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Let’s learn lessons from flaws of PBC

The Department of Health needs to learn the lessons of the practice-based commissioning experiment.

Health secretary Andrew Lansley recently told MPs there was a ‘body of evidence' that GP commissioning could work. He was referring to the experiences of practice-based commissioning consortiums, particularly high-fliers such as those in Tower Hamlets, Cumbria and Bexley.

But as Pulse's investigation this week reveals, PBC also provides plenty of examples where GP commissioning has not worked.

Of 100 PCTs who responded to Freedom of Information Act requests, half had overseen commissioning of fewer than two PBC services a year. Only 17% could demonstrate any savings. PBC has cost an estimated £440m across England, and saved less than half of that.

So what does this tell us? Should GPs lose heart, put away their commissioning starter packs and pretend to be out when Mr Lansley comes calling? Where does it leave the financial security of practices, given the Government's worrying decision to tie a proportion of their current income to the ability of consortiums to stay within commissioning budgets?

Well, first things first. PBC was a different beast from the current plans. It was hamstrung by limp incentives, fuzzy budgets, bureaucracy and the reluctance of PCTs to hand over control. Those specific flaws do not mean that true GP commissioning, where the profession has a free hand to take the big decisions, cannot be a success.

But with that caveat, we can draw some important lessons.

First, some areas of the country are far better prepared for GP commissioning than others. The Government could have got round that by opting for a staggered rollout, but chose not to do so. It needs to provide all GPs with sufficient managerial budget and access to high-quality information, but it also needs to plan the transition carefully, and target support at those areas where PBC has made the least progress.

Second, many GPs just aren't interested in commissioning. They haven't been for the last five years, and some rousing words from Mr Lansley won't be enough to win them round. That's fine, because as primary care tsar Dr David Colin-Thomé tells Pulse this week, there has to be room in the NHS for doctors who just want to be doctors. GP commissioning needs to be flexible enough to capture the enthusiasm of those who want to get involved, without burying those who don't in unwanted work.

Third, tinkering won't work. GPs who commissioned the odd GPSI clinic often spent more than they saved – they are popular and desirable but not necessarily cheaper. But GPs who carried out wholesale reorganisations of care, commissioning tens or even hundreds of new services, delivered some spectacular results.

Trying to replicate the current NHS, with just a bit of fiddling round the edges, is not going to deliver quality care and the huge savings that the Government wants.

The secret of successful PBC schemes has been GPs' enthusiasm, not managerial bullying. If the DH wants to make a success of GP commissioning, it needs to tap into that enthusiasm where it exists, without trying to force it where it does not. It must get the carrots right, and lay off the sticks.


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