Simon Stevens' piece on payment by results summarised some of the shortcomings of the system, but not all the disadvantages as seen from a commissioning and public health viewpoint, writes Peter Brambleby

For starters, it is payment for activity, not results, so it does not do what it says on the tin. It is quite possible for a commissioner to secure more activity through "technical efficiency", but since payment is indifferent to outcome, there is no assurance of commensurate health gain, let alone a money-back guarantee for adverse outcomes. "Allocative efficiency", which he dismisses as "a job for commissioners", is actually the more important aspect of efficiency because it seeks to maximise health gain from the budget available. Productivity (output from investment) is not the same as efficiency (outcomes from investment), so payment by results is at best a blunt tool.

"Patient dowries" is an unfortunate metaphor, conjuring images of daughters or sons being treated as commodities to be traded in a market. Do we really want this model where patients, or episodes of care, are commodities to be bought and sold? Is it not better to go for a love marriage between willing partners in health and social care?

Payment by results should not overstep its objectives. It was introduced primarily to encourage the private sector (like UnitedHealth) to compete for NHS contracts within an assured income. It had the secondary aim of moving care from hospitals, where the tariff was fixed, to the community, where it was not. It lacked the complementary process where patterns of care and health outcomes would be the primary drivers and payment by results tariffs simply the payment mechanism.

The prevailing ethic of those who work in the caring agencies is collaborative, not competitive. Instead of "unbundling" the tariff further - to the extent of invoicing for emails and phone calls - why not go the other way? Anyone for "rebundling"? Why not commission by health programme and adopt the model of programme budgeting, for which there is growing evidence?

Dr Peter Brambleby, director of public health, North Yorkshire and York PCT