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A sea change for management? Between the devil and the PbC

1 March 2006

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David Shields
Independent Management Consultant

David has a keen interest in healthcare reform. He has worked as an intelligence officer with NATO and the UN in the Middle East and Balkans, before resuming his former business and helping to meet the challenge of NHS reform

Much has been written, if not actually said, on what will be this year’s key concern of the contemporary NHS: practice-based commissioning (PbC). Some might therefore view this article as more of the same or mere philosophical musing. As with so many current NHS-related issues, perhaps it’s more a question of personal judgement and interpretation!

Where we might agree is that, without the full and successful implementation of PbC, most of the key benefits of other major reforms will be lost. The risk is then having just another commissioning framework, one that doesn’t quite live up to expectations but effectively prevents workable alternatives being genuinely developed at a local level. The real paradox and very effective barrier to change is that at grassroots level, as well as in the corridors of power, there is a shared recognition that PbC could either provide the glue that holds it all together or be the straw that breaks the camel’s back, depending on individual perspective.

As practice managers, do we really want to wait until all the important decisions are made elsewhere – either in a “pilot”, conducted somewhere far removed from our practice, where both practice(s) and PCT are not quite the same as yours, or worse, where another PCT and/or SHA feels compelled to do something, anything, to overcome a perceived inertia, forming a “solution” that is then picked up as a way forward for all?

There is a very real risk of this. But perhaps there has been enough of a sea change to recognise that practice management has at last come of age as a professional body, ready to take its place in the strategic decision-making process. And perhaps PbC is the vehicle for practice managers to actually make some real difference, rather than merely talking about what difference we could make if only we had the chance!

The prospect of change
PbC – or at least something very, very close to it – offers an opportunity for us all to participate. This could include, for the first time, patients routinely sharing information to satisfy our individual needs, irrespective of what those needs actually are – medical, management, financial and accounting, auditing and so on. Critically, it may allow the patient to be viewed as exactly that – not as a number, a dry statistic, an “accounting episode” or a drain on resources.

PbC could create an environment where “measuring and monitoring” are synonymous with “treatment and care”. Where “protocols and procedures” take their place as just some of the tools available in this holistic process that involves us all working in one single, unified team and not as several separate teams competing for finite resources across traditional divides, driven by parochial concerns or vested interests.

Utopian ambition or achievable reality? The province of the individual general practice manager is the only place that holds the information necessary to achieve any meaningful transition towards what the NHS aspires to become. After more than a decade of constant change, a significant number of general practices lead rather than follow. There are now enough practice managers in place to grasp fully the potential of PbC.

But is PbC a new way of working or just more of the same? Perhaps you’re thinking: “Is he actually talking about PbC at all or confusing it with some other current initiative that also claims to be central to the success of NHS reform?” Patently, what we have already on PbC is not precise enough to be used simply as a management process that we can all follow blindly. Nor is it prescriptive or formulaic – otherwise there would not now be this controversy or confusion. Management is more of an art form than an exact science, and while some managers may prefer to be directed, most welcome the opportunity to contribute in very tangible ways to the organisations in which they work.

Assessing the potential
Now, of course, we could view PbC simply as a management process that measures and monitors cost, if we believe that these roles are best left to remote managers in PCTs (and some may). But even with all the implicit tensions and complications of independent contractors working within what is still an essentially publicly funded organisation, we still might begin to see our roles and responsibilities differently, as many already do.

PbC offers us this potential for both good and bad, again depending on our individual perspectives. This may explain our reticence. It is a major undertaking, and we may already be losing sight of the wood for the trees. Change is a complex business, and we may need to “get it right first time”, to coin an expression much beloved of the TQM gurus of the 80s. Even so, we may yet find ourselves afflicted by the “paralysis by analysis” that anyone even marginally involved in planning new activities and services can recognise.
On balance, it has to be said the risk is greater from the latter than from the former! There remains a plethora of strategic-level documents still emanating from the DH and some very good, pragmatic guides being produced elsewhere.

There is still much confusion and not a little cynicism among practice managers over what PbC will actually mean for their practices and patients. Why should this be, when for so long most GPs have cried out for more control over their patients’ treatment beyond the recognised limits of primary healthcare? Perhaps for the first time we now have the means (if not necessarily the will) to share information routinely between all healthcare-related professionals, as well as those involved in equivalent social support and community care? Is it perhaps because we recognise that this is patently not yet the case and much work still needs to be done before we risk ruining all for the sake of incomplete preparation?

As always, there are more questions than answers. However, perhaps if we viewed PbC not as a complex management exercise or a single solution, but more in the manner of a “glue”, the whole process (for that is what it is) would not be nearly so frightening and the source of so much anxiety? PbC could be the glue that will hold primary healthcare in place while patients learn to exercise real choice and while the surviving PCTs learn to orchestrate and coordinate, rather than control and direct.

Sharing information
PbC is another opportunity for practices and PCTs to learn how to collaborate and cooperate routinely by-the-day, sharing information by-the-day, accepting a common purpose – the routine provision of primary healthcare for all patients, irrespective of age, colour, class or creed – by-the-day. PbC is an opportunity for sharing information in common standardised systems, each using the same information to satisfy their mutual and individual needs, getting past the old ways of working that have created so much extra work and continue to cause concern. It offers the possibility of a common culture, where reliable, real-time information is the currency of success and where the patient is routinely involved and reliably informed.

Money is, of course, a central concern, and this is why it is so vital for practice managers to be actively involved in PbC, routinely using money, among other things, as the measure of success, sharing rewards between patient and practice alike, keeping this particular decision-making process as close to the patient as is humanly possible.

PbC is the big one that will change forever the face of primary healthcare and the relationship between practices and PCTs – if not by this name, then by some other way further down the line.

This sort of change is the inevitable consequence of sharing information through robust, reliable information technology and recently unleashed market forces. It is neither perfect nor precise, but it is way, way past a mere idea. If we genuinely want primary healthcare to develop and drive the contemporary NHS, while patients learn to exercise real choice and while the surviving PCTs learn to orchestrate and coordinate, practice managers need to grasp this opportunity.

Moving forward
Not many years ago, primary healthcare was the bastion of the GP, supported by a relatively small number of related professionals in the Family Practice Committee (FPC). There were few practice managers and fewer “professional” managers in practice. We have come a long way in a relatively short time; even primary healthcare and the concept of an extended, mutually supportive primary healthcare “team” are relatively new innovations.

The rules have not yet been written! Our organisations and structures reflect this and, while it might be a very good idea indeed to talk of “choice”, patient power and integrated IT, we need to be absolutely clear that when “new managers” are appointed they bring with them fresh ideas and perspective. All this creativity and innovation should not be wasted by simply doing more of the same, relying on the direction of others less well placed to recognise the needs of our own practices.

If PbC is not simply to be another set of rules to follow, inadequately defined but masquerading as a real expression of general practice choice, we must simply wake up to the idea that our involvement should be here and now. This is the only way to help turn good, fresh ideas into a reality over which we have some control; we should not wait to be told how to manage the change.