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Has practice-based commissioning been turned against GPs?

It is five years since the Government launched practice-based commissioning with the grand ideal of allowing GPs to use their expert knowledge to reshape services and save money for their practices. Yet today not only are an increasing number of leading NHS leaders writing the policy off as a busted flush, but GPs are reporting a more disturbing twist - that it has become a crude weapon to drive down referrals and manage practice performance. By Gareth Iacobucci reports on what the future holds for the flagship policy.

By Gareth Iacobucci

It is five years since the Government launched practice-based commissioning with the grand ideal of allowing GPs to use their expert knowledge to reshape services and save money for their practices. Yet today not only are an increasing number of leading NHS leaders writing the policy off as a busted flush, but GPs are reporting a more disturbing twist - that it has become a crude weapon to drive down referrals and manage practice performance. By Gareth Iacobucci reports on what the future holds for the flagship policy.

How has practice-based commissioning fared over the last five years?

Introduced in a time of unprecedented investment in the NHS, practice-based commissioning is now struggling to survive against the brutal backdrop of the recession. It was originally viewed as a way of transferring commissioning power back to GPs - following the abolition of GP fundholding in 1998 – in order to reconfigure services and drive improvements in their quality and efficiency. But Pulse revealed last year that PCTs hit financially by the surge in GP referrals were using PBC to impose strict limits in clinical areas that had ‘over-performed' on waiting times, in a desperate attempt to claw back cash. PBC come to be seen as a valuable tool by PCTs as they case targets to cut their outpatient referrals by 10% or more. Since the onset of World Class Commissioning (WCC) two years ago, which placed greater focus on holding PCTs to account for their capabilities as commissioners of services, the Government's commitment to commissioning at practice level has been in doubt.

For its part, the Government claims most GPs still support PBC - 64%, according to its latest survey. A similar proportion now provide new services commissioned as a direct result of PBC - eight points above the result for December last year – but that is a cumulative figure covering the entire five-year period PBC has been around.

What evidence is there of PBC being used against GPs?

In this time of economic crisis, PCTs increasingly appear willing to resort to desperate measures to save money, and this is spelling trouble for some practice-based commissioners. One of the most alarming examples to date has come in Hillingdon, West London, as revealed by Pulse last week. The cash-strapped PCT was forced to draft in private accountancy firm KPMG to devise a series of cost-cutting measures, including tough sanctions to punish high referrers and a clear instruction that the chair of the LMC could no longer remain at the head of the PBC group. All GPs in the area are threatening to quit PBC in protest at the plans to use GP commissioning primarily as a tool to drive efficiencies.

There is also emerging evidence that some trusts are reneging on promises made to commissioning groups on how savings are used. The National Association of Primary Care held an emergency summit for commissioning GPs last month, to examine claims that some trusts were going cold on PBC as the financial crisis kicks in. PBC consultant Gerry McLean, who attended the summit, said two commissioning groups he was working with had been refused access to savings of £700,000 and £600,000 respectively because of their PCTs' financial deficits. Fellow PBC consultant Scott McKenzie, who also works with a number of PBC groups, said one PBC group had contacted him to say their PCT had withdrawn ‘all money from PBC'.

Dr Johnny Marshall, chair of the National Association of Primary Care, says there is ‘alarming evidence' that PCTs are increasingly using PBC as a blunt instrument to crack down on the rise in GP referrals and are pulling the plug on forward-thinking service re-design because of the financial climate. ‘In an era of economic crisis, this transactional approach is doomed to failure,' he said.

Where do the latest developments leave PBC?

On the ground, there is increasing evidence that GPs have become disengaged from the policy. Grassroots GPs tend to roll their eyes in meetings when PBC is brought up, and there are particular blackspots of disillusionment, where GPs feel they have not been supported by local trusts. In NHS East Midlands, even the Government's own survey finds only 39% of GPs approve of their local trusts' efforts at supporting the policy.

But this contrasts with a reasonably healthy 61% for NHS North West, widely considered to be one of the SHAs that has bought in most to the policy. It is areas such as this, and the handful of areas that have gone further by experimenting with real budgets for GPs, that offer a glimmer of hope for PBC. The Department of Heath recently flagged up a scheme In Bexley, south East London, where GPs made £4m worth of savings after being given real budgets for prescribing, as a blueprint for successful PBC. Dr Joanne Medhurst, GP in Sidcup and lead for the Bexley PBC federation consortiums, says giving GPs responsibility allowed them to free up resources effectively in partnership with the PCT: ‘We looked at how to take on a budget with a real risk, but with a risk pool arrangement, so no one practice does it in isolation. We also passed it through clinical Governance and made sure the LMC knew about it, and we made it go through the PEC. We enabled the doctors to do it.'

There are also positive moves afoot to hold managers to task if they are shown not to be taking PBC seriously, with the possibility of the chop if they fail to demonstrate efforts to engage with GPs. The Government has just announced it will split its quarterly PBC survey into two, with one going to lead individuals within PBC groups, and the other assessing opinions among grassroots GPs. The results of the PBC leads survey will feed into assessments for WCC, with trusts being held to account for failure. ‘Those PCTs that are simply using PBC to manage demand will get their fingers burnt by WCC,' predicts Dr Michael Dixon, chair of the NHS Alliance. ‘Frankly, it's been very easy to hide to date, but someone who is manifestly abusing PBC will be caught in the next round.'

What does the future hold for GP commissioning?

The question is whether the will to make PBC work is strong enough to overcome the current financial pressures. A common complaint from GP commissioners at the NAPC summit was that they felt their voice was not being heard, and that even the relatively few success stories for PBC were ‘framed' in terms that appealed to managers – mostly in terms of cutting costs.

Dr James Kingsland, NAPC president and the Government's national clinical lead for PBC, says that unless the principles behind the policy are adopted by all, the NHS will have to make ‘slash and burn' cuts or severe reductions in workforce and pay – ‘neither of which are palatable'. ‘Clinical commissioning is the only show in town. If clinicians are not doing it, and PCTs don't do it, it could be a career breaker,' he warns.

This move towards real budgets looks certain to accelerate, particularly if the Conservatives win the next election. Shadow health secretary Andrew Lansley has declared the current PBC set-up as ‘bust', but his plans for GPs to commission go far further than anything Labour has done. While the current Government will continue to leave commissioning as a voluntary option for GPs - albeit with greater budget-holding responsibility for high flyers - GPs will be contractually obliged to take on real budgets under a Tory Government, with commissioning responsibility transferring from PCT to practice. This will leave GPs free to use any savings they make, but also partly financially accountable for losses, although the Tories insist they will keep practice and patient budgets separate.

There is no doubt that the move would create a bigger incentive to get PBC working more effectively, and on a much wider scale. But some GPs fear it would be ‘financial suicide' to take on budgetary risks without appropriate safeguards, which have yet to be fully set out by the Tories. And GP leaders have questioned the wisdom of forcing all GPs to take commissioning – even those not interested in it – with the RCGP pointing out that GPs currently receive little if any training on how to commission effectively.

The Conservatives plans remain short of detail, but one fact is plain. However tired PBC has become, and however disliked by many GPs, it is not yet dead. With the Tories likely to form the next Government, there's plenty of life in GP commissioning yet.

PBC budget cuts

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