MIPD MHSM MSc
PBC Federation, NHS Alliance
Independent Healthcare Policy Consultant
Julie is passionate about the contribution that primary care can, and should, play in the delivery of world class commissioning and provision. She has worked with primary care from many perspectives for all of her almost-30-year career in the NHS, the last 16 of which she spent at director and chief executive levels of family health service authorities, health authorities, primary care groups and PCTs. In 2007, Julie left her PCT chief executive role and now pursues a very successful portfolio career. She combines her national role as PBC Federation Director of the NHS Alliance with a wide variety of independent healthcare policy consultancy activities
Practice-based commissioning (PBC) has been with us as a major plank of NHS policy for nearly four years, with the first target – "universal coverage" – successfully implemented, we are told, almost two-and-a-half years ago. The recent Department of Health- (DH) commissioned Ipsos MORI PBC survey suggests majority support for the policy,(1) yet many managers and clinicians remain hesitant about its impact, finding it hard to describe the benefits. In some cases, they are unable to answer the "why should I bother" question!
However, elsewhere PBC is very much alive and well, and is positively impacting not just on the shape and scope of services provided within primary care, and the priorities being pursued locally, but on the financial consequence of service change and, indeed, the health outcomes.(2)
So, why should frontline clinicians and managers continue to give it "air time" and what support can our frontline staff look towards to help them give it a go?
Despite, in some places, its somewhat tentative and toddler-like steps and some seemingly very adolescent-like behaviours, PBC has very recently been given a reaffirmed "you're green to go" call by the government and the DH.
Lord Darzi's NHS Next Stage Review final report, High Quality Care for All, and the DH's Vision for Primary and Community Care both signalled the importance of involving frontline clinicians and managers in making commissioning decisions. They made clear "that PBC should put clinical engagement at the heart of the commissioning process" and that, through PBC, GPs' "professional experience of delivering care, combined with their understanding of patients' needs, will be crucial to designing high-quality, personalised health and care services."(3,4)
The reasons for the lack of progress are well known by many, and indeed many of the reasons have been commented on by the NHS Alliance through our involvement in many national events, through our national networks and our involvement in key departmental policy groups, as we sought to persuade the DH of the problems that needed addressing if the opportunities of PBC were to be grasped.
On the one side, we saw the impact of the 2007 primary care trust (PCT) reorganisation, and its almost inevitable distraction from implementation of PBC, alongside the extremely difficult financial position the NHS was in and the difficult decisions PCTs had to take to secure financial balance, which in many places fractured relationships.
On the other hand, the new GP contract and its understandable focus for the frontline on securing core business development, the uncertainty by clinicians about whether PBC was "yesterday's idea gone tomorrow", and the disputes between the profession and the government over issues such as access all combined to make it difficult to secure sufficient desire and action to make it work. Together, these ensured a much slower implementation on both sides of the "commissioning coin" than anticipated.
However, by 2008 these issues had largely been resolved – yet progress remained patchy. Those working with the frontline to help implement and "unblock" PBC, including the NHS Alliance, were by now increasingly clear about the ingredients needed to enable PBC to flourish, which were reaffirmed by the King's Fund report Practice-based commissioning – reinvigorate, replace or abandon.5 It is now clear from all of this work that successful PBC needs the "ingredients" outlined in Box 1.
A reaffirmed vision
In December 2008, the DH, responding to a well-recognised need for more support, published its PBC development framework, which detailed the five external providers they had "accredited" to provide intensive support to local health communities to support PBC reinvigoration. The NHS Alliance/Humana PBC Partnership is one of those five providers. Together with the other four, using the initial DH pump priming funds, work is now underway with 10 health communities across the country.
Other health communities who need support are now able to access the PBC Development Framework and to draw down from it. A number already are doing this. This includes PBC consortia, as well as PCTs and strategic health authorities (SHAs). Funding, however, does have to come from the local health community. Full details can be accessed from the DH website (see Resource).
Most recently, the DH has issued its reaffirmed vision for PBC – that of clinical commissioning within a "world-class NHS".6 This makes it clear that successful PBC is a prerequisite of successful world class commissioning.
Those cynical of the DH vision may say: "Here we go again – more window dressing". Yet upon a close read, there is plenty said in terms of:
In return, the DH insists that good-quality primary care provision is a prerequisite to successful PBC, which it says looks "in the round at the quality of care offered for local patients, including the interactions between primary care, community health services and more specialist care".(6)
In its latest documents about commissioning primary care services, the DH has also made the link between service provision and PBC, and has pointed out that the vast bulk of care is provided in primary care – as is the vast bulk of commitments about future care.(7) Therefore PBC is critical to also ensuring good-quality core primary care.
Shaping service delivery
So, why should practices give PBC more air time? Well, NHS Alliance Chairman Michael Dixon, quoted in the DH vision document, sums it up:
"PBC provides GPs and other clinicians with a new leadership role in determining local services and health initiatives that will enable a real difference to be made for our patients outside of the walls of the surgery. For PCTs, PBC is the means of world class commissioning succeeding – the sine qua non. No PBC, no WCC."(6)
It is those clinicians who, through their day-to-day practice, influence the pattern of healthcare spend, and so it should be those clinicians who, working with others, are also able to make those key commissioning decisions. PBC, when properly supported, does enable clinicians, working with their managers, to shape services so they reflect local needs and to change the locus of care.
There are now many examples up and down the country where, through PBC, services are being brought away from secondary care and closer to home and/or where the quality and quantity of services now provided in primary care has been significantly enhanced.
So, looking ahead over the next year or so, what might we see? Whichever political party is in power, the involvement of clinicians in making key commissioning decisions, supported by their PCT, remains a consistent thread. The journey to become world class commissioners that we have now embarked upon also looks set to continue and, indeed, the need for effective clinical involvement in commissioning through PBC is ever more important as we move into much more financially challenged resource environments.
PBC must not just be about the financial bottom line but must be about quality, access and responsiveness of services. However, we cannot escape from the financial realities and PCTs will need to make difficult decisions as the level of resources the NHS will have at its disposal to commission services gets ever tighter. The DH has made it clear that "especially in financially challenged times, clinical empowerment is not a nicety but a necessity".(8) David Nicholson, launching the new vision for PBC, said he wants PBC clinical leaders "to go out and make trouble".(9)
As managers supporting clinical leaders, my challenge to you – should you choose to accept it – is to do just that!
Give PBC more air time. But go beyond that – embrace it and ensure your PCT does the same. It will help you as providers maintain your current key and enviable position, but will also give you the opportunity to shape what happens outside of your surgery walls for the benefit of your practice and your patients.
1. Department of Health. Practice based commissioning
GP practice survey. London: DH; 2009.
2. Gordon S. How to run low-cost high impact AF screening at flu clinics. Practical Commissioning November 2008.
3. Department of Health. High quality care for all: NHS Next Stage Review final report. London: DH; 2008.
4. Department of Health. NHS Next Stage Review: our vision for primary and community care. London: DH; 2008.
5. Curry N, Goodwin N, Naylor C, Robertson R. Practice-based commissioning: reinvigorate, replace or abandon? London: King's Fund; 2008.
6. Department of Health. Clinical commissioning: our vision for practice-based commissioning. London: DH; 2009.
7. Department of Health. Primary care and community services: improving GP services. London: DH; 2009.
8. Mark Britnell, speaking at the launch of Clinical commissioning – our vision for practice-based commissioning. March 2009.
9. David Nicholson at the launch of Clinical commissioning – our vision for practice-based commissioning. March 2009.
PBC Development Framework