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The government says that practice based commissioning offers potential benefits for patients and doctors alike, and GPs seem keen to explore the possibilities, so why does it feel like the engine won't start? Zosia Kmietowicz investigates
On paper the idea of practice based commissioning, a major plank of the government's modernisation programme for the NHS in England, seems to be a remarkably simple proposal, with few risks and potentially many gains.
The theory is that if general practices are given control of their own budgets for commissioning secondary care and community health services, the number of referrals to hospitals will fall, cutting hospitals' running costs along the way. With greater autonomy, GPs will also gain the freedom to exercise their entrepreneurial and clinical skills for the good of their patients by developing community services according to local needs.
And by providing expert care closer to patients' homes through “super clinics” in the community, GPs get to keep patients within their sights, delivering true follow-up of care and reaping professional fulfilment.
So what could possibly go so wrong? Why did Hamish Meldrum, chairman of the BMA's General Practitioners Committee, last week declare the scheme a “shambles”?
The Department of Health launched practice based commissioning in 2004 as part of the NHS improvement plan to “put people at the heart of public services,” and GPs were able to take part in the scheme from April 2005.
Despite its uncanny resemblance to fund holding—the system that the Tories introduced in the 1990s to increase GPs' financial responsibility for referral and prescribing but that was scrapped soon after Labour came to power in 1997—support for practice based commissioning has been widespread among GPs and their leaders.
The government figures show that 96% of general practices have received the first part of the directed enhanced service (DES) payments for signing up to the principle of practice based commissioning (BMJ 2007;334:922, 5 May doi: 10.1136/bmj.39202.341609.DB). And all primary care trusts are “providing practices with the budgets, information, incentives, and accountability and governance arrangements to take on practice based commissioning,” the government says.
However, general practices report that implementation is being stalled and commissioning plans are being hampered by absurd bureaucracy and scant support from primary care trusts.
James Kingsland, a GP on the Wirral and chairman of the National Association of Primary Care, disputes the government figures on take-up of commissioning and criticises trusts for delays in getting projects off the ground.
Of 800 GPs and practice managers he recently questioned at meetings where he spoke about commissioning, Dr Kingsland said that less than a fifth indicated by show of hand that they had received the full DES payment.
Half of the payment of £1.90 (€2.80; $3.80) per patient is paid up front, to allow GPs to start planning to buy in services. The second half of the payment is released when practices meet the objectives outlined in their plans.
Although Dr Kingsland admits that his evidence is “soft,” his findings among practice staff who are at the “cutting edge”—committed to practice based commissioning and already engaged in it—fall far short of the uptake rate being touted by the Department of Health.
Two other questions that Dr Kingsland put to audiences—“Have you got a devolved indicative budget for practice based commissioning?” and “Are you receiving regular hospital activity data from your primary care trust?”—were met with laughter from practice managers. He estimated that less than 10% had budgets or the data to start challenging current activity in secondary care.
Maggie Marum, a management consultant at the National Association of Primary Care, said, “The vast majority of practices have not received indicative budgets in 2006-7 and in 2007-8. Many have not received any data in 2006-7 on which to base commissioning and service redesign decisions, and those which have comment that the data is neither accurate nor timely. And because the second part of the DES has only been paid in a few PCTs [primary care trusts], there is little prospect of real engagement on the part of practices in the current financial year.”
If practices make savings through commissioning, they are allowed to keep 70% to reinvest in services. But again, Ms Marum said that “most practices tell me that their PCTs will not agree to release any saving made because of the financial deficits they are experiencing.”
Although he is not critical of Wirral Primary Care Trust itself, Dr Kingsland said that his own practice has been genuinely frustrated by what should have been a simple project for the trust to approve. The project—to take over the phlebotomy service from the local hospital so that patients can have blood tests in the practice—is worth only £6000, a “tiny little insignificant change,” Dr Kingsland said. But it was held up at the primary care trust's committee stage 12 months after it was first conceived, and the experience has left the practice's staff ready to throw in the towel.
“We had planned to redeploy any profits from running the phlebotomy service into paying for a clinical psychologist service. But now she [the clinical psychologist] has been employed elsewhere, and we have lost all our momentum and enthusiasm,” Dr Kingsland said.
Ms Marum said, “There is also almost universal resistance across the NHS to GPs holding indicative budgets.”
Brian Palmer, chairman of Essex Local Medical Committee, said that primary care trusts' financial difficulties and their short and turbulent history have led to nervousness within them.
“PCTs have only been in existence for six months, and they are now being told that they have to share their power. It would take a phenomenally strong management to be able to do that,” he said.
Stewart Drage, joint chief executive of the Londonwide local medical committees, struggles to name two primary care trusts out of 24 on his patch with successful commissioning projects. General practices in London face several problems, he says.
“There is no incentive for primary care trusts to do it [hand over commissioning to general practices], because it is a reduction in their role if they hand over control to practices. Trusts are in deficit, and there is a large amount of distrust between GPs and managers, with little signs that they [at the trust] are going to build a protected resource for commissioning,” Dr Drage said.
Cynics might point the finger at GPs for being partly responsible for the financial struggles in the NHS over the last 12 months. Not only did they secure an average 30% rise in income with their new contract, but they also seem unable to implement government policy without financial enticement, even when it is to their advantage and to that of their patients.
But Dr Drage protests that the incentive payments are “a drop in the ocean.” Even if GPs have to find funding from their practices to set up commissioning, “It is in their interests to protect their business, because if GPs don't get involved then the private sector will,” he said.
Dr Kingsland would like to see non-financial incentives offered to GPs in the form of leadership and management support from trusts and a two week turnaround for authorising plans for commissioning.
A health department spokesman said that “practice based commissioning is here to stay.” And Dr Palmer believes that practice based commissioning is still a very good idea and potentially very important. “It is crucially important for us to get involved, because if we don't we could end up with others doing the commissioning—PCTs, or worse,” he said.
And if primary care trusts don't play ball? The health department advises practices to buy in their own support.
The spokesman said, “SHAs [strategic health authorities] will be assessing the support PCTs provide for practices engaging in practice based commissioning. SHAs will work with PCT and trust leadership where they are failing in their duty to cooperate in the redesign of health services for the benefit of patients.”