Practice Based Commissioning. Hobson’s Choice? Or how to bankrupt your local hospital.

Practice Based Commissioning means that once a quarter we have to sit down and look at how much we’re spending/ being charged for our patients attending hospital. I’m not sure what the difference is, its an interesting point. Like our patients who cannot choose whether or not they are sick -if they have dreadful disabling Parkinson’s disease, Colitis or whatever, they need to see a specialist and we have no choice but to refer them. I suppose that if we think they need to be seen in hospital, we’re think we’re spending, but if we don’t think they need to be seen, -say they pitch up at A&E repeatedly because they’re very anxious, ill, or shambolic, then we think we’re being charged.

We have to find innovative ways of keeping these patients away from A&E and of making absolutely sure all our referrals could not have been managed in primary care in order to save money. Not necessarily a bad thing.

Junior doctors see patients they’ve operated on in outpatients for follow up. When we receive the letters they usually say, “I saw your patient and they were fine, all yours now, yours sincerely”, so it looks like the surgeon just saw them and waved goodbye, and in fact that’s usually what our patients report, so we’ve been campaigning for these patients not to go back to hospital because it costs us money (about £100) and our patients time. If the letters gave an indication (or if we had better relationships with the hospital) we might be aware of how important it was for young surgeons to know what proportion of their patients had complications and we’d be happier that the money was well spent.

The tarifs can be problematic. The tarif for midwives is about £180 for each patient that the midwives from the hospital see in our surgery. We organise the scans and blood tests so they can concentrate on talking to the patients. They see 2-3 patients an hour costing us £360-540 per hour. If we hired midwives independently we could make enormous savings by undercutting the hospital which cannot change the nationally set tarif. We’re £80k overspent this year… what should we do?

There are innumerable similar examples.

The consequence is that we’re forced to save money while the government encourages competing providers whilst tying hospitals to a set tarif. If we stick with the hospital we run out of money for our patients, if we don’t use the hospital they’re no longer financially viable.

Ditto also diagnostics, the PCT buys a job lot of scans and we can refer to scan.com without using our PBC budget, but if we refer to the local hospital it comes out of our budget. The hospital loses patients and money.

If you wanted to run down local hospitals and destroy integrated community care you’d be pushed to design a better system.

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