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We must move beyond PBC

Dr Judith Smith, head of policy at the Nuffield Trust, advocates a new model that would make PBC more appealing to clinicians

The NHS is facing possibly its greatest management and financial challenge for a generation. It is crucial that GPs and other clinicians are engaged in decisions about how patient services are designed and delivered and how NHS money is spent.

PBC has had limited success in engaging GPs to change local service delivery. With PCT commissioning similarly struggling to transform services, the time is right to come up with ways to boost commissioning. The answer may lie in multispecialty groups of clinicians – for example, hospital specialists as well as GPs – joining forces to form new organisations that take on real budgets and responsibility for designing, delivering and commissioning local health services.

This was the theme of a recent report published by the Nuffield Trust and NHS Alliance. We believe these local clinical partnerships would address a fundamental problem for PBC – that there are few incentives for GPs to take on greater responsibility for commissioning.

Critics may argue this is just another organisational change to make the heart sink, but we disagree. Under the current arrangements GPs hold only notional budgets – they are unable to redirect significant resources to get hospital and community services closer to home, and the level of savings kept must be negotiated with the PCT. But local clinical partnerships would hold budgets that are population-based, real, capitated and risk-adjusted.

Although there is little appetite for more large-scale reorganisation, we believe local clinical partnerships could evolve from existing arrangements – in particular, foundation trusts, social enterprise models and multiprofessional partnerships.

This would change the role of the PCT, which would become a funder, setter of priorities, performance manager and allocator of risk-adjusted budgets, especially if they continue to reduce their role in managing community health services.

The PCT would have a key role in designing, implementing and monitoring contracts, and in devising and assuring robust ways to assess financial performance, health outcomes and patient experience.

Some local clinical partnerships might source their management and infrastructure support from PCTs. Or they might seek support from other sources, including the private sector. This could reduce the number of PCTs with a pure commissioning role, holding the contracts with local clinical partnerships and other providers. However, the evidence warns against centrally imposed reconfiguration – instead, PCTs would evolve into new, larger entities when local clinical partnerships were in place.

Much would need to be done to make this a reality, not least in terms of aligning personal and organisational incentives for clinicians and renewing GMS and PMS contracts. But this approach might engage a generation of clinicians who have had few opportunities to take responsibility for, or see the benefits of, budget-holding and service development. Indeed, it might revitalise local commissioning, improve patient care and save the NHS money just when it needs it most.

Dr Judith Smith is head of policy at the Nuffield Trust

Beyond Practice-Based Commissioning: the local clinical partnership, by Dr Judith Smith, Julie Wood and Jo Elias, is free to download from