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A federation to tackle the hard times

Jenny Poole and Caroline Kerby explain how setting up a federation will put PBC at the heart of the PCT decision-making

Jenny Poole and Caroline Kerby explain how setting up a federation will put PBC at the heart of the PCT decision-making

One of the many challenges facing PBC groups is developing the organisational form which best suits what the group aspires to achieve. One key dilemma is the dichotomy between being small enough for good local engagement and shared working but working with a population size significant enough to allow real system change.

At the end of 2007 the PBC landscape in Brent showed four geographical clusters, one GP co-operative and 12 independent practices. The PCT was just coming out of turnaround after a major financial crisis with a new team in place.

Despite the fragmented nature of PBC groupings a determined number of PBC leads had been meeting regularly to try and achieve some cohesion at a strategic level with the PCT commissioners with varying levels of success. As is the norm there were a number of different agendas and local politics plus differing levels of engagement with the practices and health care community. The leads acknowledge the need for change and worked closely with Julie Woods the Director of the NHS Alliance PBC Federation in facilitating a process of change.

The initial phase of developing a new PBC structure involved a number of individual discussions with key people to build up a picture of where everyone was; what they wanted to achieve and hardest of all; would they be prepared to find a mechanism to work together. This was followed by a number of workshops working through these issues, where it was clear that the benefits of localised working were seen as vital.

The key message from Julie during this phase was think function not structure – be clear what is it you want to achieve and only then agree the most suitable organisational structure.

The other major challenge was how to operate with 12 independent practices and how could the new PCT engage meaningfully with 17 different PBC formats. The workshops clarified the function we collectively wanted - a structure that would;

* Place PBC as major player in transforming health care in Brent; Provide opportunities for large population joint working on key redesign

* Ensure clinical representation in all areas of PCT commissioning and redesign. Not dictate how we individually operated but would provide a strategic hub for discussion and a more unified relationship with the PCT

The second phase involved presenting the concept of a federal model combining local autonomy with a centralised approach to governance and engagement in Brent wide initiatives to the health care community. It was evident that the joint leadership from the main PBC groups had a major impact in practices signing up to both PBC and the formation of the Brent Federation of Practice Based Commissioners.

The federation launched on 25 June 2008 representing 96% of the population of Brent.

Structures and portfolios

The PCT supported PBC in taking the model forward and invested in appointing 2 PBC leads from each of the five groups to sit on a Federation Executive with the PCT which meets monthly. They are paid for five sessions a month. Incentive payments for practices and groups were agreed that supported joint working.

Each lead was nominated by their group and is accountable for local engagement and communication so they truly represent local views. Each lead has a portfolio for engaging with the PCT commissioners and the monthly Federation Council meeting provides a forum for leads to feedback and takes views from across Brent.

The portfolio working has meant that PBC works closely with the PCT and PEC on major pieces of work such as reshaping urgent care, developing a poly system through the Primary and Community Care Strategy, World Class Commissioning and the transfer of care close to home.

Each of the five PBC groups has a commissioning plan agreeing their own local objectives with the PCT and also sharing joint Brent wide objectives which are currently focussing on the redesign of gastroenterology and ENT pathways.

The localised redesign work on MSK, gynaecology, ophthalmology, paediatrics and "well being" initiatives allow for smaller piloting and evaluation so success can be rolled out rapidly and non achievement doesn't have a whole system impact. There is a shared Governance agreement in place and the Federation takes a major role in agreeing budget setting methodology and negotiation, establishment and monitoring of incentive schemes; data validation and contract monitoring. The Federation is based on an equal partnership between the groups and has a rotating chair which moves on every three months.

A year on the federation is maturing and as expected it has been tested at times and has been strengthened by robust discussion and negotiating a mutual position on key agendas. The code of conduct established at the inception has been a touch stone for under pinning how we work together.

In 2009 Brent were the first PCT to go live with the Department of Health investment in the PBC Development Framework; being recognised as the PCT most likely to progress. This program which delivered by NHS Alliance Humana and Dr Foster is supporting the learning and development agenda across Brent.

The work with the PEC continues on the shape of clinical leadership and PBC has become a forum for matrix working across the PCT in joining up pieces of work and monitoring investment against outcome. This ability will be essential in navigating the next few years in ensuring investment and disinvestment is made in a coherent and systematic manner.

The culture in Brent is changing and the PBC relationship with the PCT is a more adult one of partnership and holding each other accountable. It is clear that the next few years will be some of the most challenging in recent times and hopefully the Federation provides a forum to jointly tackle the hard issues. We believe the model will always ensure the grassroots engagement and broader clinical leadership in keeping the patient at the centre of transformation.

Thanks to Julie Wood, director of the NHS Alliance PBC Federation and Gill Kelly, Assistant director PBC development Brent PCT for their help with this article.

Caroline Kerby is management lead of Harness consortium

Jenny Poole is Board and Federation member for Kilburn Cluster

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