Practice-based commissioning needs major overhaul
pharmafile | November 21, 2008 | News story | |Â Â NHS, primaryÂ
A key NHS reform isn't working and requires a major overhaul, according to a new report by think tank The King's Fund.
The two year study of Practice-based commissioning (PBC) said the theory behind the policy – to devolve greater power to GPs – is sound, but that it has failed to make a significant impact.
Practice-based commissioning: reinvigorate, replace or abandon? says the government was right to recently re-commit itself to PBC, but concludes that so far it has produced few benefits for patients or NHS finances since its launch in 2005.
Report co-author Nick Goodwin, Senior Fellow at The King's Fund, said: "Practice-based commissioning has the potential to deliver better services for patients and financial savings for the NHS, but progress has been painfully slow over the past three years.
"As a policy established to pump-prime the transition of care out of hospitals by investing in alternative care in local communities, it has so far failed due to a lack of real investment, leadership, ambition and drive."
Goodwin says the government must make the most of dwindling GP enthusiasm and commit to a fundamental redesign of the policy.
The study found very few of England's GPs use the system to commission new services, despite been paid almost £100 million in incentives payments alone. The report says the policy needs a major overhaul, and lack of interest from GPs must be tackled if it is to be a success.
It concludes many barriers to progress should have been predicted given the experience of the similar fundholding system used by the Conservative government in the 1990s.
Engaging GPs is one of the biggest problems, and the think tank says GPs will be more enthusiastic if they are given more freedom. It recommends allowing them to contract independently by giving them real budgets for specific therapeutic areas.
Another key issue is lack of managerial capacity, with a new breed of administrators not currently in place. The report says the right skills, data systems and governance arrangements all need to be in place for the system to work properly.
Niall Dickson, Chief Executive at The Kings Fund, added: "The government is right to keep faith with practice-based commissioning but it must be prepared to set a clear direction, define the commissioning roles of both PCTs and practices, ensure GPs have access to the support they need to make it work and put in place the correct incentives.
"Now is the time for a fundamental reassessment of the policy. GPs reported that they had limited time to engage in the policy, and often lacked the necessary skills and data, and generally lacked support from PCTs."
Concerns over conflicts of interest in the role of GPs as both providers and commissioners of services, was also a barrier, which potentially restricting patient choice.
Dont blame the PCTs
The NHS Alliance represents many of England's GPs and other primary care workers and says the King's Fund report is an accurate reflection of the problems.
But NHS Alliance chairman Dr Michael Dixon says the blame should not lie with PCTs but rather with the health service hierarchy.
There should be no excuse for failing to provide budgets and accurate financial information to practice based commissioners. Yet that is exactly what has been happening. It is often not the fault of PCTs but of the system above them.
One particular problem Dr Dixon points out is the lack of timely and accurate data supplied by acute trusts, which GPs rely on in order to use practice-based commissioning.
The King's Fund is right to say that urgent action is necessary to overhaul PBC. But that action need not be complex or costly. The simple solution we have proposed would transform commissioning by putting the power where it should lie with the commissioners instead of, as at present, with the acute sector.
If providers find they do not get paid unless they do the job properly, that would sharpen everyones performance. And it would also enable practices and PCT commissioners to become fully engaged in NHS decision making.
King's Fund Recommendations
· The government must provide a clear vision for PBC and provide national guidance for GPs and PCTs on how to implement the policy locally
· PCTs should maintain responsibility for strategic commissioning but be informed by GPs and other clinicians, while real budgets for specific services should be devolved to GPs and PBC clusters, giving them more freedom and stronger incentives to develop better services for patients.
· High performing GPs and PBC groups should be rewarded with more independence but should not become responsible for the entire health care budget. · Budgets should only be devolved for tightly defined areas so GPs can only commission specific services directly, which would reduce clinical and financial risks.
· Conflicts of interest in the role of GPs should be formally addressed to ensure patient choice and the quality of GP referrals are not compromised and that clinical risk is managed
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