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Should GPs get real budgets for PBC?

Real budgets are the only way to get PBC kick-started, says Dr Dinah Roy – but Dr Ian Greener argues that they would create more problems than they solved

Real budgets are the only way to get PBC kick-started, says Dr Dinah Roy – but Dr Ian Greener argues that they would create more problems than they solved



Practice-based commissioning will never be any more than a tick-box exercise without real incentives and budgetary control, says Dr Dinah Roy

Practice-based commissioning – what is the point? The answer is on the Department of Health website. PBC, it says, is ‘enabling frontline clinicians to redesign services that better meet patients' needs'.

But why would anyone take on PBC? Most practices feel they have enough challenges at present just doing the day job. For all the contract reviews, increasingly complex performance targets and bureaucratic barriers, our core work is seeing patients.

Nevertheless, most clinicians I know are not short of ideas for improving care. Indeed, many speak daily of real concerns regarding the quality and effectiveness of local services, which are regularly vocalised but don't seem to bring improvement.

There are two barriers that prevent those ideas for improving care becoming reality: bureaucracy and a lack of autonomy. GPs feel ignored and frustrated.

There have to be very good reasons for taking on additional work. Participation in PBC requires time and effort from frontline clinicians. The creativity required for service design and development is unlikely to be forthcoming without appropriate remuneration, to ensure that core work doesn't suffer. Our PCT supports us with a management fund, a full-time PCT manager for our group of 11 practices and by funding my time as the PBC group chair. Practices receive some remuneration for participation via a reward scheme. But

this is not enough to deliver the full benefits of PBC.

What is missing? For us, it is having real decision-making power and a real budget.

Our key challenge lies in creating a system in which frontline clinicians have that decision-making power and autonomy. PCTs should welcome this, not fear it. True autonomy is only possible where there is true responsibility for budget management. As we have found, ‘involvement and enabling' is nothing without power – we have had ‘involvement' for years and we don't feel we have made much progress.

PBC was originally intended to be incentivised by real budget-holding, but this has not been possible because of the way that our PBC budgets are constructed, particularly the non-Payment by Results elements. They are not ‘real' budgets based on global capitation and do not reflect what happens to patients. Because of this, and although the PCT has allocated ‘indicative' budgets, the information is pretty meaningless when it comes to understanding service arrangements and moving costs around the system. We have no way of knowing how the millions of taxpayers' money spent on our 92,000 patients each year are invested, or how that can be reallocated more effectively.

This also creates problems when new cash comes into the system. Because we are not true budget-holders, PCT commissioning staff prepare and cost out plans for services outside of our own budgets. All this provides a temptation to reduce involvement in PBC to a tick-box exercise.

But we have financial support from our PCT for a project to take over real management of the PbR element of our budget. We will systematically unpick services, prioritising them by referral and activity analysis. We will then design and commission alternative services where possible and retain any money released by switching referrals from the original to the new service. The budget will be held by the group as a whole. We may also include the prescribing budget.

Budget-holding will require our group to thrash out new rules of operation between practices regarding how to deal with overspends and underspends across the group as a whole. This may appear complex but we have been working together for 15 years and have strong relationships.

This is our chance to make a difference and we are determined to see it through.

Dr Dinah Roy is a GP in Spennymoor, County Durham, and chair of the Sedgefield PBC group


Handing GPs real budgets seems sensible on paper, but in practice would be expensive and could offer perverse incentives, argues Dr Ian Greener

The logic behind PBC is fairly straightforward. To make local health services more responsive, the Government should give greater power to those closest to patients (the GPs). The easiest way to give GPs more power is to give them resources they can spend to reshape local health economies to the benefit of their patients.

What the Government hasn't done yet is allow GPs real budgets to drive the process, rather than just notional ones. Neither has it put in place strong incentives to persuade GPs to set up new services and stimulate improvements in hospital care. Within the logic of the reforms, real budgets and additional incentives are a no-brainer – they are what is needed to get PBC working.

So what's the problem? Well, I find it an odd way to think about health services. The GPs I know are deeply committed to what's best for their patients. I'm sure if they have to spend their days worrying about achieving the most efficient ways to spend their money, they'll do that. But I'd rather they spent that time looking after patients. Equally, if we put in place incentives for GPs to engage with PBC, I'm sure they'll do that too. We are all human. If you offer GPs money to change their practice then, as long as it doesn't cause them any huge ethical dilemmas or obviously disadvantage their patients, they'll probably comply.

But compliance with incentives doesn't necessarily result in better care, although as human beings we tend to to convince ourselves that any changes to our practice that came about as a result of chasing incentives were in fact justified. Academics at the National Primary Care Research and Development Centre have argued that the QOF has significantly changed the way GPs work, but that they often don't reflect on these changes particularly deeply, and come to regard good-quality care as care that fits with QOF performance indicators. This shows us that incentives matter a great deal – perhaps too much to be the instrument in driving a local health reform that looks very nice on paper (especially if you are an economist) but is completely unproven in practice.

The more PBC uses real budgets, the more it will resemble GP fundholding, and I'm concerned that we don't seem to be good at learning the lessons from that earlier policy. I and my colleague Dr Russell Mannion have published papers suggesting that, at its worst, fundholding's incentive-led approach often led to reduced patient satisfaction and that GPs seemed less likely to refer when they had to pay for it from their own budgets. Fundholding seemed to have little impact on the organisation of care in local health economies – which was one of its main aims. But it imposed significant transaction costs onto GPs – the costs involved in getting the system to work on the ground. This is likely to be the case with PBC too, and the more complex the system introduced (and real budgets would be complex), the more expensive it will be to administer.

We can offer GPs incentives to care better for their patients, but my sense is that the overwhelming majority are doing a pretty good job already. It seems rather patronising to suggest that offering some kind of financial incentive is going to make them do their job better – in fact it might do the opposite. Incentives can be powerful, but I'm concerned that getting PBC working might become more important than looking after patients. We should be designing systems that support the relationship between GP and patient, rather than presuming local markets can somehow make health services work better.

Dr Ian Greener is head of taught postgraduate programmes in the School of Applied Social Sciences at Durham University and a former NHS accountant


Yes No GP budgets

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