Practice based commissioning (PBC)

In addition to the usual mayhem post bank holiday, I've a meeting to go to at lunchtime to do with Practice Based Commissioning.

There's been no shortage of press coverage concerning the perilous state of NHS finances.

So the next great scheme to save money is PBC, with GPs shouldering the responsibility of whether it succeeds or fails.

Each GP practice has their own "indicative budget". Everything that I refer to secondary care (outpatient referrals, emergency admissions etc) has a tariff, and all the medications I prescribe have a cost. Add up the total cost of all of these, and this is what I spend out of the NHS pot. This is my indicative budget.

Now I don't get actually get a cheque for this amount, it's all a notional idea. The Primary Care Trust (PCT) writes the cheques to the local hospitals.

With PBC it is now down to me to make savings on my indicative budget. In other words I need to spend less. So how do I do this? 2 ways; I buy things more cheaply, or I buy less.

So how do I buy things more cheaply? Take the example of a patient with a heart problem. I decide to refer them. It doesn't matter which hospital in the country I refer them to because there is a national tariff, so it will cost exactly the same. However the tariffs only apply to hospital care. So if a similar service is working in the community, charging less, then I can refer here and save money. The government are pushing for this.

The current trend is to set up a service in the community with a GPWSI (see this post for what a GPWSI is). Factoring in everything, this may not actually work out cheaper at all.

As an aside, I am supposed to offer up to 5 choices to my patients as to where they would like to be referred to. If offered a choice between a consultant or GPWSI, I know who I would choose. But if I want to save the NHS some money, I must try to steer the patient towards the GPWSI option. I see this as a conflict in interest.

Coming back to my 2 options for saving money, the second is to buy less. In other words don't refer so many patients, admit so many patients, or prescribe so many medications.

And so my meeting today is to look at strategies to avoid admitting so many patients to hospital. Sounds daft? Well it is and it isn't.

There are a large number of patients (mainly elderly) who become unwell and are unable to look after themselves temporarily. They are not life-threateningly unwell, but stop coping. Ideally they need 24 hour supervision rather than acute medical care. With adequate social support, numerous admissions could be avoided. But social services have their own cash-strapped budget, and the reality is that they are rarely able to help when someone becomes ill and stops coping. The only option is to admit to hospital.

But many patients are admitted out of hours, or directly via A+E, over which I have no control.

So what's in it for me? The government has said that practices can keep up to 70% of savings to invest in its own practice. This isn't income, and there are strict guidelines as to how any savings money could be spent.

But as there are unlikely to be any savings, then the answer to "What's in it for me?" is nothing, apart from blame when it doesn't work.