Can PBC success be salvaged?

28 Nov 07

‘Practice-based commissioning is here to stay,’ insisted health minister Ben Bradshaw recently, as he sought to stem the growing tide of uncertainty surrounding the flagship Government health policy.

Yet if his words are not to come back to haunt him, drastic action is surely now needed.

This week yet another report, this time a document pulling no punches from the Audit Commission, has heaped criticism on PBC’s limited impact on patient care.

Practices received nearly £100m in incentives in the 2006/7 financial year, yet the report finds while in each of the 16 PCTs it studied, there had been some progress, the results were massively variable and too often led by hard-core enthusiasts. The majority of practices were unclear if budgets had been set, unsure of the financial risks and hampered by appallingly unreliable data.

The report found nine of the PCTs it studied had seen PBC grind to a halt because of reconfiguration.

Two ‘trailblazing’ PCTs – Craven, Harrogate and Rural District in North Yorkshire and South Hams in west Devon – which had been held up as examples for the rest of the country, were subsequently merged into Devon and North Yorkshire and York PCTs respectively and were now ‘effectively starting from scratch’.

PCTs’ ‘inability to make decisions’, reflected in infuriating delays in GPs being given budgets, was just part of a sorry tale of incompetence exposed in the report. Both PCTs and GPs cited the infamous Secondary Uses Service, memorably described by one PCT boss as ‘the most crap system ever’, as the key barrier to accurate information.

The report says this is a ‘critical’ area, with quarterly hospital activity data routinely arriving with practices and PCTs three months after the end of each period, making it worthless in managing budgets in the eyes of nearly 70% of GPs surveyed.

However, GPs do not escape the wrath of the commission.

The report claims practices are ‘more interested in increasing their own provision than commissioning from others’ and calls on PCTs to clamp down on ‘potential conflicts of interests’ among practices. There is, it says, ‘little evidence of GPs engaging with PCTs about meeting local health objectives’.

Dr Michael Dixon, chair of the NHS Alliance and now health minister Lord Darzi’s adviser on commissioning, claims the report could be the turning point which sees PBC start to achieve its potential to ‘transform the health service’.

PCTs and GPs thus far, he says, have been ‘blinded by lack of timely, usable information – and straitjacketed by national targets’. But Dr Dixon admits he has yet to get firm backing from Lord Darzi for his plan for 10 model PBC pilots, one in each SHA, in which GPs would receive far more devolved budgets.

Dr James Kingsland, chair of the National Association of Primary Care and another of Lord Darzi’s advisers, does not share Dr Dixon’s hopes for the report. ‘I remember sitting with former minister Andy Burnham this time last year, saying we’re at a critical stage for the service,’ he says.

‘But people still don’t understand it. I’ve actually just responded to an email from our PCT, which is a good example. It says, please would you consider sitting on modernisation teams to look at care pathways for COPD, oxygen therapy, and A&E attendances. Isn’t this what PBC is supposed to be doing?

‘We have to come up with solutions now rather than just going over old ground otherwise PBC hasn’t got a chance.’

Dr Ranjit Gill, a GP in Stockport, Manchester, says that in many cases ‘PCTs are not clear on what the purpose of PBC is, and GPs do not really under-stand the skill and complexity of commissioning.’

But Dr Alex Williams, a GP in Devon, says things are finally moving in the right direction. ‘We were frustrated we had to jump through more and more hoops, but having done that, the money now seems to be becoming available.’

GPC chair Dr Laurence Buckman says: ‘This report highlights what many GPs have unfortunately known for quite a while. PBC has great potential but that will never be reached if PCTs continue to block initiatives and fail to support practices adequately.’

The report also makes clear that GPs have to play their part. But, as Dr Kingsland asks: ‘How many of them will bother reading it?’