contracts extending beyond 31 March 2008.

Dr Kingsland: Even summaries need to be fairly comprehensive. GPs report it can take three to four weeks to get a discharge letter, so it would be just a start to get one within two weeks, as the original national contract specific. The idea of different regulations for acute and foundation trusts makes no sense.

No top-down targets, just ‘vital signs'

DH to publish a list of ‘vital signs' for services against which PCTs will be measured annually. The operating framework (pages 8 and 9) insists the list will not be ‘top-down targets… it will in fact be completely the opposite: it is a decisive move towards greater local autonomy'.

Dr Bulger: This is saying: ‘You will take the blame for what we direct up here.'

Dr James Kingsland is a GP in Merseyside, chair of the National Association of Primary Care and a member of Practical Commissioning editorial board.

Dr Gerard Bulger is a GP in London and at Wandsworth Prison and sits on the executive committee of DacCom PBC Ltd in West Hertfordshire

Dr Bulger a conflict of interest persistS in pcts BEING COMMISSIONERS AND PROVIDERS

A conflict of interest persists in pcts being commissiones and providers

Dr Bulger this section on ‘vital signs' is saying: ‘you will take the blame for what we direct up here'

This section on ‘vital signs' is saying: ‘you will take the blame for what we direct up here'

Dr James Kingsland NHS ribbon

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