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At the heart of general practice since 1960

How a private company partnership put GPs in control

Dr David Eyre-Brook explains how Surrey GPs entered a partnership to set up an integrated care organisation which controls a £59m budget

Dr David Eyre-Brook explains how Surrey GPs entered a partnership to set up an integrated care organisation which controls a £59m budget

Until a year ago, PBC had been unproductive and a cause of frustration for GPs in Guildford. Approval for business plans tended to be slow and referral data was difficult to interpret at a practice level. GPs didn't expect to profit from PBC – but they did want some control over how it was run.

The Guildford IHP partnership, which we believe is the first integrated care organisation in the country, was established in January this year. It is a collaboration of six GP practices in the Guildford area and management support organisation Integrated Health Partners (IHP).

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IHP has brought management muscle to PBC in our area with its business and data analysis. GPs bring clinical knowledge and an understanding of the healthcare needs of the local population.

Our ICO has a capitated budget of around £59m – that's an average cost of £800 per patient for using both primary and secondary care services (with some exclusions).

It's an indicative budget, but we are hoping for real budgets in the next year or so, if we are successful. By the end of the pilot year, the ICO plans to make savings in excess of £1m – 5%-7% of the indicative budget – which will fully compensate the PCT for all costs.

In this pilot year the PCT is paying for IHP's management and administrative costs to manage the budgets with the GPs and all service changes costs. The PCT also gives practices an allowance for locum cover needed to free up GPs to work on service redesign schemes.

So the total pilot costs are in the region of £1m – with the aim that the pilot will at least break even in the first year.

If the pilot is successful there are plans to set up an ICO company where GPs, IHP and financial backers will carry the risk.

How it started

I first heard of IHP about a year ago from an entrepreneurial Surrey GP who had met with the company at national workshops on PBC. After this I arranged a meeting with

Dr Oliver Bernath, managing director of IHP and a consultant neurologist.

It was immediately clear Dr Bernath and I were talking the same PBC language – one that was less about demand management of referrals and more about clinicians in primary and secondary care working closer together to deliver services and save costs. As a consultant, he also understood the importance of clinicians being able to test their ideas with respect to local patient needs, though we still recognise that any plans need to fit into the broader strategy of the PCT.

Getting GPs and PCT on board

I emailed the 13 practices in my cluster saying I thought an ICO could be a way to drive PBC forward. Some decided not to take part – I think they were a bit nervous about doing something so new. Six practices came to an initial meeting to discuss possibilities. Five decided to go for it, attracted by the possibility of having more control over service redesign and development.

A practice from nearby Waverley also joined us after the pilot had approval.

Surrey PCT was enthusiastic about an initial pilot and asked us to submit a business plan by September 2008. IHP drew up the costed bid after detailed discussions with the GPs in which we identified eight areas where we felt services might be delivered more effectively and efficiently. These included end-of-life care, chronic disease management, elective outpatient care and medicines management (see box below). The bid also included estimates of what extra resources would be required to set up schemes and possible savings resulting from service improvements.

The Guildford IHP Partnership carries little risk during its pilot stage. Should the pilot scheme make a loss then GPs will have to return 20% of their locum allowance to the PCT.

GPs have given up their 70% claim on any savings in the first year in return for PCT funding of the pilot.

Once the pilot has finished we will need to set up as an ICO company, which would involve the GPs, IHP and financial backers. IHP will expect GPs to take on a share of the risk. How much risk GPs and IHP will be responsible for has yet to be decided. However, it is likely that IHP and the GPs will share the first part of any potential loss but that any further loss would be reinsured by a financial backer. This will provide an incentive for practices but will not endanger their viability. Any savings would equally be divided among the practices, IHP and the financial backers in similar proportions to the risk.

Surrey PCT was extremely helpful before the launch and during the pilot process, and continues to be so. While GPs have been critical of the PCT's support of PBC in the past, we really believe it wants the ICO to work. On a day-to-day management basis the PCT is completely hands-off, but we keep its staff in the loop through monthly reports. There are also parts of our pilot bid in which the PCT has had a closer interest and we have kept it fully aware, sometimes on a daily basis.

Governance

As part of the ICO governance process, practices agreed to share all referral information, both private and NHS, with the ICO. This allows the ICO to monitor referral rates, compare how different practices are performing and discuss any concerns. The process requires a great deal of trust and openness by the GPs, but members can see its value and seem happy to share information. It's even encouraged some healthy competition between practices.

A central governance group, which includes representatives from IHP, the PCT, a member from each practice and patient representatives, meets monthly to monitor the ICO's activities.

A representative from IHP visits each practice member every month to review performance.

Each new project has a steering group to oversee its development and a clinical GP lead and a management lead from IHP to make it happen

We now talk about making projects a reality within months rather than years. Through the partnership, GPs feel they can make more of a difference to patient care because they have a bigger voice – and it's actually being heard.

By taking an integrated approach to care, we are starting to work more closely with health and social care professionals, as well as strengthening relationships between primary and secondary care.

While it's early days for the ICO, the GP members are enjoying being part of an organisation that is giving PBC some ‘muscle' and making things happen.

Before we set up the ICO, when GPs came up with a ‘big idea' they would often be unable to develop the business case to a level of detail and format necessary to navigate through the often complex PCT approval process.

As a smaller, leaner organisation, we have been able to speed up the whole process of translating ideas into services.

So much so that it sometimes feels like IHP expects a new scheme to materialise in a matter of days. We often have to explain that because we're involved with patients it might take a bit longer. But it's great to have that business perspective – to be working with people used to meeting tight deadlines and achieving targets.

Looking ahead

If and when we set up an ICO company we will be looking to transform care pathways, often by bringing care closer to home. This has the potential to cause conflict with the local hospital because less activity in secondary care means lower funding. The reality for our local hospital, the Royal Surrey County Hospital, is that it is over-capacity so our schemes should help ease staff workload.

Hopefully, hospital staff don't see the ICO as too much of a threat. We're working hard to forge relationships with secondary care, and since its launch ICO members have met regularly with consultants and hospital managers to discuss projects, which seems to have built up trust between clinicians.

There is always the danger that patients will think funding for healthcare is being taken out of the NHS and that business people, not doctors, are running services. This is why every practice regularly gives patients questionnaires asking them what they think about our services. Having patient representatives on the governance committee also means they have a chance to feel involved and air any concerns.

My advice to anyone considering an ICO pilot is to go for it. There is a need for commitment, but the potential result of putting GPs back in the driving seat of change will make it all worthwhile.

Dr David Eyre-Brook is GP lead of Guildford IHP Integrated Care Pilot Group

"GPs didn't expect to profit from PBC - but did want control over how it was run" Dr Oliver Bernath and Dr David Eyre-Brook The ICO's projects The ICO's projects

The ICO is involved with eight projects, all of which need to be delivered by the end of this year. They include:

Chronic disease management
Scheme to make the role of community matron more effective at managing chronic diseases while working more closely with GPs and social services. Will be led by a chronic disease management champion.

End-of-life care
Focus on improving end-of-life care for patients with chronic diseases that will ensure patients have the opportunity to discuss where they receive care and that, if they choose to die at home, they receive the necessary support.

Admission alternatives
We are working with the local hospital's medical assessment unit (MAU) to set up pathways for patients who require the diagnostic facilities of an MAU but are then able to return to a community bed or go home with greater use of intermediate care.

A&E front door
We are looking to redesign the ‘front door' of the local hospital's accident and emergency and walk-in centre.
As this involves patients outside the ICO the PCT is heavily involved in this redesign proposal.

60 second summary Related Seminar: PBC Masterclass

PBC Masterclass: Regional events

What: These regional PBC events are designed to equip you with the sophisticated skills needed to overcome barriers and push on towards PBC success.

When: 10 individual events running from October 2009 to January 2010

Where: 10 different regions throughout England. Each event has been tailored to address the learning priorities highlighted by practice-based commissioners in that area.

Next steps: Find out more and book

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