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Five things we did to turn round PBC

Dr Hamish Stedman and Fiona Moore explain how a disparate group of PBC clusters was brought together to form a team with shared goals

Dr Hamish Stedman and Fiona Moore explain how a disparate group of PBC clusters was brought together to form a team with shared goals

Salford is an area of the Greater Manchester conurbation that faces severe public health challenges as a legacy of its industrial past. We have significantly lower life expectancy than the UK average – men die three years younger, women two years – with higher rates of early deaths from smoking, heart disease and cancer as well as higher rates of mental health problems.

Our PCT is quite forward-thinking and quickly realised the opportunities PBC presented to benefit patients through greater clinical involvement in commissioning.

In 2006 eight clusters were formed with populations of around 30,000 each, based on geographical patches that matched local authority wards. Each had a GP acting as cluster lead.

But although the cluster arrangement was good for GP engagement, there were frustrations as it was difficult to achieve much on a local basis or commission effectively for relatively small populations. It was also hard to ensure our local acute trust, Salford Royal Foundation Trust, took us seriously as commissioners, especially when they could argue each cluster had its own priorities and approach.

The potential for PBC to evolve was clear to the leads but the milestones along the way were less so. There was continued support from the PCT, who could also see how PBC might develop. However as separate clusters, we didn't have a coherent message. It was also difficult for the clusters to hold practices to account if they weren't participating or working towards delivering agreed aims.

And so in December 2007, the PCT brought in an external consultant, Scott McKenzie, to try to unite the clusters and identify and tackle the stumbling blocks.

1 Developing teeth

We decided to create a large consortium that would cover all 51 practices across the city. We would still have eight clusters to maintain local links, but one overarching body would have the scale to work effectively with the PCT and our acute trust.

The eight cluster leads were invited to a meeting about forming a consortium.

At the first session, it was clear each cluster wanted different things – we were all looking at our own patches and ‘what's in it for me'. It took a few meetings to sort that out and come to a collective agreement. We really needed someone who could focus our minds and Scott helped us do that. He also helped clarify our vision for PBC.

There were four half-day sessions with Scott, working through a set of questions around the issues, such as the incentive scheme and governance framework. There were anxieties from some practices about what the new model meant but people realised it was better to grasp the opportunity than be left behind.

External companies brought in to facilitate PBC in this way charge between £500 and £1,500 a day. For us it was a great help having an external voice in the room to clarify what we needed to do to move forward in these meetings.

The governance structure is based on equal voting rights – one vote for each practice. An inter-practice agreement was drawn up. Cluster leads sit on the operational board, which is responsible for producing a practice and consortium level annual commissioning plan. It meets monthly to review progress and activity. In addition we ensure one person from each practice is freed up to attend regular cluster meetings, and this arrangement is funded as an element of the PBC incentive scheme.

We still have monthly sessions with Scott to help us stay on track.

As we've moved from clusters to consortium, GPs have been getting more positive about PBC. We had some who weren't sure about signing up but are now among the most vocal at cluster meetings.

The PCT was reassured that people were prepared to commit time and energy to making PBC work and invested around £1m, covering incentive payments, management costs and a dedicated team of four business managers (each working with two clusters), a business support manager and a PBC head.

The support team has been vital. It was important to have dedicated posts rather than PBC being an add-on to people's day jobs in the PCT. In the spring of last year we appointed an overall PBC manager, which has given us real impetus.

The PCT has funded this team within the region of £250,000 for an initial period of two years – due to end next year. After that the support team will be self-funding, in part through freed-up resources.

The £1m figure also includes backfill for cluster leads spending time on PBC (half a day a week).

2 Pooling money, responsibility and risk

The new consortium means we now have a pooled budget, pooled responsibility and pooled risk – a much more effective way of working, rather than paying lip service to PBC. In turn, the PCT has one body to agree objectives with and to hold to account.

Incentive cash is paid to the consortium rather than direct to practices, and paid out on delivery of agreed PBC activity, such as data analysis, referral review, or appropriate prescribing. So people really are mutually held to account – there are no free rides.

Practices that are real outliers are expected to scrutinise the reasons. If there is no good explanation, it provokes change. Practices can't get away with failing to fill in their monthly returns – and you have to take part, not watch from the sidelines.

3 Fast-tracking small business plans

The consortium operational board can approve PBC projects of £50,000 or less and the PCT commissioning board looks at projects of £250,000 or less. So we can be fleet of foot – smaller projects don't get bogged down in bureaucracy.

This may have reduced the timescale by as much as eight weeks as the PEC that preceded the commissioning board only met bimonthly, whereas the ops board meets every month. This is timed so that PBC ops board papers go to the PCT commissioning board meeting two weeks later.

4 Weaving PBC into the PCT's fabric

The PCT has looked at its structure in order to find the best way to support PBC and increase clinical engagement in commissioning. We have clinical leads

in place on all the PCT strategy groups – including diabetes, respiratory, planned care, unscheduled care and mental health.

There is a PBC stage in all of the PCT's commissioning processes. If something is a priority for us, that is now acknowledged. In some instances, business cases have been put forward to the PCT by other people and as commissioners we have questioned their value and queried whether it would be easier and more effective to do it differently.

One of the main achievements of PBC overall is that it has got practices thinking as commissioners, not just providers. We look at what the need is and how we should deliver that service, from a business case point of view.

Now PBC is becoming mainstream, just as the QOF has become mainstream. It is part of the role of general practice and that is a very positive development.

5 Earned autonomy

Everyone has bought into the vision. We are working on an earned autonomy model – if we deliver better outcomes, we will have more freedom.

In year three of the consortium, we have agreed we will move towards a limited liability partnership and transfer commissioning staff from the PCT to the consortium. If we keep delivering, in years four and five we will have a real budget rather than an indicative one, putting PBC genuinely in the driving seat and leaving us well placed for the emerging competitive market environment of primary care.

Results

Analysing data

Our PCT has an exceptionally good contracting unit, set up at the same time that PBC was getting up and running. One of the remits is to provide quality data in an intelligent form to practices and to train GPs and practices to understand that data.

In analysing the data, we are picking up quality issues and feeding them back to the central contracting team. Previously, unless there were significant events we simply didn't know about many of these issues – we are now identifying more and more areas we would like to see improve.

The contracting unit created a web-based tool so we can drill down to individual patient level, and take up any problems with the provider via the contracting unit. The contracting unit worked closely with the IT company to get it up and running – it is cost-neutral for us as partners in the development of the tool.

It allows us to monitor the quality of data that comes back from A&E and hospital attendances. If it is not of sufficient quality, that is fed back and we challenge it. For example, if patients turn up to outpatients and diagnostics are not ready, we would challenge. So we are not paying for meaningless activity and are encouraging Salford Royal FT to improve care for patients.

Because we act as one consortium, the hospital trust takes our data feedback seriously. We won £3m in refunds over the 2008/9 financial year.

Analysing referrals

As well as scrutinising attendance data, each cluster focuses on two clinical areas to review every month – recently, breast and dermatology referrals have been examined. Referrals are analysed to see if they could have been improved, prevented or referred to alternative services.

Because this process is cyclical and across the conurbation, we build up a picture of what is happening, whether there are any gaps in services or education and what has changed in the previous six months.

For respiratory cases, for instance, one cluster's work is to be rolled out across the consortium, making sure all practices have identified their COPD patients and have a care plan in place. It is simple but powerful.

Tackling excess bed-days

We have identified a lack of information on excess bed-days, where practices simply didn't know that a patient was in hospital. Quite a few patients had been in hospital for 100 days or more and although the numbers were small, it was enough of an issue to warrant dealing with. We are now requesting that when a patient has been in hospital for 30 days, practices will be told.

That means we can be proactive and, where appropriate, put case management in place to help facilitate discharge, managing these patients at home.

Referral protocols

We have also developed two referral protocols that really put PBC in the driving seat. The consultant-to-consultant protocol was introduced last autumn. We felt GPs were being left out of the loop over decisions affecting a large part of our budget. Now the protocol defines when these referrals are appropriate and the consultant checks with the GP that it is necessary.

Follow-up protocols

An outpatient follow-up protocol has gone to the Salford Royal clinical effectiveness board. The aim is to prevent patients having unnecessary follow-ups and to improve access for other patients. We held a joint meeting with the trust and had a degree of dialogue about what we wanted to do and why, and have got to a point where the local consultants are willing to go with it.

It means they have to give us a reason for the patient to come back to the hospital rather than it happening automatically.

A&E triage

We have just finished a three-month pilot trialling GP triage at the front door of A&E, which diverts patients needing primary care services to the GP-led health centre.

There was initial resistance from the foundation trust, centred around concerns that clinical care might be affected by sending a significant number of cases to a primary care centre. But we worked collaboratively with A&E staff and convinced them to see how it worked. The scheme is now being evaluated.

Dr Hamish Stedman is chair of Salford PBC Consortium

Fiona Moore is head of commissioning at Salford PBC Consortium

If you want more information on Scott McKenzie's consulting services, go to www.scottmckenzieconsultancy.com

Dr Fiona Moore and Dr Hamish Stedman: before the changes found it hard to get acute trust to take them seriously Dr Fiona Moore and Dr Hamish Stedman: before the changes found it hard to get acute trust to take them seriously

People really are mutually held to account - there are no free rides.

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