Look at the positive elements and get practice-based commissioning rolling, urge Michael Dixon and colleagues

Look at the positive elements and get practice-based commissioning rolling, urge Michael Dixon and colleagues

Recently in HSJ,.Simon Stevens joined those who suggest practice-based commissioning might not be a sufficient response to deficiencies in commissioning ('Simon Stevens on the great PBC debate'). As a key architect of recent NHS reforms, his views should be listened to. But is he wrong this time, or at least too pessimistic?

Of course, there is no single cure for the NHS's ills. But while PBC is no panacea, it could prove a powerful medicine if given a little time and a lot more support.

PBC looks to be a potent policy. It is fundamentally decentralising - frontline clinicians and managers gain a greater say in local health and services than under primary care trust commissioning, with the prospect of introducing greater sensitivity to patient needs.

This is particularly so if - as is happening - commissioners involve patients in new ways. Primary care clinicians are well placed to take an overview of the health system and to identify where services are deficient.

PBC also represents a rebalancing of clinician/manager relationships, emancipating frontline clinicians to become leaders of change rather than victims of it. And it symbolises a rebalancing between provision (historically strong) and commissioning (historically weak), with the commissioner joining forces with those most involved in the day-to-day choices patients make.

Controlling costs

PBC also has an important role to play in controlling NHS expenditure - increasingly important as incentives for providers to increase activity begin to bite. GPs and their teams hold the NHS's chequebook. This will continue whether or not PBC is a success. But PBC offers opportunities to bring greater accountability alongside the power to spend money.

So why does this array of reasoned arguments in favour of PBC not convince its detractors? Typically, PBC sceptics suggest that GPs and their teams are neither up for it nor up to it. It has been argued that most frontline clinicians do not want to participate in commissioning and those who do lack the required skills.

The number of GPs and practices interested in PBC depends on the support PCTs give it. Where teams feel unsupported, they are unlikely to embrace it. This has been underlined by a King's Fund/NHS Alliance report showing that while most practices felt they did not get basic support from their PCTs, most were committed to commissioning and expected it to generate patient benefits this year.

Even if some practices are uncommitted to PBC, the argument that there will be too few involved to make it a success should still be challenged. Figures suggest that 90 per cent of all GPs belong to PBC consortia. On average, these comprise 10 practices representing 60,000 people. Not all practice team members need to be active for these groups to be effective. Rather, this will require a cadre of clinical and managerial leaders with the skills and charisma to enthuse frontline clinicians and drive change.

While it might be tempting to see commissioning as requiring a capacity beyond primary care rank and file, the argument should be resisted. The building blocks of good commissioning are determination, intelligence and imagination, combined with a deep knowledge of patients' needs and how clinical services are delivered. These attributes are found every day in primary care. Commissioners at all levels need sophisticated support if they are to make good decisions but this should not be confused with commissioning.

There has been a tendency to mystify commissioning as an art only for experts and senior managers. A collaboration, in fact, being run by the Improvement Foundation is already showing real improvements owing to PBC.

Morale dilemma

Lukewarm support for PBC endangers frontline morale and the willingness to play any active role in commissioning in the future.

We believe there are enough enthusiastic frontline clinicians to make PBC a success. It is a bandwagon that can deliver more and more as clinicians, patients and the rest of the NHS begin to realise its benefits.

It is time for the NHS to believe in its clinical frontline to deliver, when the alternative has failed. Practice teams need effective support from PCTs, strategic health authorities and the Department of Health. Most of all, they need proper information and resources to do the job. It is worrying that this support is lacking at the time when the first green shoots of PBC are beginning to emerge. PBC is not fatally flawed, it simply has not been given a proper chance to succeed.

Dr Michael Dixon is chair of the NHS Alliance. Dr Richard Lewis is a senior fellow at the King's Fund and Sir John Oldham is head of the Improvement Foundation.