Practice-based commissioning

Our report, Practice-based commissioning: reinvigorate, replace or abandon?, published in 2008, set out the findings from our research into how well the objectives of practice-based commissioning (PBC) have been achieved, identified the barriers to progress, and made recommendations for the development of the policy.

Has PBC delivered?

• Progress had been slow in the four sites studied. Very few PBC-led initiatives had been established and there was limited impact in terms of better services for patients or more efficient use of resources.
• Where initiatives had been developed, they tended to have been small-scale, local pilots focusing on providing hospital services in community settings.
• Few practice-based commissioners had taken an interest in wider commissioning activities such as redesigning the services patients receive and the way in which they access them.
• PBC had been partially successful in encouraging GPs to become more engaged in commissioning and making decisions about budgets, but this had generally been limited to a small group of enthusiastic GPs in each PCT. Most GPs supported the principles of the policy, but were not actively engaged, preferring to let others lead on their behalf.
• PBC did have a positive impact on relationships and communication in some sites. In general it fostered more collaborative working relationships among GPs, and opened up channels of communication between GPs and PCTs and, in some cases, between GPs and hospital staff. However, in a few cases PBC had caused already poor relationships to deteriorate further.
• Enthusiasm had waned slightly between 2007 and 2008, with some GPs being deterred by the lack of tangible progress in improving services for patients.

Barriers to progress

The report concluded that despite having been in place for more than three years, PBC has made limited progress in meeting its objectives. The key barriers related to the following issues.

Roles and responsibilities
Although the lack of national guidance on the respective roles and responsibilities of GPs and PCTs around PBC offered flexibility, it had also led to disagreement. GPs and PCTs often had different visions for PBC and there had been a struggle for control over the agenda.

Capacity and capability
GPs had limited time to engage in PBC, and often lacked the requisite skills (for example, in data analysis). They needed considerable support from PCTs, but there were often limited resources – and experience – available.

Data limitations
A lack of reliable, up-to-date data in all study sites affected the GPs’ ability to develop commissioning ideas and PCTs’ willingness to approve these ideas. It also created problems with setting and managing practice-based commissioners’ ‘virtual’ budgets.

Relationships
A crucial requirement for the successful implementation of PBC was good relationships among GPs working on PBC and also between GPs and PCTs. Where relationships were not good, PBC generated tensions and caused relationships to deteriorate further.

Governance and accountability
PCTs are responsible for creating a robust governance framework to allow the financial and clinical risks involved in PBC to be managed appropriately. In all sites studied, the complexities of setting up governance and accountability arrangements considerably delayed the implementation of PBC.

Conflicts of interest
Conflicts of interest arise from the potential for GPs and PCTs to be both the commissioners and providers of a service. Some participants in the research felt that common sense and robust governance structures could deal with this problem, but others felt that it was a fundamental flaw in the PBC policy.

Wider contexts
Relations between GPs and the government have been strained by a number of recent policy developments, and many of the GPs interviewed suggested that PBC had been a victim of these disputes. Several GPs felt uncertain about the future of PBC and the government’s commitment to it.

The future of PBC

The evidence from the four case study sites suggests that, in the three years since PBC was introduced, overall progress had been slow. We have concluded that simply re-energising PBC in its current form would not work. There is a need for clarity on:

• the overall vision
• the roles and responsibilities of PCTs and practice-based commissioners
• governance and accountability arrangements.

The policy will also need to be properly resourced and supported, and incentives put in place to encourage primary care staff to engage with it.

Further work

In July 2009 we published a poll of GPs and practice managers that found commitment to PBC and optimism about its potential but also suggested that progress is still hampered by a lack of local vision, a lack of clarity over roles and responsibilities and bureaucratic governance processes.