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How a sub-group model has created real change

Dr David Shovlin explains how PBC has tapped into the potential of existing small clinical sub-groups to drive commissioning strategies forward

Dr David Shovlin explains how PBC has tapped into the potential of existing small clinical sub-groups to drive commissioning strategies forward

When West Northumberland PBC group was first formed three years ago we met on a monthly basis and were a single entity.

The remit of PBC is so huge, however, that it was impossible to address everything the 13 practices wanted to do in just one monthly meeting.

Our secondary care colleagues had no anti-PBC feelings as we have a long history of working closely with them, and a number of small, informal clinically focused groups had sprung up in the area. I was a member of the CHD sub-group and our PBC group's vice-chair chaired the diabetes sub-group – so we had a good idea of their potential.

But while these sub-groups linked in with secondary care they didn't tie into the bigger commissioning agenda.

PBC has been able to harness the good work that was happening in these groups, align it with the PCT's big agenda and improve care for patients.

Having this structure has allowed each clinical interest sub-group to develop their service and also to use the clout of the PBC group to push things through the formal commissioning route.

Formalising the groups

The PCT agreed to fund the groups for one year at the cost of £27,000 and this has paid for sub-group chairs' time, venue hire and administration. Each subgroup was asked to draw up a strategy document in line with the PBC agenda and the PCT's commissioning agenda, ratified by the PBC group and the PCT.

At the same time, to help move the vision along, all practices in our PBC group agreed to reinvest 30% of their incentive scheme payment into a management fund, which has allowed us to employ external management support.

As well as formalising the existing groups to link with PBC we have developed a number of new sub-groups.

The sub-groups are directly accountable to the PBC group and therefore the PCT in terms of the commissioning and clinical agenda and also finances.

The groups include diabetes, musculoskeletal medicine, CHD, palliative care, mental health and home care. There is also an audit, education and research sub-group that masterminds an annual audit and education programme for the whole of the PBC group. This has been key in ensuring we are practising evidence-based commissioning.

The make-up of the sub-groups varies, although they all have primary and secondary care members and commissioners from NHS North of Tyne to link to the bigger PCT agenda. All relevant stakeholders are represented, including patients and carers.

Most involve social services, carers' organisations and other voluntary sectors – for example on the palliative care group we have the local community hospice and Red Cross.

All the groups meet on at least a quarterly basis, then report back to the main PBC group. If necessary, and where there's a lot of work going on, they meet more frequently. Getting all the stakeholders to attend is not a problem as people are committed, so they make the effort to come to the meetings and are happy to take work away.

Our focus has been to improve what is already set up rather than developing new services. Most of our work has not involved a formal commissioning route, but rather getting clinicians, managers, patients and carers to identify the hiccups in the service and proposing solutions using existing resources. We take an overview of the whole area and identify the problems.

This approach has allowed people to get a feel for the potential of PBC and has really fostered engagement. We have fantastic relationships with local organisations – we are all working together to improve the quality of the services we deliver and this has been the focus right from the start.

The box below shows two examples of what the sub-group model has been able to achieve.

Evidence-based commissioning

One of the key aims we've had all along is to develop commissioning plans on the basis of hard local evidence. I chair the education, audit and research subgroup, which includes the local GP tutor as well as practice managers and nurse practitioners. It co-ordinates an annual audit plan which is worked on by practices in the PBC group.

The audit process has been indirectly funded via the PBC incentive scheme as the incentive for doing each audit largely comes from looking at high-cost, high-activity areas. Sometimes one of the subgroups throws up an issue that suggests an audit should be done. We also try to link audits to the commissioning agenda.

It is a two-way process – the PBC group benefits from getting the data and local quality information from the practices, and the practices benefit from the educational feedback on referrals, best practice and local guidelines.

The audit data goes much deeper than the data given to us by the PCT in terms of the individual patient pathway. We obtain much more qualitative information about why patients are referred, who is doing the referral and what happens to them along their journey.

The process allows us to practise evidence-based commissioning – generating local evidence from the audit programme to help us formulate business plans. We have sound data we can use to make a case for developing a local service.

Examples of audits carried out include referrals reviews (orthopaedics, dermatology, ophthalmology and chest pain), reviews of A&E attendances and short-stay non-elective admissions and annual audits of all patient deaths in the group's practices.

The same hymn sheet

Our sub-group model works because all the relevant organisations have been involved in identifying needs together . Everybody is singing from the same hymn sheet and has the same goals .

The potential for developing PBC is greater as we are working to a shared agenda and no-one has any hidden interests.

We don't focus purely on commissioning and contracting. Putting together a business case has been a relatively small part of our work. Although we recognise we need to keep to budget, we mostly look at what we can do to improve things without necessarily investing more.

As much of what we do doesn't increase costs, the PCT and secondary care are happy to give us the freedom to change things around.

The PCT has been though a major reorganisation in the last three years and PBC has not been a top priority for them. This has allowed us the freedom to develop in an unrestrained way that suits us and our patients.

However, we have great support from some of the PCT managers who have backed all the business cases we've submitted, some of which have required additional investment. We put forward seven business cases last year, including one to spend several hundred thousand pounds developing palliative care services, and the PCT has been supportive in agreeing them.

The PCT's main agenda is naturally financial balance, whereas ours is developing and improving quality of services. We accept the need to work within a limited resource, and our constitution and commissioning plan are fully in line with the PCT's.

We've tried to implement World-Class Commissioning at a very local level so that our agenda and that of the PCT are in harmony. We are generating a lot of learning, which the PCT will be able to use to develop its strategy across the rest of the North of Tyne PCT areas.

This model of locally based commissioning has proved highly effective at being able to deliver service change efficiently and with the minimum of bureaucracy. It has also helped to ensure that everybody who is delivering services approaches change from a single perspective – that of the patient.

Dr David Shovlin is chair of West Northumberland PBC group and a GP in Hexham

Initiative Integrating existing clinical sub-groups with PBC so that redesign of services aligns with the wider commissioning objectives, and uses the best evidence.

Groups are made up of primary and secondary care members,

PCT personnel and patient and voluntary groups.

Set-up costs £27,000 from PCT to fund chairs for sub-groups, venues and administration. PBC group has also devoted a third of its incentive money to external consultants to formulate roles

Outcomes Changes to patient flows and coding in the A&E department were agreed, which reduced non-elective expenditure by almost £650,000. Creation of first palliative care facility in West Northumberland. Strong clinical engagement and patient involvement.


From committee to action From committee to action

Tackling end-of-life care
Until now there has been no palliative care facility in West Northumberland.The palliative care sub-group carried out a deaths audit, which showed the need for a community-based facility.Some of the problems have been looked at by our palliative care sub-group, some by our home care sub-group. The redesign will ensure people who are terminally ill and residents in nursing and residential homes are given the opportunity to discuss their preferences.We are now redesigning a new end-of-life care pathway and have secured funding of £360,000 to pay for three dedicated palliative beds in a nursing home, together with GP cover. We have also secured further investment for a community hospice for patients who wish to stay at home.

Challenging coding

Results from the short-stay admissions audit carried out by the PBC's education, audit and research group were taken to a meeting with the local foundation trust. As a result, changes to patient flows and coding in the A&E department were agreed which led to a significant reduction in admissions and a reduction in non-elective expenditure of almost £650,000 between 2006/7 and 2007/8. This allowed the PBC group to end the financial year in surplus despite the PCT's financial difficulties.

Dr David Shovlin (centre) and sub-group members Dr David Shovlin and sub-group members sub group

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