ractice-based commissioning (PBC) cannot succeed as it now exists, because it is not in the interests of any of the vested parties for it to succeed – Primary Care Trusts (PCTs) lose control and practice-based commissioners only gain bureaucracy, a new report warns.

PBC needs to be strengthened if it is to survive and deliver the improved, efficient patient outcomes for which it was originally designed, but active political “contamination” and passive resistance by the various vested interests already in the system should not be underestimated, says author Dr Jonathan Shapiro, a senior lecturer at the University of Birmingham Medical School.

The term “commissioning” is a “weasel word” that has come to encompass all aspects of procurement, including strategic planning, service procurement and monitoring and evaluation, Dr Shapiro says in his discussion paper, which is entitled Practice-Based Commissioning: Not what it says on the tin, and is published by 2020health, a centre-right think tank for health and technology, with sponsorship from Sanofi-Aventis. But, he adds, the simplicity of the term is misleading and hides some “grating discords.”

As strategically-focused organisations, PCTs should carry out the strategically-focused tasks of commissioning, he says. Their role is to oversee their local health economies and facilitate the provision of health care without becoming embroiled in its day-to-day delivery, and their performance should be measured around this mission.

They are less well-placed to cover the other aspects of commissioning – the mechanical aspects of service procurement and organisations that are more grounded in real life. Such tasks, plus their monitoring and evaluation, is what was originally intended for practice-based commissioners, with their knowledge of clinical matters, and their ability to challenge hospital activity and judge the quality, timeliness and appropriateness of the services they received.

PBC also gave these commissioners the incentive to carry out these activities well, giving them a better sense of “ownership” of their patients’ problems and incentivising them to do more and spend less. The aim was to encourage practices to decide how much they did themselves and how much they wanted to subcontract elsewhere.

But, says Dr Shapiro, PBC is not functioning in this manner, for a number of reasons, including: - confusion as to the respective roles and responsibilities of general practitioners (GPs), PBC clusters and PCTs; - lack of mature relationships among stakeholders; - complexities around the management of financial and clinical risks; - general lack of capacity and capability; - perceived conflicts of interest at GP level and in the PCTs; and - wider factors such as changing political priorities.

The heart of the problem may be the fact that there is rarely any linkage between effort and perceptible reward, whether this is defined in terms of status, job satisfaction or money, and the challenge is to construct a system with enough personal incentives to drive performance without political or social difficulties intervening. The philosophy underpinning PBC has the potential to offer incentives whiles ensuring equity, quality and value for money, says Dr Shapiro, and he believes that it would not be difficult for the system to be fine-tuned to achieve this.

Moreover, he says, the Department of Health should create and maintain some distance between the NHS and itself, so that the day-to-day operation may run with as little political influence as possible. Without these changes, and if PBC is not seen to make a significant impact, then its current moribund state will become terminal, “and an important opportunity to engender real cultural change will have been lost,” he warns.