How our social enterprise model moved PBC up a gear
Dr Bill Tamkin explains how becoming a social enterprise helped his PBC cluster get ahead in the game
Dr Bill Tamkin explains how becoming a social enterprise helped his PBC cluster get ahead in the game
Turning our PBC group into a social enterprise company has given us more clout with providers and the PCT. Manchester Practice-Based Commissioning (South) Ltd grew out of our consortium of 26 practices known as the South Manchester PBC Hub, which was launched four-and-a-half years ago.
There was a long history of likeminded working between practices. When PBC came in, the PCT encouraged us to start working as a consortium but reorganisation in 2004/5 meant a dramatic slowdown.
Most of the people we knew in the trust disappeared and we were left in limbo as the three trusts merged into one – NHS Manchester. There was a lot of frustration from GPs and we felt we would be more effective if we had a formal set-up.
The decision to opt for a social enterprise format was both practical and philosophical. We had seen it working in Stockport and we wanted charitable status – to be a company for the community rather than being about profit for shareholders.
Having now created the social enterprise, we have the potential to hold a real budget for our 160,000 patients and an agreement to provide commissioning support to the PCT with a devolved budget of £1m.
We wanted to focus on three key relationships:
• with the PCT
• between our practices
• with the main providers.
Members felt we needed some clarity about what the new PCT expected from us and what our role was.
There was also a need to firm up relationships between practices. We are all independent and most of the time work in isolation – a more formal relationship where we all agreed to move in the same direction would be very powerful in terms of improving the quality of primary care as well as helping us negotiate with the acute sector and the PCT.
GPs had very little ability to negotiate with providers on behalf of patients. There were daily frustrations about the struggle to get good care. Tales of inefficiency, long waits, duplication of tests and futile outpatient appointments spurred us on.
Sometimes trusts would refuse to see patients because they were in the wrong patch – Manchester is one of the largest metropolitan areas in the UK with a population of more than 2.5 million and there are a number of large, powerful providers, from the University Hospital South Manchester to the Manchester Royal Infirmary, Pennine Acute, Central Manchester and others. We had no influence over these trusts as individual GPs but as a corporate entity we would be able to negotiate on behalf of 160,000 patients.
There was also a need to make sure the new organisation had longevity rather than simply relying on a few enthusiasts. We wanted to set up something that would be sustainable in its goal of improving the health of the population we care for.
And we wanted to look to the future – whichever political party comes into power, it's clear healthcare spending can't keep going up and up. PBC is currently the only game in town to tackle this. And as a legal entity we have the potential to hold a real budget for our 160,000 patients.
What kind of model?
We looked at various structures and took advice from people who had been there and done that, such as our neighbours in Stockport PBC who had set up a social enterprise – a business or service with social objectives where surpluses are reinvested, rather than being driven by the need to maximise profit for shareholders.
We wanted commissioning to be credible with our patients and the PCT. The idea of joint ownership, all being in this together, seemed to fit our approach.
But setting up the organisation was a cumbersome process. From the initial idea four years ago, it has only been in the past 18 months that things have started to happen.
We took the idea to one of the PBC group's quarterly meetings where all the 26 practices came together and supported the plan. But it took a year to win hearts and minds at the PCT, which was frustrating.
We had to keep plugging away, building relationships and showing we had a robust vision. It was about understanding the issues and the pressures on both sides.
The current financial difficulties in the
NHS tipped the balance in our favour.
To set up the organisation and register with Companies House we needed legal advice. It cost about £35,000, including employing the legal firm as company secretary. In future years we plan to have this role in house. We funded this through freed-up resources gained over the first couple of years of our consortium's work.
We went for a particular type of social enterprise structure, the Industrial Provident Society. It's a community-based organisation where all practices are members, which suits our egalitarian, inclusive commissioning ethos.
We had to hold our first AGM where we needed a quorum to vote for board members. Trying to get GPs to leave their surgeries was a challenge – the old line about herding cats comes to mind – so we made it clear the project couldn't go forward without that commitment. Then it was hard work to get people to fill in the membership forms the right way. It's something that inevitably goes to the bottom of the ‘to do' list in a busy surgery – even my own practice managed to fill in the forms wrong! But we got there in the end, with a lot of chasing and support from PCT staff.
Nowadays there's a lot more help available for people who want to go down the same route, from the Department of Health social enterprise support unit to the legal firms who specialise in this area.
How it works
We are a membership organisation where the number of members each practice has is proportionate to list size. The member could be a GP, nurse or practice manager.
I'm the chair and one of five GPs on the board. We also have five practice managers and one lay member on the board. All our GP leads have specific roles such as long-term conditions, finance and contracting, and we bring in expertise in specific clinical areas as needed. Each practice manager board member is linked to a GP lead.
There are quarterly meetings to which any staff member can come, which focus on clinical issues and service redesign. We usually have representatives from each practice and the relevant clinical leads.
As chair, I visit all the practices regularly to monitor performance and talk about PBC. It's very much bottom-up, not top-down – peer pressure is important. Comparative data helps GPs know how they are doing and helps everyone feel they are all in this together.
We don't provide services – we are about commissioning. Once we've identified a need and developed a patient pathway, we create a service specification. Procurement is handled separately by the PCT's business case approval process. The aim is to get business cases approved within eight weeks.
At first the new PCT was largely paying lip-service to PBC – we had to win hearts and minds. It's always tricky for people to give up power but there has been a big cultural change and we are now working much more closely together.
Relationships between the PBC group and PCT have developed as we've spent time together. We both now understand the two worlds we work in – so when we refer, we have an idea what the options are and what they cost, and the PCT understands how GPs work. There is better connectivity between the contracting and financial world of the PCT and the ‘coalface ‘ of general practice.
There's a real sense of joint ownership. The financial pressures have really concentrated minds and the PCT realises PBC is part of the solution, not the problem.
Day to day
We have a service-level agreement with the PCT covering processes and responsibilities. Some 16 PCT staff are seconded to us to provide data, contracts and finance support. We have a management budget of £150,000 for cover for board members and clinical leads – I spend four sessions a week working for the company, and the other board members are covered for one session each.
The amount of work continues to grow – it often feels as if every piece of paper the PCT conjures crosses my desk. Board members and clinical leads complete timesheets so we can demonstrate the scale of work involved.
Our clinical leads for areas such as diabetes and COPD go into the PCT regularly and look at activity and other data, as well as providing feedback to the PCT, practices and the regular business meeting. Practice managers meet PCT teams and PCT staff go into practices to support them with prescribing and with using data.
The three chairs of each local PBC consortium attend PCT board meetings – we are guests rather than board members but it is clear the PCT takes us very seriously.
We have an overall devolved budget of £1m, which includes money for the local incentive schemes. These include peer review of referrals, prescribing targets and attending quarterly meetings.
We've commissioned the ScriptSwitch prescribing management system. It sits on the practice computer and flags up expensive drugs, hospital-prescribed drugs and provides alternatives. For example some generics are now more expensive than non-generic preparations and this is flagged and can be changed with one click.
When we started out, there was a lot of frustration about growing demand from nursing homes and patients being discharged from hospital with little information. Now we've commissioned a team of a consultant geriatrician plus two GPs with nursing support, who go into nursing homes and actively manage patients. We are seeing a considerable reduction in home visits and admissions– in some cases visits have reduced by 50%. It was a hard slog, taking two years from idea to launch because of PCT reorganisation, but is now making a real difference.
We've also commissioned a minor surgery service. We found there were 1,700 procedures a year where patients were going into hospital for simple things such as removal of sebaceous cysts. Now there are three GP surgeons who carry out minor surgery in the community. Patients are very pleased that they don't have to wait for ages and pay to park.
We are currently working on ideas about commissioning better anticoagulation, ENT and phlebotomy services. The first is still based in outpatients, where people wait for hours (at an expensive tariff) for something that should be done more economically in the community.
One of the big performance issues is in orthopaedics, where the 18-week waiting time target is being breached and work is being sent out to the private sector at above tariff rates. We have drawn up a specification for a new service and are currently waiting for business cases to come in. Forming our company has been hard work but rewarding and has given ‘shop-floor' general practice the chance to work in the macro world of the NHS.
Dr Bill Tamkin is chair of Manchester Practice-Based Commissioning (South) Ltd