The Changing NHS

by Dr Jonathan Shapiro - Guest Blogger

Payment by Results (PbR) was introduced into the NHS to ensure that hospital activities (it was never about results, only activities!) could be linked to their costs. The idea was that hospitals would have to justify their actions to their paymasters (initially Primary Care Trusts, but ultimately Practice based Commissioning (PbC) clusters generally run by local GPs), so that the system could assure itself that expensive hospital services better matched the needs of the population, rather than the established tradition of hospital supply determining patient demand.

The system was predicated on having strong commissioners, not only at the strategic population based level (the intended role of the PCTs), but also at the more operational, individually focused level. Here clinicians (usually GPs) were intended to use their working knowledge both of individuals’ clinical needs and of local hospital providers’ strengths and foibles, to case manage their patients through the system effectively and efficiently.

So far, so sensible, but given that the notion was imposed by the Department of Health, and merely formalised the existing referral control mechanisms that had been in place since 1948, it begged the question of how to persuade the referring GPs to use the new tool, rather than ‘playing’ or simply ignoring it.

It was clearly not ‘owned’ by the GPs, and did not offer them any obvious personal or clinical advantage, but it did have the potential to introduce more control over hospital activity, itself potentially a powerful motivator.

Unfortunately, attempting to shift the locus of control over hospital activity to PbC has fuelled resistance from PCTs as well as from hospitals. A number of PCTs are resisting the introduction of effective PbC by diluting its key levers; either passively (‘PbC will work more effectively for you doctor, if we co-ordinate all your intentions’) or more actively (‘we can’t afford to let the GPs decide referral patterns, they’ll only do what’s in their own personal interests’), PCTs are finding ways of not letting go of the operational aspects of commissioning (what used to quaintly be called ‘purchasing’ in the early 1990s).

Consequently, PbC is simply not happening to any significant extent; you may argue with this point, but the reality is that PbR is still racing ahead, that hospitals are generating income by their activity, and that the intended brake on the system, PbC, is simply not strong enough or widely placed enough to slow down the express train of hospital activity.

The NHS has a tradition of muddling through (elegantly or otherwise), and in the absence of overt, clear controls, more opaque, Machiavellian, mechanisms will emerge, that are likely to reflect established patterns of power and patronage, rather than the real health needs of the population. If PbC is not clarified and strengthened quickly and radically, then the potential powerful, positive tension between PbR and PbC will be lost, to be replaced by a regression to an ineffective and unpopular mean that will help nobody, and further diminish the reputation of the public sector as a system that is capable of defining and managing its own destiny.

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