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Practice 'clusters' urged to lead next phase of NHS revolution Pharmafocus June 2006

England's general practices are being urged to seize their opportunity to re-build the NHS as a primary care-led, patient-centred service, but the government is battling against considerable apathy and doubt among primary care professionals.


Practice-based commissioning (PBC), whereby GPs and nurses control budgets to commission better, more convenient services for patients, was first proposed in 2004 as a voluntary offer to those looking to speed up change. But practices are now obliged to take part, after the government decided that universal uptake was vital to accelerate the pace of NHS reform.


A target date of 100% uptake by the end of 2006 has now been set, but while there are a large number of enthusiastic practices forging ahead, many others are disengaged from the process, suspicious of yet another Whitehall-led reform.


At a recent NHS Confederation conference on PBC, one GP asked a panel of primary care leaders: "Can anyone convince me that we aren't just being set up to fail?"


Around 20% of England's practices have signed up to PBC, which works by practices collaborating with their neighbours to form clusters, thereby pooling expertise and resources to re-design care.


One GP supporter said:  "It's the first time that lots of practices have come together. There's a real buzz about it - it's really exciting.


Despite the enthusiasm of the early adopters, the government and primary care leaders know they have to win over all practices, but, nevertheless, say PBC is the only way to create a primary care-focused health service.


Dr Michael Dixon, a practising GP and chairman of the NHS Alliance has strongly criticised how the government has gone about introducing the system.


"When all the planning, all the thinking, is done at the centre or the SHA or within the PCT, then GPs, practice managers and other frontline clinicians feel they are regarded as an optional extra.


"If no-one asks them what they want to achieve and what support they need to achieve it, then that is no different from asking: 'Does he take sugar?'"


The NHS Alliance is urging its members to take up the opportunity, but says it has found very negative attitudes towards all the NHS reforms at its workshops for frontline staff.  


Dr Dixon says attitudes are often completely changed after the one-day workshops, which show staff the potential of the new system.


Even for enthusiasts, there are considerable obstacles to overcome. The system allows PBC clusters to commission services and be in control of the budgets, while leaving the ultimate financial accountability with PCTs.


But many practices have yet to receive financial information about the cost of different treatments,  so-called indicative budgets, which are vital to planning services and investigating ways of improving services for patients, and saving the NHS money.


Mayur Lakhani, chairman of the Royal College of Physicians, is one of the primary care leaders urging clinicians to take the opportunity, but acknowledged that the administrative burden and lack of financial clarity so far made PBC a daunting prospect for some.


Practice-based commissioning is designed to be the main driver behind shifting care  - and NHS money - away from hospitals into the primary care. The government's latest blueprint for the NHS, its White Paper called 'Our health, Our care, Our say', proposed a transfer of 5% of acute sector budget into the community over the next decade.


Mayur Lakhani told Pharmafocus that while 5% may appear a modest shift over a long period, it was in fact a massive amount in financial terms, and would be a big challenge for primary care professionals to lead.


"We have to get real. There are too many people in secondary care who dont need to be there," he said.


In order to transfer funds from hospitals to the community, money must be disinvested from acute services  - something which doctors and managers in secondary care will strongly oppose if primary care leaders do not win them over early on in the process.


A number of clinicians at the NHS Confederation conference voiced their doubts about the will of government to support this disinvestment.  Equally, many also doubted one of the key assumptions behind government promotion of PBC.


The government hopes that preventing unnecessary admissions into secondary care by diagnosing and treating patients earlier within the community will reduce demand on the system and help save money.


But clinicians expressed strong doubts about this assumption, and while a lot of pioneering work done on service re-design has produced savings, some projects have suggested costs could rise as the quality of patient care increases.


Implications for pharma


The rapid setting up and growth of PBC clusters across the country presents a considerable problem for pharmaceutical companies, which need to identify and understand key decision-makers in every region.


The somewhat virtual nature of the clusters means they do not exist as bricks-and-mortar organisations, making them more difficult to track and understand than traditional NHS decision-making bodies.


NHS data specialists Binley's is one of the leaders in mapping out and understanding PBC clusters.


To date, the company identified 102 clusters nationally comprising a total of 1,035 individual practices.


On average, each cluster contains just over 10 practices, but there is no ceiling on the number allowed in any one cluster.


PCTs are accountable for the clusters and must performance manage them.  So far, just a handful of PCTs have appointed dedicated directors of Practice Based Commissioning to oversee the work in their area, but Binley's expect many more to be named across the country in the coming months.

John Chater, online development manager at Binley's said: "Understanding 300 or so PCTs is manageable, but understanding 8,000 GP commissioners is a completely different exercise, so that's yet another learning curve for the pharmaceutical industry in understanding the NHS." 

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