We're now entering the third year of the operation of Payment by Results (PbR) so it is timely for the Department of Health to issue its consultation document on the future of this policy.

However, while the consultation is welcome, the document's focus is largely technical focusing on the basic building blocks of Payment by Results and how we can make the current system more effective. Clearly there are vitally important issues about how we can make PbR work better - financial flows can make the difference between a trust or PCT being in balance or deficit. So it is right for the NHS to engage in the debate to make sure the Department of Health gets this right.

But it is just as important that we take the opportunity of the consultation to raise some wider, perhaps more fundamental, questions about where we are going with Payment by Results in the longer-term.

For Primary Care Trusts in particular, there are challenging issues around how Payment by Results can work best for the treatment of people with long term conditions, shifting care outside of hospitals and improving the overall quality of patient care.

Should, for example, care for long-term conditions be funded on the same basis as acute elective care? And if we don't do this, what are the alternatives? Does a tariff based on payment per episode put barriers in the way of transferring care closer to home? How can we fix this without losing the link between the volume of work and funding?

We should also take this opportunity to consider if the tariff could be amended to include rewards to improved clinical outcomes. Can we learn lessons from the Quality and Outcomes Framework for general practice - indeed why do we commission general practice so differently from acute care?

Finally, how should capital costs be funded under payment by results? Is there an argument to fund capital costs separately from the other costs of delivering services to patients?

I am sure that Healthcare Finance readers have similar questions of their own. Let's use the opportunity of the consultation on the future of Payment by Results to raise these sort of issues so that we can really start to think how we make sure that PbR becomes a fundamental means of driving improvement to healthcare delivery rather, than simply a means of ensuring funding of acute care on an equitable basis.

The Primary Care Trust Network was launched by the NHS Confederation in December last year to provide a distinct voice for PCTs by influencing policy, supporting senior managers and developing solutions. PCT Network members will be debating all of these issues over the coming months as part of the consultation process, so that we can make sure that our payment systems promote the improvement of patient care and experience.

Payment by Results must be fit for purpose for the different types of integrated services we want to provide for the future, as well as sustaining and supporting highly specialised services. However, we should remember that PbR is only a tool and we need to pay equal attention to deciding how we use it to change service delivery. This means shifting PbR from a tool used by directors of finance to a mechanism used by clinicians.

David Stout
PCT Network Director
NHS Confederation