Reviving the ‘corpse’ of PbC

Civitas, 26 November 2009

‘A corpse not for resuscitation’ the primary care czar, David Colin-Thome recently said of practice-based commissioning recently in an apparent lapse of concentration, protocol (or is it actually becoming DH policy)?  Roll on a month and we have the latest report attempting to provide the holy grail.

‘Beyond Practice-based Commissioning: the Local Clinical Partnership’, produced jointly by the Nuffield Trust and the NHS Alliance proposes replacing PbC with a system of new groups spanning primary and secondary care with real and larger budgets and greater powers; in effect taking on full responsibility and accountability for their population’s health.

A few questions…

• What role is left for Primary Care Trusts (PCTs), the bodies that currently have overarching statutory responsibility for commissioning?  Their role already fits somewhat uneasily with the commissioning that is currently devolved to PbC groups and it’s difficult to see how they could co-exist with more powerful local clinical partnerships.  That is unless PCTs form a bureaucratic supervisory role that is already carried out by Strategic Health Authorities slightly further up the chain.

• Is the core goal of Local Clinical Partnerships in bringing clinicians in both secondary and primary care together to guide commissioning decisions and develop care pathways not what good PCTs should and are already doing?  A significant number haven’t got there yet, but what is there to suggest that, given the geographic restrictions on commissioning groups, we won’t just have isolated examples of good Local Clinical Partnerships too?

• I’m all for increased integration between primary and secondary care (the division is a historic accident as much as anything else), but pulling the two together in a structure that in practice have dual responsibility in commissioning and provision surely creates both a conflict of interest and a local monopoly?  The flies in the face of the supposed advantage of the NHS as it stands, with commissioners separate from providers, which is that commissioners (PCTs as it stands) can act freely on behalf of patients without the burden of having to meet the demands of providers that are often virtual monopolies.  The NHS Alliance has already stated that it prefers Andy Burnham’s new mantra of the NHS as the preferred provider.  The danger is that vested interests come to the fore and Local Clinical Partnerships – involved in commissioning and provision, and under little if any competitive pressure – use money to sustain existing services within the Local Clinical Partnership (be it at the general practice or secondary care end) that may not up to scratch, rather than looking at alternative options.

I’m not convinced.  Have the multitude of perverse incentives and overlaps that will surely result been given proper consideration?