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East of England revisited

Ten months after we first looked at how PBC was progressing in the NHS East of England area, Miranda Griffin reports on whether things are moving in the right direction in this part of the country

Ten months after we first looked at how PBC was progressing in the NHS East of England area, Miranda Griffin reports on whether things are moving in the right direction in this part of the country


Since we first reported on East of England in September, the SHA says it has put in a huge amount of work at SHA, PCT and consortium level to improve matters.

The Department of Health PBC March 2009 survey results showed practice relationships with their PCT have improved. Some 26% of practices rated their relationships with their PCTs as ‘poor' compared with 39% a year ago. However, PCT relationships in terms of PBC were deemed ‘good' by only 36% of those surveyed, compared with 46% nationally.

Where there is a marked improvement is in the percentage who had agreed a commissioning plan with their PCT – at 65% this is above the national average of 64% and a significant improvement on the 48% a year ago.



Cambridgeshire – ticking along

PBC in Cambridgeshire has yet to live up to its early promise, according to Dr Luke Twelves, chair of HuntsComm consortium and a consultant for UnitedHealth. ‘We were forward thinking in our area and have done a lot in the past, but things faltered a bit and have carried along at that level,' he says. ‘There's still a good cohort of enthusiasts but the middle ground hasn't really seen results from PBC and therefore seems to be losing a bit of enthusiasm for it. I'd say PBC is gently ticking along.'

He believes the PCT is keen to help develop PBC, but says it is struggling with larger financial issues and PBC, with its relatively small budgets, has inevitably lost priority.

‘It's not through lack of willingness at the top, but when you've got large foundation trusts pushing contracts to their extremes, and the PCT is naturally struggling to keep track of those, a business case of £40,000 – while it may have a huge impact on a particular practice, doesn't have much of an impact on a £53m deficit – at least not in the short term.'

Some good schemes have been set up, he says, but the PCTs have been very keen to hang on to power and not devolve responsibility to PBC so there hasn't been any progression. ‘People are still having the same discussions as two years ago,' he adds.

A token amount of resources are being freed up. Most are being held on to by the PCT but, according to Dr Twelves, the business case process is so difficult that cases are not coming through and the

PCT can legitimately argue that people aren't making requests on the freed-up resources.

‘To a certain extent that's true,' he says. ‘People aren't bothering anymore as they feel they'll put a lot of effort in and it'll not happen or be hijacked by the PCT.'



Essex – creeping forward

Last year Dr Brian Balmer, chief executive of Essex LMCs, felt PBC was failing to advance for two reasons – a heavy-handed managerial approach from the PCTs and fragmentation of the local commissioning groups. He doesn't feel things have improved a great deal on either front.

He says: ‘Progress is still slow. We are creeping forward but PCT inertia is still there.'

And, as was the case last year, he believes a failure to see the broader picture is still holding commissioning back at GP level. ‘Some of the PBC groups are still arguing about what's in their window box rather than sorting out what's going on across the whole street. They're arguing about who makes the tea, not grasping the possibilities.'

But, he says, it's not all bad, and GPs who are grasping PBC in a more effective way are in turn encouraging the PCTs to allow them more freedom to make a success of it. ‘Where we are seeing progress it's because there is good leadership on the GP and practice side, they're thinking beyond their own patients and more about a bigger population and so in turn getting support from their PCT.'



Suffolk – greater PBC commitment

Suffolk's DH survey results a year ago for PCT relationships and support were among the worst in the country. Since then there has been a refreshing cultural change, according to Saxmundham GP Dr John Havard.

‘A lot of time, energy and commitment to partnership has been put in by both PBC groups and the PCT. They've been serious about addressing problems and have applied themselves to try to make it work. They do appear more committed to PBC.'

Dr Havard sees a shift in the PCT's attitude, to the point where he feels the PCT is now on the PBC groups' side: ‘In terms of what we've been allowed to do they are much more flexible about thinking "how can we help you make this work?". We have an enabler at the PCT and it does help having someone who knows how the organisation works and how to get things done. They take the view that they can be flexible and trust you to see how you get on rather than being rigid rule followers.'

A new gateway system is in place and all the projects submitted have gone through to the next stage, including ones on glaucoma, self-referral physiotherapy and an ‘InstantCARE' admission avoidance model providing live-in professional carers for vulnerable patients.

‘We've been trying to get the glaucoma project off the ground for years but suddenly the PCT is seeing how it can help us with it.'



Norfolk – turned a corner

Dr Farrook Mondol, chair of Norwich Health Consortium, feels demonstrable PBC success in the last year has led to increased support from Norwich PCT.

‘In the last year we have turned a corner. As we've been functioning better we've been able to make a direct impact on the PCT.

‘Before now we weren't given the right importance – the PCT's attitude towards us and PBC wasn't very positive. But PBC is a learning process for both and I feel we are getting there. Now we have proved ourselves to the PCT, it is willing to support us.'

Successful projects in the area include a crisis intervention service pilot aiming to reduce mental health referrals, a community heart failure nurse, sexual health school outreach clinics, an audiology scheme testing for hearing loss in the surgery rather than referring, identifying COPD patients who are being missed and ensuring they are properly diagnosed. They are also looking at referral management and reducing A & E attendances by patient education.

Dr Mondol admits there are still problems that need to be ironed out, particularly data, but relationships are good.

‘I see a huge effort to improve. We have had major issues trying to get freed-up resources but these are nearly ironed out and I am quite optimistic.'



Bedfordshire and Luton – enthusiasm remains

Ten months ago Dr Peter Graves, chief executive of Bedfordshire and Hertfordshire LMCs, felt progress on PBC was variable across the area, and he feels the same is true today.

He is most positive about developments in Bedfordshire and Luton. ‘There's more high-level management support to get projects off the ground and there have been successful ophthalmology and dermatology schemes set up ensuring patients are seen in the appropriate setting,' he says.

John Rooke, chief executive of Horizon Health Commissioning consortium in North Bedfordshire, is also positive. According to him, there is a lot of enthusiasm for PBC and, he says, ‘there is a genuine commitment within the PCT to move forward with PBC'.

He feels the PCT could do more to capitalise on it, however. ‘The underlying problem is practices still aren't receiving budget statements from the PCT which is quite frustrating. The enthusiasm is there but we could go a lot further. We made £1.5m savings in 2008/9 but we haven't seen the savings made available and we're in the process of negotiating with the PCT.

‘Relatively minor things get in the way but I'm confident they'll be ironed out. But next year we may be facing cuts so will have to make serious decisions about priorities.'

Dr Peter Parry Okeden, chair of Horizon Health Commissioning and a GP in Bedford, feels they are making a success of PBC, but he says: ‘We're doing it ourselves – I don't feel we're really being helped by anyone, although the SHA did come down with the PCT chief executive and other stakeholders to try to reinvigorate PBC locally and the message did come across that PBC is very important to them and they want it to be successful.'



Hertfordshire – GPs frustrated

When we last looked at the progress of PBC in Hertfordshire there was a strong feeling of lack of agreement between the PCTs and GPs. According to Dr Peter Graves, chief executive of Bedfordshire and Hertfordshire LMCs, the picture is still mostly the same, although it does vary across the region. ‘In East and North Hertfordshire GPs are feeling very frustrated as every project seems to hit a stumbling block. The PCT is unwilling to let go and GPs feel there are barriers in place.'

West Hertfordshire fares better, with more projects either set up or close to being set up, such as a successful retinal screening project.

But Dr Graves is not convinced the PCTs are doing all they can to help. ‘The main stumbling block appears to be around conflict of interest.

‘The PCTs are citing this as the reason not to take projects further, but they don't seem interested in finding solutions,' he says.

Small amounts of FUR are getting through but, says Dr Graves: ‘GPs are banging their heads in frustration. They can see the FURs on paper but they are not finding their way though to the GPs. Most GPs would say FURs are a joke'.

Miranda Griffin is a freelance journalist

Cambridgeshire Essex suffolk norfolk Bedfordshire Hertfordshire East of England survey results East of England survey results View from the board room View from the board room

View from the board room
Andy Vowles, Head of Commissioning at the SHA says: ‘In lots of the measures we've done we're leading the way nationally, and yet on the basis of the survey things are quite disappointing. It's difficult to know why this is given that we've always given PBC high priority and we've got a number of measures in place to make PBC more embedded.'
Such measures include setting up a network of PCTs and PBC consortia leads that meets every quarter, a PBC academy providing hands-on training to PBC consortia and a website for good practice exchange on PBC so someone who's pursuing a diabetes business case, for example, can find out if anyone else in the region has done something similar.
Future plans to try to turn things around include launching a support team to go round the PCTs to work out the features of those that do well in the survey results, and then take them to the PCTs which perform less well. They will also further develop an existing group of leading-edge PBC pathfinders to go further faster and to get it involved in dispute resolution.
Mr Vowles would like to see consortiums getting large scale redesign off the ground. He says: ‘There's lots of activity but it's mostly small scale change.'

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