Practice-based commissioning (PBC) is no longer

the new kid on the block of NHS reform. A direct

descendant of the purchaser–provider split conceived

by Margaret Thatcher and Alan Enthoven as part of

the market reforms of the 1990s, referred to in earlier

policy documents and developed in the White Paper on community care, Our health, our Care, our Say it is nevertheless a move towards greater partnership and

patient centredness in health care. Whereas general

practice (GP) fundholding encouraged individual entrepreneurialism which subsequent primary care groups

and trusts were never able to match, PBC, by working

directly at the coalface of primary care, does have the

potential to lead to rapid transformation more widely

Siriwardena, A Niroshan

English

University of Lincoln Institutional Repository

EditorialCommissioning for qualityA Niroshan Siriwardena MMedSci PhD FRCGPFoundation Professor of Primary Care, School of Health and Social Care, University of Lincoln, UKPractice-based commissioning (PBC) is no longerthe new kid on the block of NHS reform. A directdescendant of the purchaser–provider split conceivedby Margaret Thatcher and Alan Enthoven as part ofthe market reforms of the 1990s, referred to in earlierpolicy documents1,2 and developed in theWhite Paperon community care,Our health, our Care, our Say3 it isnevertheless a move towards greater partnership andpatient centredness in health care.4 Whereas generalpractice (GP) fundholding encouraged individual entre-preneurialism which subsequent primary care groupsand trusts were never able to match, PBC, by workingdirectly at the coalface of primary care, does have thepotential to lead to rapid transformation more widely.5I am grateful to Steve Gillam for guest editing thisspecial section ofQuality in Primary Care and attract-ing a stellar cast of contributors devoted to exploringwhere PBC has come from and how it might deliverthe quality of care that the recent investments in healthhave promised. David Colin-Thome´, the Primary CareCzar, explains how general practice is uniquely andideally placed for comprehensive care, for decisionsabout whether and what to purchase and for theextension of primary care to provide a greater rangeof services, neatly summed up as ‘make or buy’.Martin McShane and John McIvor, argue that PBCcan square the circle of an individual focus with apopulation approach and how this will require morereﬁned systems and processes for quality improvement.Mike Dixon of the NHS Alliance discusses where PBChas come from, how it has the potential to harness theenergy of primary care for transformational changeand what the consequences might be if this policyexperiment does not succeed. Finally Richard Lewisand Steve Gillam argue that for PBC to succeed weneed to increase professional engagement, providetimely and valid information and support the com-missioning process with responsive management sys-tems.Indeed, information and management systems, intheir broadest sense should be at the heart of PBC.Ben Skinner provides an overview on the increasingamount of information about tools and techniques forquality improvement. Currently, many of the modelsfor improvement are not an integral part of PBC, butcommissioning groups do have the potential to supportand measure the eﬀects of change. Indeed commis-sioning clusters and primary care trusts will needto improve the quantity and quality of informationavailable on patients’ health needs and outcomes forpatient choice to become a reality. Of course, there isalready a vast amount of data on conditions that arecommon and important, or that lead to signiﬁcantdisease, disability, death and cost. However, what isconsidered important has traditionally been deter-mined by providers of health services whether theybe doctors, drug companies or the government. In-volving patients and understanding their views onhealth needs and outcomes will inevitably become agreater priority for providers and commissioners ofservices. Information on providers can also revealimportant gaps in care through excessive variationor adverse events. There is a sense that in any processwhere there is a large variation there must be aproblem with the processes for delivering that carebut we do not deﬁne what acceptable and unacceptablevariations are and have not yet developed satisfactorymechanisms for doing this. Failure to implementevidence is often organisational and PBC clusters willneed to become more sophisticated in their approachto implementation. In the past it has been the provideror the organisation that determines where the needs,gaps and failures are and what should be done aboutthem and this is an approach that has led to hugewastes of money. The overtreatment of glue ear andincreasing use of drugs for social conditions areexamples of this.The early phase of ‘experimental implementation’in PBC is rapidly being superseded in ‘early adopter’sites by more focused approaches in primary care.Despite the evidence that there is clinical engage-ment,6 the problem is that real evidence of the eﬀectof the new policy is lacking and research, whether toinform or to understand the eﬀect of change, is oftennot high on the agenda of commissioners who areworking hard and fast to develop new models ofservice. Whether the model is of federations of prac-tices, polyclinics or another paradigm, the need tointegrate, improve and commission high-quality pri-mary care will remain. Norman Weir and colleaguesQuality in Primary Care 2007;15:323–4 # 2007 Radcliﬀe PublishingAN Siriwardena324have looked at how increasing choice through therecently implemented system of ‘Choose and Book’has supported or hindered patients’ decision making.Together these articles show what possibilities mayarise from PBC. While the debate about whether thenew policy will work still continues,7,8 the articles herehighlight the dearth of empirical research that existson PBC, and perhaps because of its complexity this isnot surprising. I hope this special section encouragesand stimulates new avenues of research and explo-ration into how PBC is being implemented and theeﬀect it is having.REFERENCES1 Griﬃths R.Community Care: agenda for action. London:HMSO, 1988.2 Department of Health. The New NHS: modern, depend-able. Cm 3852. London: The Stationery Oﬃce, 1997.3 Department of Health. Our Health, our Care, our Say: anew direction for community services. Cm 6737. London:The Stationery Oﬃce, 2006. Available at: www.dh.gov.uk4 Hudson B. Policy change and policy dilemmas: inter-preting the community servicesWhite Paper in England.International Journal of Integrated Care 2006;6:e12.5 Ham C. Improving the performance of health services:the role of clinical leadership. The Lancet 2003;361(9373): 1978–80.6 Department of Health. Practice Based Commissioning:promoting clinical engagement. London: Department ofHealth, 2004.7 Smith J, Dixon J, Mays N et al. Practice basedcommissioning: applying the research evidence. BMJ2005;331(7529):1397–99.8 Greener I and Mannion R. Does practice basedcommissioning avoid the problems of fundholding?BMJ 2006;333(7579):1168–70.ADDRESS FOR CORRESPONDENCEProfessor A Niroshan Siriwardena, Foundation Pro-fessor of Primary Care, School of Health and SocialCare, University of Lincoln, Lincoln LN6 7BG, UK.Tel: +44 (0)1522 886939; fax: +44 (0)1522 837058;email: nsiriwardena@lincoln.ac.uk

Care: agenda for action.

Does practice based commissioning avoid the problems of fundholding?

Health. Our Health, our Care, our Say: a new direction for community services. Cm 6737. London: The Stationery Oﬃce,

Health. Practice Based Commissioning: promoting clinical engagement. London: Department of Health,

Health. The New NHS: modern, dependable. Cm 3852. London: The Stationery Oﬃce,

Improving the performance of health services: the role of clinical leadership. The Lancet

Policy change and policy dilemmas: interpreting the community servicesWhite Paper in England.

Policy change and policy dilemmas: interpretingthecommunityservicesWhitePaperinEngland.

Practice based commissioning: applying the research evidence.

Commissioning for quality

Commissioning for quality

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