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Where to splash the cash?

Our protagonist has the power to decide which PBC schemes to pump-prime – and it’s fraught with dilemmas

Our protagonist has the power to decide which PBC schemes to pump-prime – and it's fraught with dilemmas

The story so far

Dr Peter Weaving is a GP in north Cumbria, whose PBC experience has ranged from chairing a large consortium to his current role as a locality lead for Cumbria PCT.

PBC has been going since 2005 – theoretically long enough for us to have got to grips with the basics, such as holding a budget, monitoring acute hospitals' performance, validating the sea of data and, most importantly, spotting those service developments that will deliver both for your patients and your balance sheet.

It's the changes in the way you commission services, or indeed provide them yourself, that has been the real dilemma, as your poor diarist has had to confront over the past year. Step into my shoes…

You are the clinical lead for 100,000 patients and their dozen rural practices, which range in interest and ability from cutting-edge to hedge-cutting. Your kindly PCT – in a moment of madness – has given you £100,000 to pump-prime and incentivise practices' ingenuity and stimulate the delivery of care that is closer to home and easier on the wallet.

You've drawn up a decision-making board bristling with governance, public health, probity and patient involvement members. You're heavy on financial ‘advice' from the PCT and perhaps a little light on employment law, but you're up and running. Throw the doors open and let's see what the practices come up with.

First on the table, an easy one – a couple of grand to set up a local anticoagulation service. No problemo! What a pity we blew a third of a million quid last year on the one run by the acute trust, which billed us for an outpatient haematology consultation for every single venepuncture.

Next we have another no-brainer – start-up costs for a practice-based ophthalmology service. This will be run by one practice's GPSI for all practices. He has every known eye qualification, comes complete with mentoring at the acute trust, bills at less than 80% of tariff and everybody loves him.

Now we have a proposal for a gold-plated psychological service – cognitive behavioural therapy, counselling and management of post-traumatic stress disorder – to be provided in-house.

This has been catalysed, perhaps, by the receipt in the practice of yet another letter from the primary care mental health team stating that, when they contacted Mr Smith about attending for his first session, he ‘declined to make use of their service at the present time'.

Well that's because poor Mr Smith was referred in 2005 and, since you don't have a devolved mental health budget, you can help neither Mr Smith nor Dr Jones, who will just have to continue to provide primary care mental healthcare in the time-honoured way for seven-and-a-half minutes once a week.

Your final conundrum involves stirring up both the PCT's physiotherapy service and the orthopaedic department. One large practice has teamed up with a private physio firm and a local non-NHS chiropodist to establish an alternative biomechanical foot and ankle service with extended-scope physio screening of all orthopaedic referrals.

Since your biggest elective spend is orthopaedics, and foot and ankle referrals are head and shoulder above the rest of the joints, you will support this one. Or won't you?

Now this is where it gets tricky. The practice would like some capital costs and, initially, running costs for their scheme. But it is an independent provider, albeit a small one.

At the same time your PCT's provider arm announces it would like to provide an identical NHS service. Will the national guidance, with which your board is so familiar, get you out of this one?

The technically correct answer is to approve both services, put them on Choose and Book and let them sink or swim in the currents of referral market forces.

But you know if you choose that option, the independent sector plan is too fragile and will never be launched and you will not fulfil your other obligation under Department of Health guidance to encourage contestability and a plurality of providers.

After three rites of passage through the decision board you get out of your cleft stick by agreeing to fund the independent sector start-up with NHS money on the basis that you will recoup it through reduction in orthopaedic spend further down the line.

Will this all result in a leaner, more effective health service or simply hunter-gatherer mentality and the demise of the Neanderthal trust? While you ponder that, you've got the other small matter of doing your day job as a GP.

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