Primary care is losing out to the “gaming” tactics acute care trusts use to bolster their income, claims GP chair of the NHS Alliance, Mike Dixon.
Interviewed in the latest issue of the British Journal of Healthcare Management, Dr Dixon says that Payment by Results (PBR) is fundamentally a good principle, even if flawed in practice, because it provides primary care with a real opportunity to assess how money is spent.
But codings are problematic, especially for very complex care, he says, and PBR allows for “gaming,” such as treating antenatal patients as hospital admissions, payments for emergency care, and “upcoding.”
“Given that the average patient has two or three codings, that could mean up to 40% of work is being wrongly coded,” he says. “That’s a lot of potential error in favour of acute trusts,” he contends.
He calls for completely independent codes and “decent benchmarking” to spot anomalies quickly and prevent the necessity of checking each and every bill and the emergence of yet more bureaucracy.
Moving on to Practice based commissioning, he suggests that this has the potential to make real changes, but the data on which it is based are letting the whole process down.
“It’s not just about getting the right data, it’s about getting the right data in usable form, so you can change behaviour in referrals and use of diagnostics, and properly check that you’ve got what you’ve paid for,” he claims.
GPs should not be afraid to take advantage of the experience and know-how of private providers, who can really help PCTs to speed up commissioning by enabling them to access the required information, he says.
Dr Dixon also supports the much touted concept of polyclinics, suggested by the recent Darzi interim review of the NHS, but leans towards a model of retaining local practices, but with access to central resources and improved diagnostic and outpatient facilities.
But at the moment it is unclear who will run and finance them, he says, adding that the term itself puts people off. “Polyclinic is a pretty bad word…It has ghastly Eastern European tractor factory connotations.”
Asked about the criticism levelled at GPs over the new contract, and the BMA’s role in negotiating it, he accuses the doctors’ union of being far too concerned with money.
“I think it’s ridiculous when the BMA always first talk about how things have to be paid for, without providing leadership and clear vision of what we actually want to see general practice look like in the future,” he declares.
“…the professional tradition, commitment and compass of GPs has always been about giving a bit more than you get. Long may it be so.”
British Journal of Healthcare Management 2007; 13: 416-20.