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An elephant in the room

This month, our diarist contemplates what should or shouldn't go into a devolved budget and finds the answer is anything but simple.

The story so far

Dr Peter Weaving is a GP and locality lead for Cumbria PCT, which is launching two ambitious integrated care pilots and – like all PCTs – is contemplating leaner times ahead. As a former chair of a large consortium he can see both sides of an argument…

‘So who's going to do that?' says one of our senior PCT managers, who would score nine on the Moh scale of hardness. Her rotating gaze comes to a halt on me and she inclines her head slightly forward, at the same time raising one eyebrow. I recognise a direct order when I see one.

‘Er, that would be me,' I croak.

‘It' was the writing of an options appraisal document on integrated care organisation (ICO) arrangements, structures and funding streams. It needs to outline the ICO philosophy – that real integration of primary care and community services will deliver better health outcomes (measured in admissions avoided, shorter hospital stays) and use fewer of those dwindling health dollars.

More important, it needs to appeal to the wonderful spectrum of human nature in our practices. It needs to inform, entice and engage them all – the practices that are straining at the leash to hold the budget, flex their muscles and take control (the tigers), to the practices who know that messing with bureaucratic nonsense like commissioning gets in the way of good doctoring. This latter group, through an accidental acronym of their practice names, has become known as the waifs. Of course, docs being docs, some of the tigers are more like Tigger and some of the waifs want to walk on the wild side.

My natural allergy to writing corporate documents notwithstanding, there are some interesting issues being thrown up by the ICO model that make detailed description challenging. Let's take a basic example – such as the budget. What's included in the devolved budget from the PCT down to the locality and its federated groups of practices? Clearly the prescribing budget, the PBC budget for all tariff-based activity – elective and emergency care, the community services budget and the GMS/PMS budgets. Not so simple!

At our last locality executive meeting, Charles, the deputy director of finance for the PCT, gave a presentation and suggested that if an ICO was receiving a lot of GMS/PMS funding its other budgets should be reduced to deliver a fair shares weighted capitation determined health care amount. Both tiger and waif factions sat in stunned silence. But not for long. Before you could say ‘My children need shoes', the chief executive of Cumbria and Lancashire LMCs was on the phone and Charles was giving the same presentation to the LMC. Charles's point is reasonable – all these budgets are coming from a finite pool and should be distributed equitably on a needs basis.

The elephant in the room is the link between practice income, services provided and expenses. If I don't replace a practice nurse and community staff pick up the workload, my personal income will go up. Conversely, if my community services budget is reduced because I have a high GMS/PMS share and I have to provide more nursing services, my income will fall.

Now, how far do you think I've got with that options appraisal document?

The perils of devolved budget assessments