Published: 10/03/2005, Volume II5, No. 5946 Page 17

It is that depressing time of year when the focus on financial balance means that conversations with acute trusts become heated and there is the inevitable tension about endof-year finances. This year the ante has been upped further by a persistent rumour that primary care trusts which overspend will score an automatic zero-star rating.

This financial year has seen increased pressure from uncoded and hitherto unseen activity appearing in baselines, as well as the predicted rise of complexity in case mix.

Never has the activity and accuracy of the coding department been so important. This means, of course, that acute trusts must become more accurate in what they measure, but it also requires PCTs to be more dynamic in deciding what and where they buy activity. The real source of active help in achieving this goal is practice-based commissioning.

From my point of view, practicebased commissioning is a partnership between the PCT and clusters of practices that can realise the choices open to patients who need elective care. It can also make real the developments in community-based care that can prevent unnecessary admission or attendance at hospital.

Too often PCTs, or previously health authorities, have implemented new community services, based on good practice or royal college guidelines that have not been taken up by local GPs and patients. This has reinforced the view within some hospitals that community services never deliver the promised benefit and therefore the only way to affect change is to invest in acute care.

What many of us have been guilty of is using the evidence to set up the service and forgetting to get the buy-in of the local clinicians. We do not ask, 'why should they change?' Clinical champions can advise and design a service to increase the possibility of it delivering the desired outcomes, but local practitioners need to be convinced of the benefits, if they are to make the necessary changes to their daily practice.

Practice-based commissioning aligns the incentives so that a change in care for the practitioner, be it referring to a community-based service or treating the patient in house, delivers benefits for the locality or cluster of practices. Hardnosed business cases that deliver real savings, without being detrimental to quality, have much more impact if practices can see and share the financial windfall.

Thus the real benefits from practice-based commissioning can only be achieved with the active engagement of GPs. Scepticism from the dissolution of fundholding, together with inconsistencies in the policies that are abundant at the moment mean that we in the PCT are having to campaign actively on the advantages of practice-based commissioning - which is a bit like turkeys voting for Christmas.

Since that rarely happens, suspicion is rife. 'What's in it for us?' or 'what's the hidden agenda?' are phrases commonly heard. Our task is made even more difficult when we have difficulty in lining up the various policies designed to take forward agreed service improvements.

Locally, we have agreed to move the care of patients with chronic disease into the community - providing increased access and appropriate care. In the days of fundholding, practices were able to make service changes in an ad hoc way - practices had different priorities and so trusts were left to pick up the consequences of many minor changes.

Today, PCTs and practices should work together to identify priorities for action and models of care. But the guidance is imprecise and even some academics are promoting the freedom for practices to experiment without reference to the need to co-ordinate action to maximise benefits.

The importance of the local delivery plan in cementing service developments together is being at best underplayed and at worst ignored. In systems where there are significant financial problems, only by acting together can sustainable solutions be found.

Even where consultants, hospital staff, community and GPs can agree on priorities and models of care, implementation comes up against policy issues.

Under payment by results, a service change that moves care from a hospital means less income for that trust. If this occurs in a significant way, the hospital has to pay for its infrastructure costs from reduced revenue.

Most costs are tied up in staff, so the obvious way forward is for staff to transfer to run the service in the community. This seems sensible as it ensures good use of scarce talent and also means quality of care is protected.

However, practice-based commissioning guidance stresses the ability of commissioners to provide service using different skill mix - for example, diabetic technicians caring for stable diabetics rather than nurses or dieticians. Similarly, there is significant emphasis placed on the opportunity for practices to treat more patients 'in house'. making demand management a reality not the Holy Grail.

Neither of these ideals seems to help the health economy balance the books and where the opening position is acute deficit, then it seems perverse to argue for the desirability of practices taking work from hospitals.

Overwhelming evidence shows that much more care could be delivered cost effectively in the community, so the direction of travel is right. But the problem is how to manage local finances while giving practices sufficient incentive to get involved and deliver changes in care. Answers on a postcard, please.

Lise Llewellyn is chief executive of Brent primary care trust.

HSJ is staging a practice-based commissioning conference on Thursday 28 April in London. Key note presentations come from Julie Taylor, programme director for system reform at the Department of Health and national clinical director for primary care Dr David Colin-Thomé.

For details, visit www. hsjgpcommissioning. co. uk