Lack of high quality data is one of the key factors behind the poor progress of practice-based commissioning, the King’s Fund has concluded.
The think-tank is calling for a major shake-up of PBC, following an in-depth, two year study of four primary care trusts in England.
The report, Practice-based commissioning: Reinvigorate, replace or abandon? says data was a key problem for all four of the PCTs studied, with lack of timely and accurate information having a knock-on effect on business case approvals. GPs also lacked the appropriate skills to carry out data analysis.
The report welcomes Lord Darzi’s commitment to persevere with PBC, but concludes that it has so far proved to be an expensive investment that delivered little in terms of better services for patients or financial savings for the NHS.
It found that very few GPs are using PBC to commission new services, even though GPs have received almost £100m in incentive payments.
Report co-author Nick Goodwin, senior fellow at the King’s Fund, said: “As a policy established to pump-prime the transition of care out of hospitals by investing in alternative care in local communities, it has so far failed due to a lack of real investment, leadership, ambition and drive.
“The NHS must harness what remains of the limited enthusiasm of GPs and commit to a fundamental redesign of the policy if it’s to live up to its potential.”
The report’s authors found that all the case study sites had experienced data problems, either because data was out-of-date or, in the case of one PCT, because the introduction of a new IT system at its main acute provider had led to a significant loss of data.
“Even where data was available, and practice-based commissioners had an inclination to use it, few GPs appeared to have the requisite data analysis skills to interrogate and analyse it properly,” the report adds.
“PCTs reported providing some training in computer systems, but most GPs reported having struggled with the process and having ‘given up’.”
Many GPs also reported a high degree of distrust in the accuracy of the data they received from hospitals. This led to problems and disagreements about budget-setting and budget expenditure, which meant it was difficult for GPs to make and retain ‘surpluses’ with any degree of certainty.
All four sites had also experienced disputes about the Payments by Results tariff, with disagreements about whether services provided outside hospital should be paid at a rate lower than the standard national tariff.
The report says: “The lack of standard national tariffs for such component services outside hospital, or for non-PBR services, is posing significant challenges to PCTs which, at present, do not appear to be confident enough (or equipped with adequate data) to be able to set rates locally.”
However, it also argues that many of the barriers that have stalled progress, including problems with data, should have been predicted – since they were also experienced when the Conservative government first devolved budgets to GPs through GP fundholding in the 1990s.
The King’s Fund has recommended that the government should set out a clear vision for the future of PBC and provide national guidance for GPs and PCTs. It says PCTs should maintain responsibility for strategic, population-wide commissioning while real budgets for specific services are devolved to GPs.
Conflicts of interest in the role of GPs being both providers and commissioners of care should also be tackled head on through robust governance arrangements, it concludes.
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Practice-based commissioning: Reinvigorate, replace or abandon?