Practice Based Commissioning: A world class update commissioned by the Rant Foundation.

PBC: Pigshit, Bullshit, Chickenshit?

Dr Rant is almost enjoying the slow motion car crash that is the end of this Labour Government. Enoch Powell said that “All political lives end in failure” It’ so sad that theirs also started in failure and progressed. TFBUNDY by now.

The unlamented Patricia Hewitt was reported to have wished that “we had developed the commissioning function of the NHS more strongly.” This may have been one of her more lucid moments in a career otherwise misspent a few stops beyond Barking.

Anyway in the NHS we now have “Practice Based Commissioning” and we have a Director, Mark Britnell, who is going to give the NHS “World class commissioning” which will apparently achieve a balance between commissioners and providers, service redesigns, patient involvement, clinical engagement, efficient use of resources for maximum health gain and an end to health inequalities and probably world peace as well. If it sounds too good to be true it probably is and progress with implementation of this confused and contradictory management fad is slowing towards non-existent.

There’s lots of talk, and lots of meetings, but precious little is coming out from the initiative. The twaterati are, of course, loving it, but they never liked doing any work, or seeing real patients with their messy lives, that screw across all those lovely management schemas the management consultants so helpfully and expensively provide.

Anyway this week Dr Rant got around to reading Pulse magazine’s exciting supplement “ Practical Commissioning” You’ll get the flavour from these selected highlights. Bear in mind the articles are mostly written by PBC enthusiasts, or at least people trying to stay engaged witht he process- the messiahs of PBC- and listen to all their buts,

“PBC should be made an “emergency” policy in light of alarming referral increases across the country, according to the NHS Alliance” (p5)
What the fuck good will this do? Lot of meetings, then memos round to tell everyone that they are naughty boys and girls for referring too many patients for hospital care? Please don’t refer anyone…as the hospitals…or the budget cannot cope?

“Real change or just good headlines?” (Nigel Watson)
Good title- good headline- but PBC isn’t causing real change on the ground:-

“Of note is that the PCT commissioning department is still not closely aligned to PBC and commissioning new services is still a laborious and over bureaucratic process given the values of the contracts”
(Translation: The PCT doesn’t trust PBC, commissions as it likes, or as it did last year- and we have lots of meetings that sweat over the small stuff.)

“The challenge for the trust is now, having established a solid foundation, is to allow greater freedom and closer working to let PBC deliver change. Then there will be more material for ministers to include in their speeches”
(This from Hampshire which Ben Bradshaw has recently cited as a PBC success story. Probably about as successful as the new dental contract.)

PBC postcard from Dr Ruth Livingstone, Chair of Wellcomm Commissioning Group, Liconshire.

“The word that best sums up local GPs attitude to PBC is apathy” (Dr Rant can understand this)
“The obvious lack of enthusiasm from GP colleagues has been my biggest regret. (but your colleagues may have evaluated the PBC game sensibly.)
“The most frustrating thing about PBC is the very slow pace at which things happen”
“Inertia is the biggest threat to PBC’s success” (If we ignore this long enough it will go away)
There you have it. And that’s from the chair of a commissioning group!

Seven Steps for Successful Data Mining

I didn’t go into medicine to be a miner. Nor to mine data. Nor to spend my time checking data accuracy. I read this article and thought, “I’m a doctor: this is not medicine. This will not help my patients. This will not do any good for my blood pressure. In fact it’s so crap that I need a rant."
And if the data mining needs at all, doing get some bugger else to do it. Not my practice staff. Oh and my patient records are confidential- not public property.

P19 “Without data competency you will find it very difficult to make your case or commission new services” Am I bovverred?

P27, Interview with Mike Ramsden of NAPC.

“There’s nothing to indicate the government’s commitment to PBC has diminished”
(Forward, once more into the iceberg)

“There’s a gulf the size of the Pacific Ocean in the difference between what ministers and civil servants expect with PBC (everything) and what’s happening on the ground.” (Nothing)

“There’s a handful of GPs who have done great things with PBC and then there’s a good number who haven’t engaged with it at all. And then there’s a rump in the middle who are frustrated and don’t feel it’s happening. (That’s right, can’t feel anything happening anywhere…as nothing is.)

“If more GPs get frustrated with PBC and drop out, things could easily stall in the next five years” (Were things ever going at all?)

Then the “special at the back of the magazine, “Focus on Health Inequalities. (p37 onwards)

The idea that we can commission services which will solve health inequalities is a management fantasy rather less sensible than the attempt for the perpetual motion machine. The idea is absurd de novo, as people who know the health inequalities literature could explain. However PBC is such a splendid absurdity that learned doctors and managers make great pronouncements such as,

“PBC provides the mechanisms for engaging effectively with local communities to determine collaborative actions for improvement” Really? Has Prof Chris Drinkwater (who’s usually sensible) read the same PBC stuff I have? Is he trying to fudge this year’s DES in his practice? Dr Rant knows of no way in which PBC could possibly achieve this. He may have missed the point of PBC but many people claim to know what PBC is…but it’s different things to different people, as confirmed by one PBC chair from Wandsworth says, “In taking on the role of clinical lead for RoeHill cluster I truly had no idea what to expect. There were so many descriptions of what PBC was going to be”

Anyway the government is going to measure the success of its great scheme. I’m sure those metrics will be beautifully measured, and utterly misleading.

Then Dr Rant read the considered debate on commissioning run by Civitas. You read between the lines and it’s obviously an emperor’s new clothes scenario. We have an idea, we need to pretend it works, and lots of our jobs depend on it. The usual suspects spoke for GPs, and it’s obvious they have a different attitude to diagnosis from me. For example Mike Dixon says, “But where I live down in the marshy bog-land of real life in general practice – where only 50 per cent of the time do I make a diagnosis and only 25 per cent of the time if I’ve made a diagnosis is there an evidence-based treatment I can give them – it’s very different.” Dr Rant likes to think his problem solving skills are rather better than that- and regards a statement, “There is no recognisable medical problem in your case” to be as much a diagnosis as “gallstones.” And often to need more evidence to back it up, so it stands up to future examination if anything new develops.

Dr Rant’s higher nonsense detector has been bleeping away like mad. PBC isn’t happening, and looks unlikely to happen. He thinks he could spend his time far better, and to greater effect on any other activity. However he was in good humour, and thought that people might like seeing the absurdity in action. Hopefully this is one failing policy, amongst several others than Andrew Lansley will drop when he comes into government. Dr Rant has a list of other policies that need dropping here.