This site is intended for health professionals only

At the heart of general practice since 1960

Does practice-based commissioning have a future?

PBC is general practice's last defence against private firms, argues the NHS Alliance's Dr Michael Dixon – whereas Dr Jonathan Heatley counters that it is destabilising hospitals and has delivered GPs mountains of paperwork

PBC is general practice's last defence against private firms, argues the NHS Alliance's Dr Michael Dixon – whereas Dr Jonathan Heatley counters that it is destabilising hospitals and has delivered GPs mountains of paperwork


Practice-based commissioning is general practice's only future. It provides us with a new and enhanced role within the NHS.

First, PBC hands us an opportunity to make a difference within our local communities. It gives us an unprecedented ability to shape and improve primary and secondary care services and local health. When it comes to individual patients we can have a much greater impact than previously on their personal health, wellbeing, and ability to help themselves before the consultation, and on the services and support they get afterwards.

Second, PBC assures us of a future as providers of general practice and primary care services. If we take on enhanced responsibility for our patients and communities, that will position us as allies and partners of PCTs, and inevitably make us the preferred providers of new services – especially when these are only possible because of savings we have made ourselves.

Commissioners, who might otherwise award tenders purely on the basis of price, may view favourably bids from practices who are also involved in PBC. They will see such practices (unlike other providers) as being concerned about the cost-effective use of resources, as well as wider issues surrounding patient self-help and population health.

Our role as practice-based commissioners puts us in charge of our own destiny and in a strong competitive position. If we create an extended provider role for ourselves, which is adequately paid but not for profit, then we will not only create more integrated services that have a strong ethical relationship with our local communities, but also withstand the pressure from corporate enterprise, ever waiting in the wings, to purchase any successful businesses we might establish.


If PBC has no future, then what is the alternative? At best, we will be throwing ourselves on the mercy of PCT commissioners, entirely on their terms, without the goodwill and mutual aims that PBC brings. We would simply have to hope they would want us to continue providing core general practice services in a world of tenders, competitive bids and local contracting.

At worst, especially if PCT commissioning fails, as is likely without PBC, we may end up being commissioned by large private corporates or being employed by them or foundation trusts.

As GPs we can take on a leadership role, help PBC succeed and save general practice and the wider NHS. It will not be easy. We need to encourage PCTs to improve their own commissioning and provide more effective help for PBC. Every GPs will need to not only support the leadership of their PBC collectives but also examine their own role in making PBC a success.

Alternatively, if we choose to be selfish, lazy, greedy or myopic and turn our backs on commissioning then we cannot complain about the inevitable consequences: others commissioning primary care, who know less than ourselves about our patients and their needs and whose ignorance, lack of compassion and vested interests may destroy everything that has made the NHS special.

I believe the family doctor is not dead, and GPs are first and foremost altruists with a vocation, who want to make a difference for their patients. I also believe we have the talent to innovate and deliver a better NHS now that we have been given the means to do so. GPs who are doom-mongers over PBC are spelling their own doom. Because if the bell tolls for PBC, it tolls for general practice too.


Am I the only frontline GP who has lost all faith in practice-based commissioning? The medical press is full of articles extolling its opportunities – how it is the only game in town and why we all need to sign up to it. The Government has made it a central plank of NHS modernisation and PCTs are under intense pressure to make it work.

Yet there are very few stories of new services set up by happy and fulfilled GPs. Instead, we are starting to hear tales of huge amounts of time spent trying to set up PBC in vain. There are endless meetings with a wide variety of participants, but very little to show for it.

Holding companies are set up and debates held over whether to be profit-making or not-for-profit. There are discussions over how the board should be configured and arguments about liabilities and insurance, to say nothing of clinical governance, accountability, protocols, best practice, competitive tendering, audit, appraisal and employment legislation.

We are doctors, not administrators. We signed up to run primary care, which we do pretty well, but not to police and run secondary care. How do we shift services around while reducing the financial input on struggling local hospitals? Do GPs want to have a hand on the tiller when the ship is going down? The Government is desperate to find someone else for the public to blame when services are cut – step forward the local commissioning group!


Suppose we work hard and save money in one area of referral. The savings then get ploughed into another less efficient and overspent area. So GPs simply remove money from new and efficient services set up with local specialists, which is hardly an incentive for setting such services up.

We are supposed to check hospital activity for our practice's patients but have had an almost impossible task getting anything meaningful out of them. Any GP who has tried to make sense of hospital activity data will realise it is hopelessly inaccurate, usually by mistake but recently and more worryingly by design. If departments of dedicated hospital staff make such a mess, how on earth are busy GPs expected to check it all?

And if they do check, what then? One local practice installed software for this purpose and the PCT refused to honour its findings, claiming it would ‘destabilise the local secondary care provider'. The practice invested large amounts of time and money doing exactly what was asked of it only to have the work binned.

There are new services such as GPSI clinics that have worked and seem to be saving money. But they have been set up by PCTs outside of PBC. In our local area we have singularly failed to produce anything under PBC despite the time invested.

One of the problems is that this Government so over-regulates – with one set of rules overriding another. Take for example the rules on patient choice. We will soon be penalised if we don't offer choice, but most of the money-saving services set up ostensibly under PBC, such as musculoskeletal medicine and dermatology, don't offer it. Instead, they funnel everyone into a triage system. Which has precedence – choice or commissioning?

PBC seems doomed to a slow death from the sheer weight of attendant bureaucracy and internal inconsistency. When are we going to admit this and find a workable alternative that does not burden us with interminable paperwork? We need a system that lets GPs and consultants co-operate, but with proper administrative support.

Dr Jonathan Heatley is a GPSI in dermatology in Horsham, West Sussex

Dr Mike Dixon Dr Michael Dixon, chair of the NHS Alliance and a GP in Devon Dixon thumbnail Dixon quote

GPs who are doom-mongers over PBC are spelling their own doom.

Dr Jonathan Heatley Heatley quote

PBC seems doomed to a slow death from the sheer weight of attendant bureaucracy and internal inconsistency.

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say