Commissioning practice imperfect

The future of social care, particularly for adults, is entwined with that of primary health care. While the forthcoming white paper on social care and health and the reorganisation of primary care trusts have occupied much attention, social services have already had to get to grips with practice-based commissioning, another policy that aims to make services more responsive to needs.

Since April, doctors have been able to hold “indicative budgets” allocated by PCTs so they can directly commission services for their patients. The idea is that GP practices should identify the health needs of their local population then arrange services to meet them. By this time next year, the government wants all GPs to be engaged in practice-based commissioning.

But there has been some disquiet in social care circles about the impact this policy might have on the strategic planning of health and care services across local authorities, particularly those for people with long-term conditions. These were highlighted last week by Roy Taylor, director of community services at Kingston Council in London, during a King’s Fund debate (news, 24 November).

Also, in October, no directors who replied to a Community Care survey thought they had been given satisfactory guidance on practice-based commissioning, and more than three-quarters were unhappy with the way it was being rolled out in their area (news, 13 October). Royal College of General Practitioners chair Mayur Lakhani has faith in its ability to improve services, despite saying that the implementation of the policy has proved “challenging”.

Opportunities abound
It’s not all doom and gloom on the social care side though. Jeff Jerome, co-chair of the ADSS disabilities committee, thinks practice-based commissioning “opens up a lot of opportunities”. He says GPs can be the “natural allies” of social services because they are focused on local level needs. He feels the policy will be more effective if GPs form large clusters. At his own council, Richmond, south west London, practices  organised themselves into four localities, then into two, making it easier for the council to get an overview of all the services required in the borough.

But he has some concerns about how the policy will develop. “What everybody fears is that a number of groupings of GPs will want to do their own thing or will want to take over the whole thing,” he says.

Lakhani disagrees, saying GPs want to work with social services, but he argues that there should be better guidance in place for GPs on how to commission services.

Trusts maintain key role
Jerome predicts that PCTs will play a major role in the commissioning process for the foreseeable future. He says that GPs are “probably not well enough equipped” to manage the commissioning of all services by themselves for some time yet and will rely on their PCTs for support.

Jo Webber, deputy policy director at the NHS Confederation, says that while practice-based commissioning will enable decisions to be made based on local needs, PCTs will still play an important role in supporting GPs in strategic commissioning.

But a King’s Fund report last month labelled PCTs’ commissioning skills “underdeveloped” and Lakhani says PCTs’ record in commissioning has been patchy.

Local circumstances will dictate the scope and size of commissioning groups, says Webber, who believes GPs have much to learn from social care, and vice versa. “Social services have good procurement methods that health can tap into,” she says, “and there’s also some of the public and patient involvement mechanisms they have.” On the other hand, she says, social care can take advantage of GPs’ knowledge of the underlying health needs of the local population.

Although in some areas GPs are likely to form clusters that will overlap different councils, Webber does not think this will cause too many problems. “There are places that are natural health communities although a local authority boundary runs through them,” she says.

Webber also expects the government to publish more guidance on practice-based commissioning. Maybe this will go some way towards allaying the fears of social services.

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