Archway Surgery. Archway Development & Consulting Ltd
Prison Services
Dacorum PCT
NHS Organisations impacting Primary Care
Freedom of Information Act
NPfIT site
Primary Care Computing Specialist Group
TheRegister on IT
Foundations of Iraq






NatPact Web Site
GP contracts
Choose and Book



Archway Development &   Consulting Ltd
54 High Street
Herts HP3 0HJ
Tel 01442 817217
Fax 01442 879647
email here
Registred in England
Company No 3326461
Registered Office
C21 Herbal Gardens
9 Herbal Hill
London EC1R 5XB




   NHS Guidance pdf     Commissioning Web Site     Payment By Results Delay  Primary Care Contracting

Primary Care Based Commissioning
The Answer lies in Outpatients


•    Herts “Investing In Your Health” plan assumes there is a transfer of activity from Secondary    to   Primary Care.  Similar plans exist in other Health Authority areas.

•    Payment by Results needs G.P.s to validate the data.

•    Choice and Choose & Book are with us.

•    New Estates Strategy is under way. This will attempt to develop services such as polyclinics and Diagnostic and Treatment Centres.

•    Need to reduce casualty use.

What G.P.s see for PBC now:
The current plan for PBC excludes outpatient services and casualty attendances, and only includes elective operations.  Since G.P.s cannot book operations without the first outpatient attendance, the current PBC model has limited appeal for G.P.s, quite apart from little concrete evidence of a management allowance to run with it. PBC seems weaker than Fundholding in its approach and has more limitations than that scheme.  There seems little in it for practices and their patients.

The Technical Guidance on PBC is so brief that it is neither technical nor guidance, so it seems PCTs can develop their own models.

Over the last few months government policy has become more overt.  The Shipman Report may have outed the Government on its unwritten policy that bigger practices are better. Jo Whitehead, of the Department of Health, outlined the policy at Practice Based Commissioning Conference Hammersmith on 10th March  The G.P. "list" would go, there would be walk-in centres and G.P.s would be in large practices of at least 10 doctors.  This is already in play; in 2004 the number of single-handed practices collapsed, by more the fall throughout the previous decade, from 2,578 to 1,918. The overall number of G.P. practices fell by 291, the largest fall since 1994.  The new vision is:

There will be three levels of Primary Care:
•        Tier 1 – non registered access  (i.e. walk-in centres)
•        Tier 2 – registered access for LTC/serious episodes of care
                       Diagnostics and treatments: typically 10+ GPs?
•        Tier 3 – Access to a specialist, diagnostics, outpatient attendance, pathology, and day-case             surgery.

Whilst the medical press has been cross about the implied demise of small practices, they have missed the huge opportunity offered by Tier 2, and particularly Tier 3 where outpatients is now to be part of Primary Care.

Idea to Discuss:
All local G.P.s form an APMS company to run CURRENT outpatient services.

Why take this route in PBC?  Because other methods to reconfigure health services failed in the past.   We heard all the wonderful things that “PBC” could do back in the Fundholding era.  We seem to be in a time warp.  Commissioning and contracting produced little change to the structures of the Health Service then, so why should it now?  Fundholding shifted the power for a short while, but the mechanism to shift resources and restructure services failed.  One could argue that Fundholding had not had enough time to bed in.  However the same forces of resistance that caused the demise of Fundholding would be applied to PBC and Payment by Results as a whole.   PBC would fail if we simply followed a commissioning model on its own.  One of the reasons that Fundholding was abolished was due to the tensions of the purchaser/provider divide within a fixed budget economy. 

G.P.s owning and managing outpatients, through a new APMS, would fit with Government policy, and be more likely to create change than relying on practice budget setting and contracting processes alone.   If it is sensible and economic to move the physical location of these services to new centres, then we would do so over time.

Why outpatients?
The outpatient service is grossly inefficient.  Although there are more doctors, nurses and clerical staff, outpatients cannot even cope with the throughput of an average general practice. Patients and G.P.s are not very happy. Both seem to get little out of it, especially from follow up attendances. I have no evidence for that assertion as yet….references appreciated!

•    The role of outpatients is help G.P.s manage patients.  It is almost part of the education process for G.P.s.   It is not a system for consultants to develop their own lists.

•    Outpatients are a training tool for hospital staff and G.P.s, but are poor at this role.

•    The follow-up ratio has remained constant since 1948: three to one.

•    The number of new patients seen by consultants has fallen every year since 1948.

•    Lack of access to outpatients and diagnostic facilities FUELS the use of A & E departments.

•    Outpatients are aeons behind in the use of I.T.  G.P. input would help the LSP/NPfIT make an impact.

Primary Care needs to wrest the management and budget of outpatients from the local Trust, so that we can really reconfigure services. As an APMS there would be a real incentive keep costs down.

Waiting until we develop new facilities would be almost capital-based planning.  Changing buildings is one thing; we need to change systems first; this would be quicker but harder work. DacDoc showed that local G.P.s can run companies to manage local services. 

Back to page one on Practice Based Commissioning


BMJ 1995;310:581-582
Consultants' workload in outpatient clinics
David Armstrong, reader in sociology as applied to medicine, Mick Nicoll

BMJ 2002;324:135–43
Getting more for their dollar: a comparison of the NHS
with California's Kaiser Permanente
Richard G A Feachem, Neelam K Sekhri, Karen L White

BMJ 2004;328;969-970
Jennifer Dixon
NHS Payment by results—new financial flows in the NHS

NHS publication:
Modernisation Agency Action on Dermatology 2004

Linda Gask
Role of specialists in common chronic diseases

BMJ: 2002;325;370-371
Andrew B Bindman
Christopher B Forrest, Azeem Majeed, Jonathan P Weiner, Kevin Carroll and
United Kingdom and the United States
Comparison of Specialist Referral Rates

BMJ 2004;328;340-342
Penelope Dash
New Providers in Health Care

BMJ 2003;327;84
Thompson, L Lewis, R Currell, S Parker and P Wainwright
P B Jacklin, J A Roberts, P Wallace, A Haines, R Harrison, J A Barber, S G
Virtual Outreach clinics General practitioner for a specialist opinion
Teleconsultations: Costs

BMJ 2002;325:1086–9
Benson Tim,Why general practitioners use computers and hospital
doctors do not

BMJ 2002;325;1263- BMJ
Kamaldeep Bhui, Naomi Fulop and Peter Tyrer
Mike J Crawford, Deborah Rutter, Catherine Manley, Timothy Weaver,
Involving Patients in planning and development of health care: Systematic Review

HSJ April 1995
Semi-Urgent Care; Immediate &  Necessary  G Bulger