What is holding back the spread of PBC?

Big savings are possible through PBC, but not all GPs have had a chance to get involved. Tom Ireland reports.

In some PCTs, practice-based commissioning (PBC) is freeing up millions of pounds a year, while others are saving nothing, a GP investigation reveals this week.

If the £6 million saved through PBC in NHS North Yorkshire and York last year is proof that PBC can be successful, how can so many trusts have failed to identify any savings at all?

Of 62 PCTs surveyed, over a fifth (22 per cent) confirmed that no savings were made in 2007/8 from PBC. That a further nine trusts could not even provide an answer is just as troubling - managing a budget seems too great a challenge for certain PCTs.

NHS Peterborough, for example, claims its 'finance systems are not intelligent enough' to work out if its PBC schemes are saving the trust any money.

Reasons for variation
Dr Michael Dixon, chairman of the NHS Alliance, believes there are many reasons why PBC savings are so varied.

'In some cases it is because savings have not been made. In some cases I'm sure the figures aren't completely accurate. And of course in some cases the whole PCT is in deficit, so money will often disappear that way.

'But the most pertinent question is whether PBC is effective or not in that area.'

Dr Dixon believes PCTs that have failed to make savings will all share one characteristic - they have not motivated their GPs to get involved.

'Motivation is feeling that you are able to make a difference,' he says. 'If you feel like decisions are made elsewhere, and you are becoming the whipping boy for financial deficits, then why would you get involved?'

Dr Kailash Chand, a GPC member based in Ashton-under-Lyne, Lancashire, believes the poor relationship between GPs and the DoH has undermined interest in PBC.

'GPs are concerned about MPIG and contract impositions - PBC is not a priority,' he says.

Where GPs have taken on PBC, PCTs have not always stuck to the rules. Practice-based commissioners should receive 70 per cent of any savings they generate to reinvest. But Dr Jane Lothian, medical secretary for Northumberland LMC, says local PBC groups were receiving much less.

'PBC is getting a lot better but our trust has been in deficit since who knows when. PBC groups were given back substantially less than the guidance suggested.'

What GPs think of Practice-based commissioning
  • "Some practice-based commissioners think they are heading for a nice little surplus and then the money disappears somewhere else at the end of the year." Dr Michael Dixon, NHS Alliance chairman
  • "There was initially enthusiasm, but I think four years down the line, it's been so difficult to do anything - we can't access the savings." Dr Jane Lothian, Northumberland LMC medical secretary
  • "The bottom line on PBC is that there remains a great deal of frustration in general practice. The process is just torturous." Dr Nigel Watson, GP and Wessex LMCs chief executive

Measure of success
Dr Mark Spencer, PBC lead for the NHS Alliance in the north west of England, argues that cash savings are not always the best measure of PBC. His PCT, North Lancashire, has generated no savings, yet he believes PBC is working well there and across the North West.

'Within my own PCT there have been some very good service redesign ideas. It has certainly improved patient care in areas deemed to be priorities, which is what PBC is about.'

Dr Spencer argues that other factors beyond the control of PBC consortia can affect PBC budgets. A surge in costly elective care this year, for example, has thrown PBC spending off course in some areas.

A recent study by the King's Fund however, says that although £100 million has been spent on incentive payments to GPs so far, more funding is needed to get them involved.

However, Dr Chand feels providing GPs with support and relevant skills is more important. 'We as GPs are not trained - we need the managerial skills to run these schemes,' he says.

Dr Dixon believes that the DoH's relaunch of PBC this year will identify the weak areas and force them to change.

'GPs need the power to demand help where things aren't moving. By the end of this year, those who aren't keeping up will be in the minority and under great pressure to improve,' says Dr Dixon.

However effective a relaunch is, shadow health secretary Andrew Lansley may prove to be the most influential figure in the future of PBC.

With a Conservative government by 2010 looking increasingly likely, his policy to make PBC more or less compulsory may put commissioning responsibility in the hands of GPs whether they like it or not.


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