Published: 07/04/2005, Volume II5, No. 5949 Page 30 31 32

With practice-based commissioning under way, HSJ surveyed 140 decision-makers in primary care trusts and practices on progress to date. We start with the trust perspective; overleaf, the view from practices. Alexis Nolan dissects the results

The practice-based commissioning revolution has begun. From the beginning of this month, GP practices have been able to request indicative budgets for the services to which they refer patients. This is the first step in directly linking the referral decision of GPs to the finance needed to buy those services.

The aim is to give GPs more visibility and control over their decisions, to deliver better patient care through redesigning pathways and to fund new primary care services through the savings the redesigns would release.

Underlying this is the fact that practice-based commissioning counterbalances the incentive payment by results provides for acute trusts to treat as many patients as possible.

But will it work? Last month, HSJ carried out a major survey in association with the National Association of Primary Care, the NHS Alliance and the National Primary Care Network.

Over the next three pages you can read the opinions of 140 decision makers in primary care trusts - including 31 chief executives and 35 professional executive committee chairs - and practices, including 56 GPs and 31 practice managers.

Two in three PCT chief executives feel that practices have at best poor readiness and capacity to deal with practice-based commissioning. Perhaps unsurprisingly, PEC chairs do not feel the situation is as worrying, with the corresponding figure standing at 46 per cent. One in three feel that practices are ready.

Although both groups feel that the biggest impact of practice-based commissioning will be to create a greater incentive to reduce secondary care referrals (93 per cent of PCT chief executives and 85 per cent of PEC chairs) and deliver greater clinical engagement (93 per cent and 74 per cent), there are other differences between the two groups in how they view practice-based commissioning.

Two thirds of PEC chairs feel it will produce more cost-effective commissioning, something with which less than half of PCT chief executives agree. And while 82 per cent of the chief executives feel their organisations will shoulder an unfair burden of the risk, just 47 per cent of PEC chairs agree.

More than twice as many PEC chairs as chief executives feel that practices will be able to make good use of efficiency savings and they are also more convinced that patient care will be enhanced.

NAPC chief executive Eric McCulloch says the finding that almost a quarter of PCTs expect more than 50 per cent of their practices to be actively involved in practice-based commissioning during the course of this year was a 'significant achievement' for what will be, for many, a preparatory period.

'Given that the technical guidance has only recently been issued, one would not 30- expect practices or PCTs to be prepared to undertake practice-based commissioning at this point, ' he says. 'Six months further on and the picture will change significantly.' He also welcomed the finding that 98 per cent of practices intend to be involved in practicebased commissioning by 2008. 'This is an amazing figure, ' he says. 'Practices are recognising its value for their patients.' National Primary Care Networks leader Edna Robinson welcomed the optimism of clinical leaders. 'While There is a difference between PEC chairs and PCT chief executives about practice-based commissioning, That is understandable given the kind of roles in their organisations.' She also expects to see practices' initial interest in elective care as they take on commissioning budgets and target efficiency savings to evolve into other areas. 'I hope that we will see a move towards more complex and urgent care, ' she says. 'Practices do identify service redesign as core to this [practice-based commissioning].'

Find out more

Although the survey was confidential and anonymous, if you are interested in finding out more about the results, e-mail alexis. nolan@emap. com.

National Association of Primary Care www. napc. co. uk NHS

Alliance www. nhsalliance. org

National Primary Care Network www. natpact. nhs. uk/cms/367. php


Fewer than one in four PCT respondents said that more than 50 per cent of practices in their area would take an active role in practice-based commissioning over the course of this financial year.

While the take-up is modest, but still significant, the amount of money expected to be handled by practices is significantly less. Just 12 per cent of PCTs expected practices to actively manage more than half their commissioning budget this year.

What proportion of GP practices in your area do you estimate will take an active part in practice-based commissioning between April 2005 and March 2006?

do not know (3%)

51% plus (24%)

31-50% (17%)

Less than 10% (27%)

11-30% (29%)

What proportion of the PCT commissioning budget do you expect to be actively managed by practices by March 2006?

do not know (14%)

51% plus (12%)

31-50% (8%)

11-30% (27%)

Less than 10% (39%)


What specialisms do you expect practices will be most interested managing the commissioning budget for?

Electives 24%

Outpatients 22%

Community nursing and services 21%

Long-term conditions 21%

Emergency 20%

Diagnostics 14%

Orthopaedics 12%

Dermatology 9%

Diabetes 8%

Prescribing 7%

Mental health 6%

Do you expect groups of non-practices - for example, nurses - to manage commissioning budgets in your PCT during 2005-06?

9% Yes

91% No


Will your PCT develop a contingency fund to help manage the risks of overspend?

80% Yes

20% No


This will not make good reading for the government. Yes, the idea of practicebased commissioning is good: better clinical engagement, fewer referrals to acute trusts and altogether more cost-effective commissioning and, probably, better patient care. But PCTs are worried about where the financial risk lies and feel that guidance has been unclear and incentives to practices are lacking.

Which phrases do you believe most accurately describe the current proposals?

It will enhance patient care 52%

It will reduce the quality of patient care 0% It will produce more costeffective commissioning 58%

It will produce less costeffective commissioning 7%

It will deliver greater clinical engagement 88%

It will reduce prescribing costs 18%

There is enough incentive for practices to adopt commissioning budgets 19%

The rules and guidance around practice-based commissioning are clear 10%

Practices will be able to make good use of efficiency savings 37%

It will give GPs a greater incentive to reduce secondary care referrals 86%

PCTs will be asked to shoulder an unfair burden of financial risk 53%


At face value, it looks as if the government could be setting itself up for a fall by making practices that want to adopt practice-based commissioning commit to its choose and book programme. The overwhelming majority of practices do not support the link between the two. However, more than half are planning to actively manage budgets this year and only one of those not planning to do so highlighted the requirement to use choose and book as a reason.

What impact do you think the government's insistence on using choose and book will have?

Greatly encourage practices to adopt practice-based commissioning 2%

Encourage 17%

Greatly discourage 23%

Discourage 57%


Will you commission individually or with other practices?

36% Indidvidually

64% With other practices

2005-06 ADOPTERS

Half of practices (53 per cent) are expecting to manage budgets under practice-based commissioning this year. Almost two-thirds said it would enable more cost-effective commissioning and good use of efficiency gains.

What would you spend any efficiency savings on?

Specialist care 44%

Diagnostics 58%

Medical equipment 48%

Staff 74%


Top 12 specialisms practices want to commission a budget for



All Community nursing


Long-term conditions

Mental health


Ear, nose and throat





Why will you not be adopting practice-based commissioning in 2005-06?

Too little incentive 58%

Process for setting practice budgets is unfair or inaccurate 33%

Do not believe it will enhance patient care 30%

Do not have the necessary skills within the practice 30%

Do not have the necessary workforce within the practice 64%

Our PCT is being obstructive 6%

Acute trusts are being obstructive 0%

The rules/guidance around practice-based commissioning are unclear/confusing 73%

We are unsure that there will be sufficient finds to cover management 55%

The top-slicing of devolved budgets to provide a risk management 15%