Practice managers faced with agreeing business plans, scrutinising referral data and managing risk are asking themselves whether practice-based commissioning (PbC) should be welcomed or treated with suspicion. For the optimistic, PbC will mean greater clinical engagement for those who are best placed to make commissioning decisions – that is, the GP and those in the frontline. It will give practices the chance to innovate and redesign services to better suit patients' needs, improve efficiency and free up resources for practices to reinvest in patient services.
The Department of Health says it envisages that patients will benefit from a greater variety of services, from more providers and in settings that are closer to home and more convenient to them.
Many managers will be tempted to view the new policy as a return to fundholding. But there are fundamental differences. The first is that only half of all practices were ever fundholders, while the government is insisting that all practices sign up for PbC by December 2006. The second is that PbC is inextricably linked to the government's payment by results and patient choice policies. PbC will help with the management of demand for services and prevent unlimited choice running out of control.
The more pessimistic managers worry about the financial risks and how they will find the capacity to take on PbC, and say the policy is so new for everyone that nobody can be sure it will succeed.
The government says that PbC is not just about commissioning, but also about changing the delivery of care and shifting more of the services provided by hospitals into the community. If GPs do not take on the task of commissioning, other groups from the private sector will move in to fill the gaps.
The Department of Health claims that 70% of practices believe PbC will bring benefits.(1) However, it seems that for practice managers the jury is still out. Ray Wilcox, a director of the practice managers' website First Practice Management, which has 4,500 registered members, says practice managers are in general not very excited about PbC:(2) "We have tracked the initiative since it was first announced, and we have found practice managers are not inspired by it and therefore not very much is happening on it.
"It's a lot of hard work at time when there is lot of other hard work around, and there is a general feeling among GPs of financial contentedness. The new contract is bringing GPs in around £100,000 a year for working only four and a half days a week with no nights and weekends, so they are saying, why do I need to put myself through a lot of hard work taking on PbC?"
Mr Wilcox adds: "It is not easy to identify where the immediate benefits of practice based commissioning are, the information systems are not there to get it going and moving along and there is no money attached to it, so why should practice managers get excited about it?"
Sonia Clark, practice manager at the Moss Grove Surgery, Kingswinford, West Midlands, is cautious about PbC. She says she has picked up lot of negative vibes among fellow practice managers, particularly in the chat room of the First Practice Management website. "Everyone seems to be either burying their head in the sand or wondering whether it is going to be worth the risk," she remarks.
There are gripes that no money is on offer to help managers pay for administrative support to enable them to spend the time that is needed to set up PbC.
"With fundholding we had a management allowance which allowed us to have some backfill, but practice-based commissioning is still just as much work but without any support."
She also feels PbC is quite restrictive. After doing a presentation to her patient panel, they told her that they felt patient choice was a waste of money and they would prefer to go by the doctors' decision about which consultant they would be referred to.
In the Dudley South area, practices have formed themselves into three clusters for PbC. Ms Clark is concerned that one practice in their cluster might wish to commission services from the City Hospital in Birmingham, which is some distance away from their practice area. Her patients have said they prefer to use the local hospital only a couple of miles away.
"In fundholding we had a similar problem because we had about 60–70 patients waiting for a cataract operation, which we could have got cheaper at a hospital some distance away – but only two accepted."
Ms Clark says her GPs are also concerned that local secondary care services should not be destabilised by any changes in their referrals.
Another worry is that the practice could overspend its commissioning budget and the resulting debt would then have to come out of the GPs' pockets. "What happens in three years time if things haven't gone to plan?" asks Ms Clark. She says her Primary Care Trust (PCT) has not given any commitment that any overspend will not come out of GPs' pockets. "That's my biggest worry," she explains, "so we are going to go with safe things until there is a lot more information around. We are testing the water a little bit but not doing anything too radical."
Initially her cluster of practices has decided to concentrate on fundamentals such as commissioning a physiotherapist to work from the practice, an initiative that worked very well under fundholding.
Ms Clark says she would also like to have a district nursing team on secondment to help build up an integrated
nursing team for the practice.
But one thing she would look forward to is restoring the excellent rapport and liaison with the Dudley group of hospitals that they enjoyed with fundholding. "When we were fundholders the marketing and commissioning people gave us input on what was going wrong and did something about it. Hopefully with PbC we will be able to open up direct liaison with the hospitals again," she says.
Ms Clark concludes: "I don't think the take-up of PbC is there at the moment. I have heard talk that incentives may be introduced. They are going to have to produce some carrots if they want to achieve anything, because people's morale is low. At the moment with PbC, there is too much risk and not enough gains."
The Westward view
Wendy Evans, practice manager of College Surgery in Cullompton, Devon, a large practice with 10 partners and 14,000 patients, says a lot of managers are suffering from change fatigue and are viewing PbC as a chore. The majority are probably still sitting back and waiting to see what happens.
The NHS Alliance lead for practice management, Ms Evans says there is also currently only patchy support from PCTs – some are enthusiastic and supportive, but others are worrying about their budget deficits and are not ready to proceed.
But she says she is an optimist: "There are a group of us, and I include myself in this, who see PbC as a fantastic opportunity to really make a difference to local services."
PbC, she says, must be led from the top by the practice partners. They have to be prepared to look at their referrals, which involves a lot of work. "We went 'live' on October 1," she says. "Going live purely means looking at quality of referrals. Before you do any service redesign you have to know exactly what's happening. We have been collecting referral data for 12 months.
"We have had the quantitative data and now we are looking at quality of the data and looking at each GP, which ones are high or low referrers, looking at why they referred particular patients and whether they could have done something differently if there had been a different service in place.
"This is something GPs are finding very useful and interesting. We have tried to look at it in the past, but you have to make time for this," says Ms Evans, who is quick to point out that she does not intend this as any criticism of doctors who say they would prefer to spend their time seeing patients.
The practice has been scrutinising in particular areas such as ENT and dermatology where referrals are high and looking to see whether there are local GP specialists to whom they could channel patients more effectively. But with this work there is also a concern that referrals could go up rather than down, and so they are also having to look at their resource allocations and make sure their budget does not double by the end of the year.
A district nurse has been appointed modern matron for the area, and the practice is hoping that her role can be linked in to PbC and that she will be able to help them to cut down on emergency admissions.
The patient liaison group has been brought onboard and has been given the opportunity to have a say. Patients say they want more chiropody and complementary therapies, and the practice would like to reduce prescribing.
Ms Evans is in no doubt that PbC will bring benefits: "With contestability we have to be ready for the NHS of the future, otherwise we may find we are struggling. But I think a lot of other practice managers would think I am in cloud-cuckoo- land."
Val Hempsey, practice manager of the Gateshead Health Centre and a Fellow of the Institute of Healthcare Management, believes a number of practice managers are very excited about PbC. "But it's a big issue and it's very challenging," she says.
"A lot of managers have probably been aware of a lot of waste locally, that there has been a lot of misinformation or bad data being used, and anecdotally felt things could be better but have had no mechanism for changing things. PbC potentially has the power to do that."
PCTs are at different stages. "In Gateshead our PCT has been very inclusive of practice mangers and have asked their opinions on different things. We are not as far ahead as some but nowhere near as behind as others," she says.
Even where PCTs or strategic health authorities have not taken any action on PbC, Ms Hempsey says practices have begun to band together into groups and have started to discuss what patients want them to commission locally. These are the practices that believe there will be rewards.
Ms Hempsey says PbC is likely to be a good business opportunity: "GPs, nurses and practice managers very shrewd business people, and when there is a reason for doing something and they feel they are not being shafted then they will pull out all the stops. This is business to general practice."
She says one of the problems is that many people are viewing PbC as fundholding: "They have got the wrong idea – they are trying to hang on to fundholding, but it's not fundholding. Any practice which thinks that it can go it alone as it did with fundholding is misguided."
"I believe that at the moment a lot of practice managers don't understand the importance of PbC. They don't feel that they understand enough about it and think it's just another change."
But Ms Hempsey, too, is one of the optimists: "I see this as the biggest revolution for general practice that has happened since the 1990 contract, and we have to embrace it and make it ours. I'm quite excited but also bit negative, because so many things could go wrong. But I can live with that. I do think this is an opportunity for general practice."