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Gold, incentives and meh

What does the future hold for practice based commissioning

As a report brands PBC an expensive flop, experts disagree on how to revive the flagging scheme. By Gareth Iacobucci investigates.

By Gareth Iacobucci

As a report brands PBC an expensive flop, experts disagree on how to revive the flagging scheme. By Gareth Iacobucci investigates.

If practice based commissioning were a horse, ministers might well be reaching for the shotgun.

The Government's flagship strategy is reeling from perhaps its most thorough dismantling to date, in the form of a highly critical report from prestigious thinktank the King's Fund.

The verdict – the policy is an expensive flop. The authors conclude that despite more than £100m being pumped into incentives for GPs alone, PBC has had ‘little impact in terms of better services for patients or more efficient use of resources'.

Yet rather than being put out of its misery, PBC looks set to soldier on, albeit perhaps with significant changes in GPs' roles and responsibilities.

The King's Fund report tracks the faltering progress of PBC over the space of a year in four PCTs who - thankfully for them - are anonymised.

Its conclusions are damning. PBC has been hampered from its launch, back in 2005, by woefully ill-defined aims, apathy among GPs and feuds between those few who have taken it on and their hapless PCT paymasters.

The King's Fund authors call for a fundamental rethink.

There is the odd bright spot, with some evidence the working relationship between GPs and PCTs has improved, although even here the picture is not consistent.

GPs apparently lack the skills needed in crucial areas like data analysis, and PCTs lack the skills to provide the data in the first place.

Worse still, PBC is bedevilled with conflict of interest, with PCTs too often favouring their own services and GPs too tempted to be both provider and commissioner.

Yet the report claims to abandon PBC altogether would be a betrayal of the trust of those GPs who have engaged and would risk scuppering any future involvement of GPs in commissioning - especially as its predecessor, the Tory-brainchild GP fundholding, was abandoned as a disaster.

So what on earth can be done?

Dr Nick Goodwin, senior fellow at the King's Fund and author of the report, says new services are simply not being commissioned through PBC.

‘Where it has happened it's tended to be very small bits of work. Apart from in a few limited examples where they've really invested in the management of the whole process, very, very little has resulted.'

‘We need clarification of what the Government wants to achieve, prioritisation at every level, not just incentives, but with all the necessary support functions to make it a reality. It's pretty fundamental really.'

The report proposes GPs be handed real budgets for some services, and urges policy makers consider a ‘matrix' approach, which would allow different types of commissioning to be handled at different levels.

Dr Goodwin explains: ‘You place the budget where it can most effectively be utilised. The NHS has always wanted to place commissioning budgets in one pot; we've gone through reorganisation after reorganisation trying to decide where that is.

‘I think we should stop now and say OK, the pot sits with the PCT, and some of that can be devolved to locality level, some can be shared with the local authority and so the PCT becomes the kind of broker of the commissioning relationships.'

But he admits this will require far greater management skill than PCTs have shown to date.

The Government is of course all too well aware that PBC is floundering but has yet to convince even its own advisers it knows how to begin the salvage work.

Lord Darzi's next stage review pledged to ‘reinvigorate' PBC.

The Government's World Class Commissioning (WCC) framework, another three-letter word that no doubt has already provoked the odd four-letter one, has been talked up as the vehicle to finally hold PCTs to account.

Practice-based commissioners have also been invited to bid for regional SHA innovation funds, and a separate £100m DH pot for science and technology, which has been set aside to help PCTs meet the pledges from the Darzi review.

Yet Dr Michael Dixon, chair of the NHS Alliance, GP in Cullompton, Devon and Lord Darzi's chief adviser on commissioning, says talk has yet to be translated into action.

‘There's an awful lot of talk, but we need a sterner hand in making sure this happens,' he warns.

‘I've had assurances the innovation funds are not all going into secondary care. The difficult issue is, how does a practice-based commissioner put in a bid that matches up against a foundation trust with their 2 million surplus and huge resources? It's David versus Goliath but this time David may not win.

‘SHAs need to show they won't give priority to things like the 18-week target. PBC needs to be seen as a high priority.'

The impression SHAs that think there are bigger fish than PBC – in the absence of any real evidence of tangiable progress - has left enthusiasm waning among even GP enthusiasts.

While the latest DH figures show 46% of practices have commissioned at least one service under PBC, more than a quarter still had no indicative budget.

Sir John Oldham, former head of the Improvement Foundation, who now runs consultancy Quest and is a member of Government's PBC Implementation team, was commissioned by the DH to find out what about PBC was working.

Sir John asked each SHA to nominate the PCT it considered best performing. Of those that were identified, three were considered as ‘no more than average'.

‘There is an oasis of interest in a desert of apathy right now towards PBC,' he says, although he does claim there have been some notable successes.

One PCT-wide GP consortium reduced referrals for orthopaedics and rheumatology by 60% reduction and turned a £2m pre-PBC deficit into a £675 saving.

He has identified a series of features of successful PBC, including PCTs that offer administrative support and good quality data to GPs, as well as less tangible features such as clarity over roles and supportive leadership (see box).

But he admits those features are not found everywhere.

‘It's down to SHAs and PCTs to do their bit. But from practices' point of view, making PBC work is going to be one of the few routes for investment in primary care over the next few years. There would seem an imperative to make this happen.'

Three years after its introduction, the Government is due to publish its own ‘PBC Vision' next month and the stakes could not be higher.

Primary care tsar David Colin-Thome has been given the job of leading a national PBC improvement team to clamp down on underperforming PCTs.

Whatever the fallout from the latest criticisms of PBC, it promises to remain a core policy, even if there is change in government.

The Tories want GPs to take on more commissioning responsibility, not less, and whether they want to or not.

Shadow health secretary Andrew Lansley warns the party would also go on the offensive against conflict of interest, saying PBC is ‘about ensuring the reward to the practice is based on outcomes and results and not just on the fees and services that can be generated by placing contracts with yourselves'

He blames the top down nature of PBC for its failure to date, adding: 'This is completely upside down. If you give PCTs all this control and give SHAs all this control there isn't much left for PBC.

'Successful PBC means shifting real budgets into the hands of primary care commissioners, primary care commissioners to reinvest savings as they see fit, and not as the PCT demands

'If you are the customer you have control.'

Dr Shane Gordon, a GP in Tiptree, Essex, and chief executive of the Colchester PBC group, claims criticism of PBC ignores the success stories.

‘In the east of England, every time we meet there are new success stories,' he says, adding PBC is the only way the Government can achieve the aims of Lord Darzi's NHS Next State Review.

‘If anybody is going and implement the aims of Darzi's report, they have to engage primary care clinicians in designing and managing services. PBC is the only show in town.'

It may be the only show, but many GPs appear not to have liked what they have seen so far. The Government's latest vision will be awaited with much interest and not a little scepticism.

A winning formula for practice-based commissioning?

Features common to the most successful PCTs

Supportive PCT leadership – not only verbal, but active support and clear commitment to the principles of PBC

Clarity about roles – establishing ground rules early on. Joint process, not handed by diktat from the PCT

Timely and accurate data – SUS system widely criticised. One consortium had created it's own parallel system

Locality structure – integrated working, making meetings easier, allowing greater sensitivity to local need

Management support by the PCT – active allocation of personnel days of activity to consortia

Management allowance - varied according to total level of support. Gave practices sense of not being overwhelmed with extra work, as they could employ people to assist and locums to cover clinical work

Incentive schemes – usually a LES, with payments for coding checks and data validation, prescribing, identifying and managing frequently admitted patients

Meaningful involvement in PCT commissioning decisions – consortium leads sometimes on PEC, or on PCTs' commissioning committees.

Source: Sir John Oldham. See his attached article 'A winning formula for practice-based commissioning' for more.

PBC is at a crossroads, with Lord Darzi's pledge to 'reinvigorate' it yet to be translated into action Sir John Oldham Sir John Oldham

There is an oasis of interest in a desert of apathy

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