Practice based commissioning in the UKBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b832 (Published 13 March 2009) Cite this as: BMJ 2009;338:b832
All rapid responses
Gillam and Lewis's assertion that there is little evidence that any
form of commissioning has greatly affected hospital services in the last
two decades is no surprise to me but seeing this revelation written down
is still truly mind-blowing - just think of the money time and effort
expended - all to no avail. They rightly warn that reinvigoration of
Practice Based Commissioning (PBC) will require more than just extra
funding but they have missed the diagnosis of three main diseases in NHS
The first malaise is top down management which totally ignores the
business needs (well known to all practitioners on the ground) of
delivering health care preferring to follow the latest fancies and
dictates of politicians, ministers and top civil servants.
The second illness is the severely bureaucratic system of management
found in all public services in which managers at each level filter out
bad news and pass up the good in what which Mr. John Spivey in a recent
letter to the London Times calls the 'sycophantic pyramid' so that
ministers at the top feel able to report that the evidence shows that all
is well and going according to plan whereas we at the pyramid base know
things are not at all right!
The third, possibly terminal, condition is the failure to provide
joined-up information systems linking primary care with other care systems
to allow informed evidence based commissioning decisions to be made.
This dangerous syndrome results in prejudice based health service
management and encouragement and perpetuation of non evidence based
The solutions suggested by Gillam and Lewis lack clarity and do not
go far enough. There should clear remedies prescribed to treat the
1) Radically change commissioning methodology. Use the excellent data
on General Practice (GP) clinical systems to inform commissioning
decisions and feed data from all other care systems to the GPs.
2) Make organisational changes in Primary Care with a new business
model to unify primary care, community care, social care - leading to
creation of Integrated Care Organisations.
3) Devolve responsibility for all commissioning to primary care
(which is where the government wants it)
Over the last two years the charity Doctors' Independent Network
(DIN) has been planning, designing and piloting a project using pooled
anonymised GP practice data to map each patient journey in secondary care
from referral to final outcome. This work can be used to model changes in
DIN would be interested in accessing the 'investment of £1m that has
been made to pump prime practical support for practice based commissioners
and their primary care trusts' for this project.
Roger Weeks is Managing Director of SafeScript Ltd., a company which provides coding and drug database services for health care IT. He is also acting chairman of Doctors'Independent Network (DIN)
Competing interests: No competing interests
Unfortunately Gillam and Lewis’s assessment of Practice-based
Commissioning gives an incomplete picture, missing some significant
evidence from a study undertaken here at the National Primary Care
Research and Development Centre. This study not only used interviews, but
also collected large amounts of data from the observation of meetings and
other activities related to PBC. We believe that this mix of methods
provides a more complete picture and avoids the problems inherent in
relying upon the opinions of respondents. We did find considerable
problems with some aspects of PBC, particularly relating to managerial
support from PCTs, provision of information and difficulties relating to
budget setting. However, our study found greater engagement with PBC than
did the King’s Fund. We were able to observe grass-roots GPs taking part
in meetings, engaging in peer-review of their referral and prescribing
behaviours, taking part in audits and making changes in their practices to
meet PBC objectives. We found that what was required was not universal
enthusiasm, but rather an acceptance by grass-roots GPs that the PBC
project was legitimate and agreement to set up systems within their
practices to meet objectives. Many of the changes we observed were not
those apparently anticipated by the initial PBC guidance, and it will only
be clear in the longer term what the impact is, for example, of GPs
systematically and regularly reviewing one another’s referral behaviour.
The interim results from this study are in the public domain and are
quoted in the Kings Fund report. A final report will be published shortly,
and a number of academic papers have been accepted for publication [1-4].
1. Checkland, K., Coleman, A., Harrison, S., and Hiroeh, U., 'We
can't get anything done because.' making sense of barriers to Practice
Based Commissioning. Journal of Health Services Research & Policy,
2009, 14 (1) 20-26
2. Checkland, K., Coleman, A., Harrison, S., and Hiroeh, U., Practice-
based Commissioningin the National Health Service: interim report of a
qualitative study. 2008, National Primary Care Research and Development
Centre: University of Manchester.
3. Checkland, K., Harrison, S., and Coleman, A., ‘Structural interests’ in
health care: evidence from the contemporary National Health Service.
Journal of Social Policy, In press.
4. McDonald, R., Checkland, K., Harrison, S., and Coleman, A., Rethinking
collegiality: Restratification in English general medical practice 2004-
2008. Social Science & Medicine. In Press, Corrected Proof.
KC, AC and SH have recently finished a research project relating to PBC
Competing interests: No competing interests