Doctors are still largely committed to the government’s flagship health policy of practice-based commissioning, but key barriers remain that are holding back its potential in improving patient care, a report by independent think tank The King’s Fund has found.

Introduced in 2006, the idea behind PBC - whereby primary care trusts are given their own budgets to make local decisions on what to commission - is that it will foster better clinical engagement, provide a better, more tailored service for patients, and encourage better use of resources.

But the reform policy was beset with problems right from the start, with many practices reporting a lack of support and information to help them set up the necessary infrastructure, and others flagging the absence of adequate governance for any commissioning plans, excessive bureaucracy, national targets and structural reorganisations as major problems holding back its uptake.

Just last month a new report by Dr Jonathan Shapiro, a senior lecturer at the University of Birmingham Medical School, claimed that PBC cannot succeed in its current state because fundamentally it is not in the interests of any the parties involved for it to succeed, as primary care trusts lose control and those commissioning services only gain bureaucracy.

And this followed a King’s Fund report from late last year, which warned that PBC is still failing to deliver on its promises and that progress has been slow. According to the report Practice-based commissioning – reinvigorate, replace or abandon?: very few PBC-led initiatives have been established and there seems to have been little impact in terms of better services for patients or more efficient use of resources”.

However doctors remain optimistic about its potential to improve patient care. In a survey of 320 GPs, practice and PBC managers, published last week by the think tank and NHS Alliance, 78% said they were firmly committed to the policy and 72% felt that care improvements could be achieved within the next two years.

But respondents also described what they felt are still key obstacles getting in the way of PBC’s success, with: 52% reporting that they did not feel very or at all engaged by their PCT; less than half agreeing they were receiving enough support from their PCT; and 29% of those who had submitted a business case noting that, on average, it takes at least 25 weeks to get the go-ahead.

New vision
The government is, however, making some moves to address these issues, and maintains that PBC plays a vital role in the reform of health services. Earlier this year, the
Department of Health unveiled a new vision for PBC to help breath new life into the policy and accelerate its uptake. For example, to address lack of information and support from PCTs a new accountability process has been introduced under which trusts will be assessed on their commissioning skills and expected to reach certain targets. In addition, trusts now have to provide every practice with an indicative budget and an agreed management and financial support package by May 1 every year, and are also required to agree PBC incentive schemes to help promote better health and better value.

According to the survey, many respondents have reacted positively to the government’s new vision for PBC, as it has helped to generate more optimism amongst healthcare professionals about the policy and also puts clinicians at the centre of commissioning.

“We are pleased to see that commitment to practice-based commissioning is on the increase and that people feel positive about it,” commented Julie Wood, co-author and director of the NHS Alliance’s PBC Federation. And while she conceded that many issues need to be addressed, particularly regarding engaging clinicians and other health professionals at local level, “the fact that the NHS is heading towards a deep financial crisis makes the case for PBC even more compelling,” she said, claiming: “PBC is the only answer in terms of re-creating a cost-effective NHS through involving clinicians, who directly affect NHS costs, and galvanising local support to sometimes difficult issues of prioritisation”.