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This month’s Focus On... features ways to get practice-based commissioners to step back and look at the bigger picture of what PCTs are trying to achieve. Dr Donal Hynes explains the importance of focusing on areas that have the biggest financial impact

This month's Focus On... features ways to get practice-based commissioners to step back and look at the bigger picture of what PCTs are trying to achieve. Dr Donal Hynes explains the importance of focusing on areas that have the biggest financial impact

Practice-based commissioning is going to have a very different focus over the next few years. Until now the attention has been mainly on clinical pathway redesign with financial implications often a secondary consideration. But the forthcoming financial climate will place far more importance on effective use of resources.

It has often been this issue that has led to conflicts between PCTs and practice-based commissioners. In many parts of the country, scenarios have developed where commissioners have focused on a particular pathway and successfully instituted reform. But disputes have arisen over what happens to the identified freed-up resources.

In reality, the total commissioning budget has often been overspent, in spite of savings being made in the pathway that was reformed. As the PCT cannot legally set a negative budget, the first call on resources has to be to meet the overall PBC spending. And so the freed-up resources from the pathway redesign are used to meet the bigger-picture overspend.

It is at this point that many PBC enthusiasts become disillusioned.

But the problem was generated at the beginning of the process, when the priorities for areas of reform were agreed. There has been a tendency to focus on subjects where there is clinical enthusiasm for reform rather than areas that have the maximum financial impact. So although the budget may be underspent in the cherry-picked area, the fact that this makes up only a small part of the entire budget means such savings are swallowed up by the overspend. PBC has always been about the overall budget rather than individual elements.

From the outset there needs to be a sharing of big-picture priorities between the PCT and commissioners.

These lessons become even more relevant as we enter new financial circumstances. The challenge facing all PCT boards and directors of finance is no longer about how to spend the 5% increase in budget for the forthcoming year but how to deliver core services and reduce cost as well. For many, this is completely new territory and will require a new approach.

The traditional option open to directors of finance is the slash-and-burn approach, where each directorate is given a reduction target of between 10% and 30% and services are salami-sliced to meet that target.

But the more enlightened approach is to look at the overall delivery of high-cost services and to devise quality reforms that deliver the same service more efficiently and cost-effectively. And this altering of core services puts clinicians at the heart of reform. Salami-slicing can be done at a management level. Core reform needs clinicians.

So the new financial climate means that, from the outset, PCTs need to share the big picture with PBC enthusiasts. There needs to be identification of the high areas of spending increase – typically areas such as emergency admissions – and agreement that these are the areas where reform is needed.

Similarly, practice-based commissioners need to share the priorities of the PCT. So they need to not only be co-owners of the overall financial responsibilities but also incorporate the outcome measures agreed in the World-Class Commissioning process.

Practice-based commissioners need to present themselves to PCT boards as the solution to economic and other pressures. And PCTs need to ensure that PBC consortiums are embraced as partners in the delivery of core services.

The following series of articles addresses these issues. It provides tips for sharing the bigger picture effectively. It also gives examples of where trust is being built up between commissioners and their PCT using earned autonomy and finally how a PBC group has harnessed the work of existing clinical sub-groups to help build the PCT's big picture .

Dr Donal Hynes is a GP in Bridgwater, Somerset, and vice-chair of the NHS

Thinking big Thinking big

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