Practice Based Commisioning

An Ivory Tower yesterday.

Of all the misinformed, misbegotten and ill implemented changes that have been inflicted on the NHS this could be one of the worst.

I’d better start by saying what it is supposed to be, at least as far as I, or anyone might know- the details are sketchy and the practice patchy and inconsistent. The official links are here and here and here
and here

“We believe that Practice Based Commissioning will produce the following positive outcomes:
• A greater variety of services, from a greater number of providers in settings that are closer to home and more convenient to patients.
• Increased support of clinician-to-clinician dialogue about improving and developing care processes.
• Early and continuing involvement of practitioners in service development
• An additional set of levers to aid demand management.”

Additionally PBC may solve the long standing problems of health inequalities according to this piece in HSJ

“One of the stated aims in the Department of Health's vision of world class commissioning is to eliminate health inequalities. Not to reduce them, but to get rid of them altogether.”

Oh and all this will involve world class patient engagement as well!

“Picker Institute chief executive Angela Coulter said engaging patients would be vital. 'Commissioners need to get beyond talking to the usual suspects,' she said. Rotherham PCT chief executive Andy Buck said: 'Probably the greatest challenge for PCTs is to find radically better ways of seeking out and acting on public and patient expectations and experience.'”

The document envisages PCTs with high levels of clinical engagement, which it says is 'integral to the process of commissioning'. Dr Rant has commented on world class this before- Our engagement with it is of course world class!)

Finally I love this recent quote from NHS Confederation PCT network director David Stout 'This is the first time we have had a coherent sense of what commissioning means and where we are trying to get to.'
I love the fact that he now (October 2007) has a coherent sense of what commissioning is. (First launched about 2004) I doubt anyone else does yet, and I doubt his current clarity will last for long.

The PBC enthusiasts are an odd lot. They have a messianic fervour, and believe great things will be achieved by PBC. They have a variety of motives.

Some are former GP fund holders and want to get their hands on budgets again. Some imagine that primary care will improve by getting its hands on “all that money going into secondary care.” Dr Rant thinks that beggaring secondary care will do nothing for primary care.

Some don’t like patients, or doing surgeries, and prefer twateratus type work on committees. They talk about ever more “patient centered services delivered closer to home” but actually you’ll never catch them delivering it themselves. They like patients so much that they don’t like seeing them. They may however exploit, sorry employ, a salaried doctor to provide the service and take the profit.

From the above we can see that PBC is trying to achieve many things at once.
• A greater variety of services, from a greater number of providers in settings that are closer to home and more convenient to patients.
• Increased support of clinician-to-clinician dialogue about improving and developing care processes.
• Early and continuing involvement of practitioners in service development
• An additional set of levers to aid demand management.”
• Also an end to health inequalities
• Also full clinical and patient engagement

Now there are many problems with all this. Firstly the agenda is too huge. PBC is becoming seen as a panacea for all NHS and the NHS as a panacea for all society’s ills. Inequality is a fact of life in UK for at least the last 2000 years. Edwin Chadwick and team first documented the problems…or was it William the Conqueror with the Domesday Book? The fact that wealth inequalities show up as health inequalities is well known. The medical system can only deal with the casualties of this, not the causes. The medical system in any country is not a mechanism that can or will reduce health inequalities, although hopefully it will give equal (equally bad) access to treatment to all classes on basis of need.

Secondly PBC is currently a mechanism for taking money off “over funded expensive hospitals” and giving it to “other providers” Who the other providers might be is not clear, but current government plans for GP in Tesco and Boots show that existing GP services are out of favour. Also these new services look likely to be set up with no local consultation with GPs or patients, and PCTs will probably consult central government diktats so they don’t get clunked by the Great Clunking Fist. Local decision makers will be ever so empowered by strong central direction.

Thirdly there is a worry about the ability of trusts to manage existing budgets, let alone to set up a new way of commissioning services. Apparently this worry is so great that “external expertise will be needed” (The management consultants again). How they know any more about commissioning than anyone else is a mystery to me and anyone else…and probably to them…but as long as they keep on spinning the yarn the emperor’s clothes will look ever so grand. Won’t they? CLUNK.

PBC as currently set up is a mishmash of conflicted politically correct sounding, nominally patient centred initiative that is supposed to get more and better services by spending less money. Actually it is a time consuming excuse to go to meetings rather than actually see any patients.

Dr Rant agrees there are efficiency savings that could be made in the NHS. Stopping PBC would be one of his suggested cuts, along with closing down PCTs. PCTs are not primary, not caring, and not trusted by doctors, patients, or government.

I think PBC could be dead in the water, but no doubt it will get resurrected into another form or incarnation. I told you the messiah has spoken…