Even on an island surrounded by silver beaches of the stuff, there is a limit to how long one can bury one's head in the sand. And so it is that, overcome at last by the ever strengthening ripples emanating from the mainland, we have had to face up to the reality of Practice Based Commissioning (PBC). Fortunately there are active minds at work in West Cornwall prepared to come to grips with what PBC might mean, and how it might be implemented, and all we have had to do so far is sign up to the collective agreement that makes us part of the Commissioning Group. Furthermore, the cost and inconvenience of crossing the 25 miles of water that separate us is accepted as a valid excuse to opt out of attending board meetings, and our minute practice size renders us almost insignificant in its deliberations, our ‘weighted value’ of the indicative budget (and the associated anticipated dividend from projected savings) being a paltry 2.5%. All the same, I feel duty bound to make some effort at least to understand the latest reform to have been foisted on us, however unwelcome it may be.
Our Commissioning Group makes no bones about what PBC is, describing it as, ‘the central pillar of current NHS reform’; it ‘encourages progression of the market economy by using a plurality of providers’ and facilitates ‘the transfer of more health care from secondary to primary care settings through greater GP control of commissioning’. As for the objectives of PBC, in this neck of the woods anyway, they are to reduce nonelective admissions across all specialities; to reduce excessive bed days incurred by patients in secondary care; to reduce new GP referrals to consultants; and to reduce outpatient follow-up rates. Member practices are responsible for undertaking a monthly review of activity data, limited to ‘the 10 most expensive patients’, and any specialities that have seen a 5% increase or decrease in activity.
So far, so clear, but not so good. Did I vote for progression of the market economy in the NHS? Did you? Did anyone? Is a plurality of providers going to improve efficiency, or is it more likely to pave the way for further privatisation? Is there good evidence that GPs are any more qualified to commission services than experienced managers?
The whole thrust of PBC assumes that care at or near to home is necessarily preferable, and generally cheaper than secondary care; that consultant-led services in secondary care premises are expensive and often inappropriate; that GPs make excessive referrals; and that we are wasting resources on ‘expensive’ patients. I am not convinced that there is good evidence for any of these assumptions, but if there is it has not been widely or convincingly disseminated. Does it make sense for consultants to waste valuable time in traffic jams on their way to and from outlying clinics, where diagnostic and treatment facilities are often unavailable? If the argument is that such facilities will be made available at numerous satellite locations, will this save money?
If a plurality of providers drives NHS hospitals out of business and renders NHS specialists redundant (it is, after all, cheaper to bring in doctors from other EU countries at lower salaries, as is happening at some independent treatment centres), do we care? If GPs and consultants become opponents in a bidding war rather than colleagues with different areas of competence who cooperate in the management of patients, will we not have lost a precious relationship that has served the NHS well, and increasingly well over recent years as notions of hierarchy have diminished? And once the GPs have done the government's business of carving up secondary care and disempowering hospital consultants and their teams, will they be surprised when they are next in line? GPs are, after all, very expensive creatures to train and maintain.
I hope that my misgivings are misplaced, and that the enthusiasts for PBC have thought through the implications of what they are setting out to do. But I suspect that we are being taken for a very nasty ride that will end in division of the profession and dismemberment of the NHS. And now I'm going back for my bucket and spade …
- © British Journal of General Practice, 2006.