THE EMPEROR’S NEW CLOTHES, OR WHY PRACTICE BASED COMMISSIONING IS
A CON
Am I the only working front line GP who has lost all faith in PBC? The
medical press is full of articles extolling the opportunities of PBC,
that it is the only game in town and why we all need to sign up to it.
The government has made it a central plank in their “Modernising
the NHS” and the PCTs are under intense pressure to make it work.
Yet there are very few stories of new services set up by happy and fulfilled
GPs. Instead, beginning to creep into the news, are stories about huge
amounts of time having been spent trying to set up PBC in vain. There
are endless meetings with lots of varied participants spending a lot of
valuable time with very little to show for it. New holding companies have
to be set up and debates gone through as to whether it is best to be “for
profit” or not for profit” , to be owned by all the local
GPs or just a few and how the board is configured. What are the liabilities
and insurance issues? – to say nothing of the accountability, clinical
governance, protocols, best practice, competitive tendering, audit, appraisal
and employment legislation. For some of us you also need to factor in
local trust financial indebtedness, whether the hospital or the PCT, or
in our local case, both.
Look at the poor doctor who represents you on your PBC board and check
how thick his paperwork is. My partner has collected well over an inch
thick of tedious statistics, SLAs (service level agreements) and mind
numbing minutes of long meetings and he has only been doing it a couple
of months!
Another year of it and he will lose the will to live. We are after all
doctors not administrators. And furthermore we signed up to run primary
care which we do pretty well but not to police and run secondary care.
Then there is the issue of vulnerability to moving services around or
reducing the financial input to the local struggling hospital, Do we as
GPs want to have a hand on the tiller when the local ship is going down?
The government is desperate to find someone else for the public to blame
when services are cut-: step forward the local commissioning group!
Which GPs have the necessary time or energy to invest in these potential
new services when we are all “quoffed” out? We must also cope
with the new electronic results and problems with communicating computer
systems, the expanded QOF framework, appraisals, the new MRCGP, the new
F1 & F2 training grades and all the extra general practice teaching
involved. Then there are the disastrous reorganisations of the PCTs and
on top of this we have failing OOH and a government intent on undermining
our professional status and public standing. At least in this latter case
they will probably shoot themselves in the foot as we still benefit from
higher public support than current politicians. But the daily grind of
paperwork leaves few of us with the energy to take on yet more as PBC
demands.
I don’t dectect much enthusiasm for it from the PCTs, let alone
the hospitals. It tends to drive a wedge between us and the local consultants
and we would be held responsible for moving money out of secondary into
primary care if we ever do get to set up a service. Suppose we work very
hard and save money in neurology referrals. The savings are then returned
to the practice and ploughed into another medical area that is less efficient
and overspent. Thus we as GPs are removing money from a new and
efficient service set up with local specialists, only to pass it on elsewhere.
Funny kind of incentive for the specialist GPs and consultants who have
probably spent many boring afternoons setting up the service.
One of the government’s obsessions is to rubbish and degrade the
trust placed in professionals. The Shipman and Bristol affairs have been
used to denigrate medical professional standing and integrity. In its
place they have put in appraisal and validation that undermine trust and
pride. These are also expensive and time consuming with very little in
the way of positive outcome.
I personally have to do three personal development plans and have 3 appraisals
as a GP, as a dermatology GPSI and thirdly as a training doctor. Admittedly
a lot of it overlaps and is simple repetition but it also demands a lot
of audits, clinical governance and afternoons spent justifying my medical
activities to other doctors and lay people.
We are supposed to check the hospital activity for our practice’s
patients but have had an almost impossible task in getting anything meaningful
out of them. They haven’t got a clue! Any GP who has tried to make
sense of hospital activity data realises that it is hopelessly inaccurate
usually by mistake but recently and more worryingly by design. They are
getting clever at costing inpatient activity at its most expensive and
are hopeless at assigning it to individual practices. If their departments
of dedicated staff make such a mess of it how on earth are busy GPs expected
to check it all – and at least six months later. Then when we do
find irregularities, who will mediate? And if proved correct how do they
get the “virtual refund”? One local practice installed checking
soft ware for this purpose and the PCT refused to honour its findings.
One of their reasons was that it would “destabilise the local secondary
care provider”! The practice invested large amounts of time and
money doing exactly what was asked of them only to have it binned. Who
has this kind of time, memory and stamina? And what is the purpose of
it if everything is virtual?
There are new services such as GPSI clinics that have worked and seem
to be saving money.
However they have been set up by the PCTs outside of PBC. In our local
area we have singularly failed to produce anything under PBC despite spending
a lot of time on it. The one area we are motivated to commission under
PBC is district nursing. Our PCT is making a dangerous mess of the new
“virtual ward” and many experienced DNs are voting with their
feet and leaving. This service, however, seems to be out of bounds for
PBC, and is instead being foisted on the primary care team with minimal
consultation and disastrous results.
One of the problems this government creates is over regulation and one
set of regulations contradicting another. Take “Choice” for
example. We are soon to be penalised for not offering it but most of the
money-saving services set up ostensibly under PBC such as musculoskeletal
and dermatology don’t offer choice. They save money by removing
the GP and patients’ choice of who they see and funnel everyone
into a triage system. Which has precedence – Choice or commissioning?
Ask around and no one has an overall consistent view.
In summary, practice based commissioning seems doomed to a slow death
due to the sheer weight of attendant bureaucracy and internal inconsistency.
When are we going to admit this and find a workable alternative that does
not burden us with interminable paperwork but instead allows GPs and consultants
to cooperate and then request the administrators to facilitate the improvements?
Dr JONATHAN HEATLEY
General Practitioner
Horsham, Sussex
(Parts of this article first appeared in “Pulse” in February
2008)
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The NHS Consultants' Association
