GPs warned choice may sink PBC

Practice-based commissioners could face cash-flow problems that force them to ration care, if patients choose private providers when choice extends nationwide.

The DoH's choice policy currently allows patients in England a choice of up to four hospitals in their area, but from 1 April 2008 this extends to all providers in the country that meet NHS criteria. Choice goes nationwide for orthopaedics from 1 July 2007.

But DoH guidance reveals that GP commissioners could be forced to pay up to 40 per cent more for operations with non-NHS providers, although the cash will be returned later.

Under Payment by Results, commissioners pay a fixed tariff per operation, equivalent to the price of an operation in the lowest-cost area in the country, Cornwall. The DoH then tops up the income providers receive to reflect regional variations in the cost of providing services. This top-up is calculated by multiplying the tariff by a provider's 'market forces factor' (MFF).

The higher cost of wages and infrastructure in London - the most expensive part of the country - means the total amount paid to a provider there would be 40 per cent higher than the fee due to a provider in Cornwall.

All operations commissioned from NHS providers have an identical impact on commissioners' budgets - they pay the tariff, and top-ups are settled at the end of the financial year by the DoH.

But guidance released last month said PCTs have to pay the tariff plus MFF in full immediately when they commission services.

The DoH document Choice at Referral: Guidance for 2007/8 says: 'For activity commissioned from independent-sector providers via the national menu, PCTs will be invoiced at tariff x MFF during 2007/8.'

National Association of Primary Care (NAPC) executive member Dr Tim Richardson said: 'If patients go to independent-sector providers in high MFF areas, commissioners will have a cash-flow issue. This may mean PCTs put pressure on GPs not to use independent-sector providers.'

NAPC chairman Dr James Kingsland said: 'This is a potential incentive not to refer to independent-sector providers.'

Dr Kingsland agreed there was a risk when choice extended that people may choose to travel for operations 'if waits were long'.

Independent-sector treatment centres will eventually carry out 10 per cent of elective procedures, the DoH has said.

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