Type PbR into Google and as of end September 2008 you will get 6.9 million hits. The first two are what you and I understand PbR to mean.

I was briefly distracted by the third listing on Google - Professional Bull Riders. Don't you just love the English language!

I accept the one positive aspect of the PbR instrument - it has the potential to reveal the income side of a health transaction, appreciating that since the 1970s the only increasingly numbing noise emanating from London was costs, costs and costs.

I say potential because that is what it remains - the potential. Read the history of the NHS and restructure after restructure has been in part blighted by lack of cost transparency. Most of you will know that delivering health is not the same as delivering cat food. The price structure for feeding our environmentally wasteful feline friends is easy to work out, with or without that extra special Chinese ingredient; calculating the price structure for your subsequent kidney failure therapy is unfortunately not so easy.

NHS organisations are generally not able to apportion with any accuracy or consistency the indirect costs that have to be added to delivering a ward round or a dialysis session, but we are trying, and it is a steep and precarious learning curve requiring time and financial resources that will never be accounted for in pricing the PbR policy as a whole.

Despite PbR still being an immature instrument, service damaging decisions are being made within organisations and across regions as managers think and behave on the basis that activity is everything. The latest twist is to try and attach a quality rider to a very small part of the overall PbR income. The patient deserves quality but we apparently need the activity - a policy consequence that could have been predicted at A-level economics, never mind the MBA. Could the acute sector benefit (or afford) what motivated primary care, QOFfs?

QOFfs - work this one out and post your response anonymously - that way I can't send you the prize.

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