How integration could recast PBC

Integrated 'commissioner-provider organisations' are forecast to be the next phase for PBC. Susie Sell reports.

Dr Jenner: financial risks for GPs under proposals are 'pretty great'
Dr Jenner: financial risks for GPs under proposals are 'pretty great'

Nearly six months after the DoH's primary care czar called practice-based commissioning (PBC) a 'corpse', a remark he later retracted, the initiative may finally be heading for the scrapheap.

Two documents jointly published this week by the King's Fund and the Nuffield Trust suggest that PBC is in for a radical overhaul. The next likely step, the reports say, will see the scheme absorbed into 'integrated commissioner-provider organisations'.

Under this model, PBC consortia would link with providers to secure all necessary care for a given population. They would bear the financial risk in doing so by taking on real budgets.

The reports say there is no 'magical formula' for how these organisations should work, suggesting this would be determined locally.

They would be 'rooted in general practice', but could involve complete integration of primary and secondary care, in a model similar to US-style health management organisations.

The authors describe this vision as a radical departure from the status quo. The NHS in recent years has been preoccupied with splitting provider and commissioning functions.

Under the DoH's Transforming Community Services plans, PCTs are expected to decide who will take over community services they currently provide by the end of this month.

But the documents suggest integration is one of the only viable options to kick-start PBC. The result, it says, would be more efficient and effective care across a range of providers - a crucial outcome in an environment of tightening financial pressures.

Dr David Jenner, policy lead at NHS Alliance, agrees that PBC in its current form is 'extinct'. He suggests that this has been clearly signalled by its non-appearance in the NHS operating framework for England for 2010/11.

GPC deputy chairman Dr Richard Vautrey says commissioner-provider organisations would be a 'fundamental change' that the GPC would welcome.

'A collaboration between commissioners and providers would allow for the removal of the unhelpful divide that currently exists,' he says.

Dr Vautrey warns that he would be 'very concerned' about any plans to merge GP practices and hospitals.

But he adds: 'The challenge in the current system is that hospital providers are seen as competition. If we can get beyond that and into a position where hospitals are working together with primary care I think that will be better for everyone.'

Choice and competition
Competition is unlikely to be fully removed from the integrated commissioner-provider system, however.

The reports acknowledge that integrated organisations would have to accommodate the commitment to patient choice set out in the NHS Constitution.

The organisations would have to allow patients to choose services outside their own network in order to maintain free choice, the authors say.

However, NHS cash shortages may put GPs off getting involved, Dr Jenner warns.

'I think the integrated commissioner-provider (model) does make some sense, and we may get there in the end.

'But practically, in the current financial climate, the risks involved for GPs in setting up these organisations are pretty great,' he says.

Dr Vautrey agrees that GPs taking on real budgets is a 'huge risk' and one that the profession would be very anxious about if it was not given the appropriate support.

But despite uncertainty over getting involved in new organisations of this kind, Dr Jenner maintains that there is still a willingness to work collaboratively with secondary care.

He backs 'step by step' moves towards integration or PBC reform. 'The NHS needs another whole reorganisation like a hole in the head,' he says.

'What we should have in the first instance is practice consortia, PCTs and secondary and community care providers working collaboratively to define the best model to deliver care safely, effectively and efficiently. From that plan these new organisations may well appear,' he says.

Dr Judith Smith, head of policy at The Nuffield Trust, says it may be time for radical changes.

'We could limp along making some sorts of alterations to the incentives around PBC or changes to the payment regime, but we also say there is a more radical and risky option.'

Next step for PBC

Key characteristics of integrated commissioner-provider organisations (ICOs):

  • Rooted in general practice.
  • Real budgets set using risk-adjusted capitation methods.
  • ICOs formally contract with PCTs to deliver a range of services.

Source: King's Fund/Nuffield Trust


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