A new report from the influential Kings Fund think-tank warns that GP practice-based commissioning (PBC) is still failing to deliver. The report, Practice-based commissioning – reinvigorate, replace or abandon?, is based on new research, and confirms the findings of previous reports on PBC. PBC is a core DH policy to the development of world-class commissioning (which is basically the iterative analysis of local populations’ health needs, and the redesign of services to meet these needs in the community where possible).

PBC is intended to increase the involvement of GPs in commissioning decisions, since they are responsible for the allocation of around 75% of the NNHS budget with their treatment and referral decisions. However, the principal complaints about PBC have been that the data and management resource (both in capacity and capability) provided by local NHS primary care trusts (PCTs) to PBC consortia have been too slow, late or incomplete and inadequate to meaningfully inform PBC commissioning decisions.

Furthermore, although PBC consortia are menat to receive budgets, these are indicative only (i.e. no real cash is associated with them), and ‘freed-up resources’ through savings from PBC are rarely apparent in most cases.

The Kings Fund report says that “Progress to date has been slow in all sites: 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.

“Where initiatives have been developed, they have tended to be small scale, local pilots focusing on providing hospital services in community settings. Few practice-based commissioners have taken an interest in wider commissioning activities. Whether this represents a failure of the policy depends on whether it is seen as a mechanism for achieving widespread change, or as a more modest lever for enabling small-scale innovation.

“PBC has been partially successful in encouraging GPs to become more engaged in commissioning and budgetary decision-making, but this has generally been limited to a small group of enthusiastic GPs in each PCT. The majority of GPs were supportive of the principles of the policy, but this has not translated into active engagement, with most GPs reporting that they were happy to observe passively and let others lead on their behalf”.

Barriers to PBC progress
The report also identifies the mian barriers to progress as data; capacity and capability; roles and responsibilities; local relationships within health economies; conflicts of interst; governance issues and wider policy and operational contexts.

It suggests that “a ‘matrix’ model” is needed for PBC, “that recognises the multilayered nature of commissioning and the fact that certain types of commissioning are best performed at different levels … responsibility for strategic, population-wide commissioning would remain at the PCT level, but would be informed by a panel of GPs and other primary and secondary care clinicians who would be provided with incentives to play an advisory role. This would seek to build on the positive relationships that have emerged in many cases as a result of PBC”.

The report also calls for PBC consortia to get real budgets in tightly-defined areas (thus becoming statutory organisations ), which follow PCT strategic direction but can gain ‘earned autonomy’ (in the same manner as NHS foundation trusts have) through high performance.

Welcoming the report, NHS Alliance, which represents primary care and has been strongly supportive of PBC, state that its findings “exactly echo the NHS Alliance’s nationwide information on progress”. NHS Alliance chair Dr Michael Dixon GP called for PBC to be given “real teeth”, suggesting that hospital discharge information should be altered toinclude financial information about treatments performed, thus effectively becoming the ‘invoice’. Such letters are frequently sent so late as to be useless for practical purposes of checking on activity and outcomes: however, under NHS Alliance’s proposal, “if the letter is late or inaccurate, payment would be delayed”.

Dr Dixon said, “there should be no excuse for failing to provide budgets and accurate financial information to practice based commissioners. Yet that is exactly what has been happening. It is often not the fault of PCTs but of the system above them.

“The King’s Fund is right to say that urgent action is necessary to overhaul PBC. But that action need not be complex or costly. The simple solution we have proposed would transform commissioning by putting the power where it should lie – with the commissioners instead of, as at present, with the acute sector.

“If providers find they do not get paid unless they do the job properly, that would sharpen everyone’s performance. And it would also enable practices and PCT commissioners to become fully engaged in NHS decision-making.”