Innovation is vital if PBC is to succeed

27 May 09

Dr Paul Charlson, GP and chair of the Conservative Medical Association, reflects on what’s held PBC back so far

When I mention practice-based commissioning to my colleagues, responses range from a glazed look of bewilderment to unprintable expletives broadly translated into ‘a waste of time and money’.

This seems to be the national sentiment. Many GPs are signed up to the process and attending meetings but not much commissioning is happening. Indeed, the King’s Fund recently called for a major rethink of PBC, citing almost £100m being paid to GPs for very little result.

So why is this? Are GPs just lazy? In my experience that is not the case. There are many reasons why PBC has faltered.

One reason is that a shift of the balance of power from PCTs to GPs has not occurred. I suspect this is partly because the Government also stated that PBC needs to support PCT priorities – and a major priority of trusts is to balance their annual budgets. Innovation threatens this goal. New services can result in short-term increased activity and costs.

Similarly, a lack of dialogue between GPs and trusts means the main priorities are far from clear. Hospital trusts, although not actively engaged in PBC, have continued to wear the trousers in regard to configuration of services and this has mitigated major service redesign.

Another reason is that the skills and priorities of individual GPs and practices within PBC groups differ. Our PCT organised us into localities, which was logical but brought together practices with disparate priorities. Individual GPs had various hobby horses, which hijacked meetings and allowed little tangible progress.

A lack of useable data and a difficulty in unbundling tariffs have also made it difficult to develop local services. Our PCT has wrestled with ‘any willing provider’ contracts, the start dates of which seem to slip and slip. Confusing, ever-changing and conflicting guidance has not helped.

The result of all the above has been predictable: disengaged clinicians, risk-averse PCTs , over-dominant hospital trusts and demoralised alternative providers.

“We must discard the mantra of equal provision - inequality is necessary if innovation is to happen.”

What started out as a good idea has so far failed. Yet it has worked in some areas. Making it work nationally will involve encouraging and supporting innovation.

We need to discard the illogical mantra of ‘equality of provision’ – some inequality is necessary for innovation to happen. Funding and opportunity should be equal across the country, but we must embrace innovation. Equality of provision means that if only some practices provide better services then it is more equal if nobody has them.

Part of enabling innovation is allowing PCTs to balance their budgets over three years rather than one. This provides an opportunity for cost-saving measures to take effect and some risks to be taken.

Another important measure is to trust frontline clinicians to develop services further. There are potential difficulties with purchasers also being providers but this should not present an obstacle if the right governance frameworks are in place.

This Government is big on regulation but this is often heavy where it should be light and, at times, the other way around. A lighter, less regulated commissioning and tendering process would help speed up the development of new services.

Given the right environment PBC can work but only if clinicians lead the charge.

Dr Paul Charlson is a GP in Brough, East Yorkshire