An investigation into the current state of play with practice-based commissioning has found that implementation of the initiative is much slower than originally envisaged by the government, and that primary care trusts are, in many cases, failing to provide the level of support and information to make it a success.

The idea behind PBC, a key component of the government’s healthcare reforms under which 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 service for patients and encourage better use of resources. “By giving practices the ability to develop new services for patients within a framework of accountability and support, PBC will improve access, extend patient choice and help restore financial balance,” according to the Department of Health.

The Commission, an independent body responsible for ensuring that public money is spent economically, efficiently and effectively, looked 16 PCTs and found that some progress in implementing PBC has been made in all of them.

Key in its uptake to date has been an incentive payment to practices and requirement on PCTs to provide a supporting infrastructure. For the year 2006/07, nearly all practices were awarded incentive payments totalling around £98 million; about half of this came from signing up to PBC and accepting an indicative budget, while the rest was conditional on PBC plans being achieved by practices, the Commission noted.

Varied engagement
However, while success has been achieved in some areas, the report found the engagement of practices and the quality of the financial infrastructure for PBC to be varied. Crucially, practices were reporting an inadequate level of support and information from their PCTs to help them better manage and get the most out of resources available. But, as the Commission warned: “PBC will not work without robust budgets and sound information”.

The findings echo those of a survey by Ipsos Mori for the DH published at the end of October, which found that less than half of practices had agreed a commissioning plan with their PCT, and over half of respondents said they weren’t getting enough support from their PCT, with 26% even going so far as to state that managerial support was “very poor”. Further evidence to suggest that the effective implementation of PBC has not been as seamless as the government had hoped.

Furthermore, the Commission’s report also highlighted a lack of adequate governance for practices’ business plans, and that doctors’ confidence in where any savings generated by successful PBC would be diverted was thin, with many savings arrangements still “theoretical, unclear or criticised, particularly where savings would be retained by a PCT to cover any overspend”, according to the report. And another barrier slowing down PBC’s success is the failure of many practices to mesh with public health staff or with local authorities to help design services that match the PCT’s strategic objectives, which is critical to managing resources, it said.

The report concluded that, while most PCTs seemed to view PBC as an important catalyst for boosting patient care and making the best of resources, to achieve the scale of service change targeted by the government “PCTs will have to improve the level of engagement of practices and shared ownership of objectives, but also address key points about the infrastructure for PBC”.

Potential not being met
Commenting on the Commission’s findings, Dr Laurence Buckman, Chairman of the BMA’s GP Committee, said it “highlights what many GPs have unfortunately known for quite a while - PBC has great potential but that potential will never be reached if PCTs continue to block initiatives and fail to support practices adequately.”

Last month the BMA conducted a survey of GPs in which nearly a third claimed their PCT was “either obstructive or uncooperative in relation to PBC”, and two thirds said resources were not being made available to support the workload.

“In the few areas where PBC is working effectively then patients and practices are reaping the benefits. At its best it can free up NHS resources, give GPs greater control over service provision and improve patients’ access to care closer to their homes. The PCTs that aren’t operating effectively would do well to look to these models of good practice,” Buckman concluded.