Leader: Commissioning is matter of faith

The long-awaited DoH guidance on practice-based commissioning promises much. As well as being paid up to £1.90 per patient under the directed enhanced service, the guidance says GPs should be able to keep at least 70 per cent of savings.

But look closer. In fact, GPs will only be able to keep the savings provided their PCT does not need them to reduce overspends in other areas. In addition, health minister Lord Warner says there are no plans to enforce the guidance. GPs should 'start from a position of trust until proved otherwise', he says.

So the rewards for practices that take on practice-based commissioning will be dependent on the financial management of their PCT. Lord Warner says only six PCTs are in financial difficulty at present, so he does not expect this to be a real problem. But what about the next year and the years after that?

NHS patients are being promised access to new expensive treatments, but PCTs are not receiving extra funds. The NICE ruling that statins should be available to patients with a 20 per cent 10-year risk of a cardiovascular event makes an extra 3.3 million people eligible. Even when a treatment is not recommended by NICE, it seems PCTs are now obliged to consider it, as with Herceptin. It is a tall order to ask GPs to put their trust in PCTs in such a climate. Even now, one third of PCTs are not spending to the minimum floor for enhanced services.

The DoH is keen to move services from secondary to primary care, but PCTs must be made to realise that in order to save money in secondary care, they have to spend in primary care. Allowing practices to keep savings from practice-based commissioning is vital because it will allow them to invest in the infrastructure necessary to increase the range of services that GPs offer, which will create future savings.

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