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What size is our destiny?

Our diarist considers what the future holds and wonders whether PBC will stand the test of time in its current form.

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 facing lean times ahead. As a former chair of a large consortium, he can often see both sides of an argument...

‘Peter, this is not good use of my time. I want to see patients, not waste afternoons in management meetings. You may like it, but we do not. Are you listening to me? PETER?!'

I snapped out of my reverie and returned to the practice meeting as Carol's decibels rose. We were discussing the implications, at practice level, of being part of a federated grouping with other practices for commissioning purposes.

This prospect throws up a number of questions. For example, how much time would it take to sit down and integrate with the community staff or indeed merge district nursing with practice nursing? What would be the effect on workload and staffing if, for example, the diabetes nurse started seeing patients in the community (and ours is a far-flung rural one) instead of a practice-based clinic? Her productivity would drop from seeing a dozen patients a session to less than a handful.

How much time would we spend working out detailed commissioning plans for a diminishing healthcare budget that became increasingly inaccurate the further down it was devolved?

It was these and other knotty problems that were, quite reasonably, exercising Carol and the rest of my partners. I felt doubly guilty because, as I am the PCT's locality lead, my partners should be ahead of the game on this. But like the cobbler's children, their needs had been somewhat overlooked.

However, that was not the subject of my meditations. No, while we debated commissioning for a few thousand patients, I was at the other end of the spectrum and thinking about the county-wide health economy for half a million people. In some ways PBC has failed us in Cumbria – it has not delivered enough service changes to ensure future stability. We have got by for now but we will struggle in the financial future we expect. We are not going to count our way out of trouble by creative accounting or challenging coding.

So the internal market has not sorted healthcare for Cumbria. Indeed, that market has blocked change because of its failure to stimulate a market mentality – because rural healthcare will always be a monopoly. So perhaps we should take a different approach. That approach could be a single vertically integrated organisation providing community, primary and secondary care for its hundreds of thousands of patients. It would be clinically led by individuals whose only loyalty was to deliver the best healthcare in the most appropriate setting – whether the city's modern ICU, a ward in the community hospital or the patient's own home.

Do you see the dilemma? Do we go smaller to deliver better, more effective care or go large – perhaps very large – leapfrogging yesterday's polysystem to form an HMO covering half a county?

Carol gave me a hard stare. ‘Next on the agenda is the practice barbecue,' she said firmly.

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