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Practice based commissioning is failing to deliver the benefit for patients envisaged by the government because of a lack of incentives to get GPs on board, says the public spending watchdog.
The policy to devolve responsibility for commissioning services from primary care trusts to general practices at the local level was introduced in 2005-6 and is a main plank of the NHS reform programme. But the Audit Commission says it is suffering from poor support from primary care trusts for GPs to develop projects—including accurate information on budgets, what savings have been made, and how these savings could be used to develop other services.
“Unless you get the financial infrastructure right it [practice based commissioning] won't work,” said Andy McKeon, managing director for health at the Audit Commission.
For its new report the commission interviewed staff at 16 primary care trusts and three general practices and conducted a survey of 623 general practices, to which 122 GPs and practice managers (20%) replied.
“The scale of service redesign achieved through PBC [practice based commissioning] has been modest so far,” says the report.
Most practices reported that they had neither the resources nor the time to implement commissioning; only 18% of practices responded positively to both questions. Nearly three quarters of survey respondents said that their primary care trust was not supporting them in building capacity to implement commissioning, and more than two thirds said they were not “sufficiently incentivised” to engage with the policy. A number of GPs said they were more interested in achieving a high quality and outcomes framework (QOF) score, which detracted from their attention to commissioning, says the report.
“It has been a slow start, which had been hampered by PCT reorganisation in a number of places,” said Mr McKeon. GPs' engagement with the policy has been variable, he said, and was led largely by a “small group of enthusiasts, many of whom have a history of GP fund holding” and other similar schemes.
Steve Bundred, chief executive of the Audit Commission, said, “At the moment patients are losing out because they are not benefiting from the service improvements which practice based commissioning can provide.”
Although the Department of Health reported that in April 2007 nearly all general practices have received incentive payments totalling an estimated £98m (€140m; $202m) for signing up to practice based commissioning and for achieving their commissioning plans (BMJ 2007;334:922 doi: 10.1136/bmj.39202.341609.DB), this was not a sign that the policy was delivering what it promised. “Genuine engagement . . . requires practices to be actively managing indicative budgets,” and this was not true in many cases, says the report.
Among those GPs who had been given a budget some had not understood the nature of the policy. “It was clear that many practices were more interested in using their budgets for the direct provision of new services rather than to commission others,” says the report. “In both cases there needs to be more consistent provision and proper assessment of sound business cases to ensure best use of the funds available.”
It also says that little evidence was shown that practices were engaging with public health staff or with local authorities to match resources to the strategic objectives of primary care trusts.
Although almost half the respondents to the survey said that they were using public health data to inform how they used their resources, “the evidence from our fieldwork visits indicated that the provision of practice level public health information was very limited,” says the report.
Putting Commissioning into Practice: Implementing Practice Based Commissioning through Good Financial Management is available at www.audit-commission.gov.uk.