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Changing the local PBC dynamic

Runcorn PBC group brought in consultancy Catch On Group to revitalise PBC by improving relationships between GPs and the PCT. Dr Cliff Richards, chair of Runcorn PBC consortium, explains what happened

Runcorn PBC group brought in consultancy Catch On Group to revitalise PBC by improving relationships between GPs and the PCT. Dr Cliff Richards, chair of Runcorn PBC consortium, explains what happened

A year ago our PBC group had a realisation that things couldn't continue without there being some big changes made. I had just taken over as chair and things came to a bit of a head when the PBC manager left shortly afterwards. Employed by the PCT but working in a GP environment, she was inevitably caught in the middle of different agendas.

I held an awayday for all the GP members shortly after I took over as chair. We thought about what our aspirations were for PBC and I fed back to the then-PCT chief executive that we felt PBC had to be a bigger deal for the PCT and much more about commissioning in the round rather than smaller schemes. The chief executive listened, agreed with where we were coming from and asked what we wanted.

The desired changes

At this point we were very clear about what we wanted to change – and less so about what we actually wanted from the PCT to make this possible. The stumbling blocks we identified were:

• Disagreement over savings. We appeared to have saved £1m but the data was not robust enough to support this. The PBC consortium had been satisfied with how the budgets had been set but the director of finance questioned whether genuine savings had taken place or whether the budget had not been set as tightly as it could have been in the first place.

• A question mark over how the PBC manager should be replaced.

• PBC board meetings were a talking shop. Made up of 20 people, the majority from the PCT, little was happening in terms of business plans, workstreams or influencing commissioning.

• A feeling that we wanted to make PBC more about commissioning for the overall better health of Runcorn, a deprived area coming under Halton which has the third worst female life expectancy in England, higher than average rates of obesity, CVD, and alcohol-related hospital stays.

• All four consortiums in the PCT seemed to have different cost envelopes for PBC.

• We were not getting routine basic data on hospital activity, referral rates and so on.

Appointing consultants

Catch On Group was already providing management support for a neighbouring PCT so they were on our patch. We invited

a number of consultancies to pitch at a consortium board meeting and rates ranged from £500 to £1,500 a day. Catch On was the most focused on what we wanted and is

one of the five organisations appointed by the Department of Health to support PBC. The PCT funded our work with Catch On, initially for six months and then another six – we are now just coming to the end of this.

When we told the PCT about wanting to work with Catch On we simply explained the PBC manager had left and we wanted to use an external agency. They agreed, bearing in mind the cost of appointing a new manager and paying GPs to do some of this work would have come to more than £100,000. Catch On doing eight to 10 days a month comes in at about £7,500 plus VAT.

And because of the inactivity following the resignation of the manager, we had not fully dipped into the amount set aside for our PBC group for that year.

Making changes

From the start, Catch On were clear our focus should be on what we wanted to achieve for the people of Runcorn. Our acute hospital, Halton General, had merged with Warrington some time before and for a variety of reasons was unable to sustain a range of services locally. So there was the opportunity to provide clinically appropriate services locally so patients didn't have to go off our patch.

Catch On and I visited each member practice to explain the direction – that we wanted to become an autonomous consortium and therefore we needed to put some structures in place.

Catch On gave us an external view of our arrangements. We needed someone with enough clout and authority to say ‘this is what is right and acceptable'.

They told us we wouldn't get anywhere unless we made certain changes, particularly concerning the board structure, and they helped us talk to the PCT with some authority rather than just sounding as if we were moaning.

There were four stages to Catch On's work as outlined in the box below.

Outcomes

Becoming independent

We wanted to be independent from the PCT and Catch On provided clarity that having

a business manager employed by the PCT wasn't the way to achieve this. Catch On had a very clear expectation of what the board was supposed to be – that it is a job of work, not just turning up to meetings. And that it was about seizing the agenda ourselves.

They suggested we move to a smaller core board of six GPs responsible for the overall strategy. Larger operational groups, made up of a mix of GPs, nurses, practice managers and so on, to focus on a particular project.

We now have a more streamlined process for business plans. Those under £50,000 will go to a smaller group at the PCT, including the four local PBC chairs, so they can be signed off much faster. Individual practices are now committed to, and held accountable for, delivering those workstreams. We have got a number of business plans that are being submitted, including cardiovascular risk screening. And we are refreshing

a number of other business plans that were already in place but not really active, such as extra services for mental health. Some £498,000 of submitted business cases have now been agreed in principle.

Drawing a line under the ‘savings'

The savings issue was a thorny one and it's very difficult given our circumstances to know the reality of the situation. The PCT and consortium have drawn a line under it and there is an agreement to provide recurrent funding of £1m a year for our PBC group – separate from PBC incentive funds and management allowance – so we are clearly going forward.

We've agreed we won't get too hung up on whether the funding is from consortium savings as long as we get good services into place. That's what's important, not whose budget it is. The director of finance told me ‘we should give you the budget and let you get on with it'. Whether that will happen,

I don't know, but there is a sea change in how business should be done.

Fairer funding

We now have a standard cost envelope for running all four PBC boards across the PCT patch, with the same funding per head. Catch On provoked some real cultural change there and the system for funding consortiums is a lot clearer and a lot fairer. The final figures have not been agreed yet but we submitted a document to the PCT outlining our expectations and explaining what we considered to be acceptable and those points were applied to all four PBC groups.

Better data

We had some real problems with data. Catch On helped us to negotiate and the PCT responded by making some real changes. Now each practice sees its own data for referrals and hospital activity monthly, including admissions for one day or less. And the PCT has provided support with analysis. Its approach now is to ask ‘what do you need and how can we help you?'. Before, we were getting excuses and excuses, now we are getting really useful data we can actually unpick.

Last November, the PCT scored 10 for performance management under World Class Commissioning, but one for information. Now the PCT has set up a clinical care group where we GPs sit around the table and talk about what information we need. We get details on the top 10 patients who have attended A&E or been admitted as electives. And we can look at how they presented, whether it was by

GP referral or self-referral or 999 and what condition they were admitted for and what the communication was between secondary and primary care.

With finances, before it was always a bit of smoke and mirrors. Now we understand budget-setting methodology and how funds can be released against business plans.

Better PCT relations

The PCT has responded very well to our grasping the nettle. Without Catch On, things might have been very different. We now have good representation at PCT level on all the various commissioning groups. There seems to have been a sea change in how PCT managers view the consortium – they realise their aspirations for health gains can't be achieved without us. So now the consortium is working with the PCT on the same agenda around health gain.

Dr Cliff Richards is a GP and chair of Runcorn PBC consortium

Four-stage turnaround process Four-stage turnaround process


Chris Webb, senior consultant and lead nurse at Catch On Group, explains how a turnaround was engineered

1. We carried out a review of the state of play in the consortium, going through the documentation, meeting the GPs and observing the board in action.
We brought our knowledge of the wider context of PBC to bear on this.

2. We made recommendations to the PBC board about its structure and about where it should be going. We made proposals about how it should be reformed so there was a clear direction and a clinical focus, rather than a talking shop that was top-heavy with PCT managers and taken up with papers from the PCT. Now the board is entirely composed of clinicians, with others attending when there are relevant agenda items, and discussing their proposals for PBC rather than going through PCT papers.

3. We helped board members to review their commissioning intentions and linked them to the PCT and the North West SHA priorities, to make sure PBC business cases were linked to the overall strategy, not just ‘I want to do this because I feel like doing it'. We also worked closely with the board to challenge the PCT on elements it was not delivering, particularly on resources for GPs doing PBC work and providing crucial data.

4. We found resources for backfill and to free up GP time for PBC had not been made available. We supported chair and board to get the message across to the PCT. To the credit of the PCT managers, they responded very positively and reviewed the resourcing of all the PBC groups in the area to make sure it was equitable.
We continue to work with the consortium as its business managers, supporting the chair and board rather than attending meetings with the PCT ourselves.


Chris Webb, Dr Cliff Richards and Catch On Group chief executive Christine O'Connor Chris Webb, Dr Cliff Richards and Catch On Group chief executive Christine O'Connor The PCT's view

Rob Foster, director of performance, Halton and St Helens PCT

It's fair to say that as a PCT it's only in the last 12 months that we have invested significantly in making PBC work so the PBC groups are at the heart of the commissioning process. It was Runcorn PBC group that took the initiative to get in touch with Catch On.
I was concerned practices didn't have routine data about contract performance, referral trends and productivity at secondary care level.
PCT mergers three years ago meant there was a huge amount of disruption. The reality is the PCT didn't really have any systems in place to provide detailed information to PBC groups and practices, it was just headline figures.

What has changed?
We have clarified the role of PBC and got the remuneration right to free up GPs' time so groups can commission planned care.
We have put a new information system in place, and are just evaluating it. Working with the PBC chairs and Catch On has really given us a focus on providing information that is what PBC groups and practices need – on COPD, cardiovascular disease and diabetes and looking across the quality and outcomes framework, medicines management and hospital data.

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