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How to…develop PBC muscle with an integrated care approach

Zoë Nicholson, Dr Peter Devlin and Dr Jonathan Serjeant on how the creation of a not-for-profit organisation has turned round PBC in Brighton

Zoë Nicholson, Dr Peter Devlin and Dr Jonathan Serjeant on how the creation of a not-for-profit organisation has turned round PBC in Brighton

The idea for Brighton Integrated Care Service grew out of great frustration that PBC was not achieving its potential locally.

At the heart of the problem was poor information as PBC proposals were at the time dependent on unreliable secondary care outcome data, and frontline clinicians had limited capacity to put in the time to turn their PBC ideas into reality.

41228341At the same time GPs felt Choose and Book was an extra hurdle in the 10-minute appointment, instead of an enhancement of care. Brighton was near the bottom of the league tables on the choice target and GPs found Choose and Book hard to use and time-consuming.

To tackle these frustrations, a not-for-profit umbrella organisation was created. BICS is owned and led by local GPs and primary care staff – practice managers, nurses and company employees. The three PBC consortiums still exist but the three PBC chairs are all executive directors of BICS.

We have introduced major changes to the way referrals are handled in Brighton. All referrals now go to one place, obviating the need for Choose and Book in the consulting room, and are reviewed by a team of local GPs who triage all referrals.

This process not only enables us to get the patient seen by the right professional in the right place at the right time but also means our data is rich and meaningful.

The data we now gather shows the whole patient journey from the GP surgery, rather than simply outcomes from secondary care. Owning that data really gives PBC some muscle, and has helped transform the relationship between primary and secondary care as well as being a key driver in pushing up the quality of outpatient services.

Our Eureka moment

Some 18 months ago, the PEC committee suggested a visit to see what had been achieved by Epsom Downs Integrated Care Services in Surrey. EDICS is a provider organisation that maintains an up-to-date database on the 200-plus care options available locally. For those cases that do not need the high-tech approach of a hospital, EDICS provides more than 20 clinics in the community. By increasing options in the community, the 17 EDICS practices are able to offer their patients an enhanced level of choice. EDICS has a gateway team of GPs to select cases that are suitable for these community clinics.

A group of PEC members – including GP Dr Peter Devlin who is now one of BICS' six executive board members – and PCT managers visited EDICS in September 2007. Some of us had a Eureka moment when we realised the value of the gateway service in terms of energising and regenerating PBC.

A joint approach

On our return from the EDICS visit a project group was set up to try to get our own referral management scheme off the ground and explore the type of organisation that needed to be created to do this.

The PCT was very supportive in creating this project group and understood that change brought about in a top-down way would not work. The ideas needed strong local GP ownership and so the project group consisting of GPs, a project manager and Zoë Nicholson, who at the time was doing PBC consultancy work for the PCT, was jointly funded by the PCT and PBC consortiums.

The creation of BICS would not have been possible without the foresight and vision of our PCT – and without buy-in from local GPs the scheme would have failed. BICS could not exist without their referrals, so our first key task was to secure GP engagement.

This proved easier than we anticipated, helped by negative feelings about PBC and Choose and Book. We found we were knocking at an open door and had almost all practices on board within three months.

The most common question we are asked by outsiders is how we managed to persuade 150 GPs to agree to having their referrals looked at by other GPs. But most GPs felt it was becoming increasingly difficult to keep up to date about the services one could refer into, and it's hard for any individual clinician to keep abreast of the very latest information about every specialty or service they might deal with.

We also emphasised the new service was about ensuring patients were seen as effectively and efficiently as possible – it wasn't about bouncing referrals back or rationing services.

Another factor that found favour with local GPs was that we would be recruiting local peers to carry out triage who would be a mixture of partners and sessional GPs, both leaders in the community and those with portfolio careers.

Our proposal also meant local GPs never needed to open Choose and Book on their desktops.

Within just two months we had 97% of practices on board – it was an idea that came along at exactly the right time.

Now that people can see how it works in practice, the feedback has been very positive. BICS has improved the inherent risks that exist in the patient journey from the consulting room to the outpatient department. Clinicians are engaged, keen to create an organisation that can provide them with useful data and feedback – and this gives PBC real power.

The new referral process

A pool of 36 local GPs, a mixture of partners and salaried doctors, carries out clinical triage of more than 40,000 elective care referrals in the city each year.

They confirm the referral is going to the best service or specialist for that patient's needs, and check all the necessary tests and paperwork have been completed and attached. This helps ensure all practices and patients have the same access to services.

In about 15% of cases, we change the original referral, to ensure patients are turning up to the right clinic, avoid duplication and ensure all the investigations have been done.

Where we make a change – for example, to upgrade a referral to a two-week cancer pathway – there is a GP-to-GP conversation between triager and the referring doctor.

In 10 months, we've only had one GP who complained about a referral being redirected. Patients are contacted by our booking management advisers to discuss where and when they would prefer to be treated.

How the organisation works

Each of the PBC groups in Brighton has its own strong identity and local priorities and we didn't want to lose that.

The PBC groups have 30 or so GPs at their meetings and we could never co-ordinate such involvement from a single organisation, but meaningful local dialogue is maintained and it means there is grassroots scrutiny of BICS proposals.

BICS is a not-for-profit organisation owned by some 200 shareholders, representing 47 local practices made up of local GPs, practice managers and BICS staff. There has been no capital buy-in by any shareholders and the shares are non-transferable. The shareholders have the power to vote directors on and off the board and vote at general meetings. BICS doesn't pay dividends so there is no financial benefit to any of our members. Were the organisation to be wound up for any reason, any surplus would be returned to the NHS.

BICS has been set up as a lean organisation, without any unnecessary bureaucracy. We have an operational director, two clinical directors who are GPs – Dr Peter Devlin and Dr Jonathan Serjeant – and the three non-executive directors who are also PBC GP locality leads.

Our relationship to the PEC is such that we feed in strong clinical engagement to its decision-making processes but are not involved in the procurement side.

All our data is publicly available so we don't have any competitive advantage.

BICS has a £3m SPMS contract with NHS Brighton and Hove that began in September 2008 to run over two years. The contract is to:

• Create a referral management scheme that would replace Choose and Book and provide peer review of all referrals. The previous Choose and Book scheme would have cost our PCT about £250,000 a year.
• Redesign 12 elective care services.

Becoming a provider

Using our new data we have been able to take a look at service redesign with a new set of eyes. Most PBC groups have to rely on being told which procedures were done in outpatients – this doesn't tell us which conditions patients were presenting with that led to those procedures.

Our current approach is to put complete service redesign proposals to the PCT. Plans for ENT and ophthalmology have been submitted, and we expect to finalise dermatology and gynaecology projects by April. These include a GPSI-led service for the treatment of otitis externa and waxy ears and a primary care team (nurse, optometrist and GPSI) for minor eye conditions such as blepharoconjunctivitis, dry eyes, styes and lid lesions.

We are looking eventually to support the provision of some of the service redesign models and other marketing opportunities. Our expertise can be used by local practices to reduce the risks when expanding service provision.

Our dermatology proposal offers an integrated model for the treatment of acne, psoriasis and eczema, where patients will be seen by a primary care team including a GPSI and a nurse, with support from a consultant. In gynaecology we are developing a primary care team for menstrual conditions.

BICS will do the bidding but the actual provision will be effectively subcontracted to GPs within the PBC groups using agreements with BICS.

We don't see BICS taking on a whole patient population budget as we feel there is a danger we wouldn't add value if we took on responsibility for all patient pathways. Instead we will look at clinical pathways individually, and manage the budgets for those in which alternative models of care can have a significant impact. We intend to stay small, agile and responsive to the needs of primary care.

Our aim is to start delivering clinical services over the next year.

We will be focusing on the interface between primary and secondary care and working to improve equity of access across the city, helping smaller practices offer patient services that they just don't have the muscle to set up on their own.

A new primary care voice

BICS has already given primary care clinicians a voice with secondary care – the secondary sector used to think the PCT was primary care. Now we have regular contact with Duncan Selbie, the chief executive of our acute trust, Brighton and Sussex University Hospitals. One of the two BICS clinical directors is seconded to the executive team of the acute trust.

BICS is about clinical leadership of service redesign, not just clinical involvement.

We have clinicians, across primary and secondary care, leading the work, making decisions together about current and future services, and developing shared learning about referral practice and quality.

BICS is working towards building a future for primary care in an increasingly competitive environment where there will be a range of providers in the market.

It is difficult for small and medium-sized practices to tender for services but BICS provides the management support both to allow primary care to respond to PCT testing of the market and to take the initiative and create our own proposals.

We believe we can provide extra resources for practices to take part in the developing market in primary care, improve care for patients and meet the objectives of the PCT in driving up the quality of primary care itself.

Dr Peter Devlin and Dr John Serjeant are clinical directors of BICS and Zoë Nicholson is operational director

60-second summary Left to right: Dr Jonathan Sergeant, Zoe Nicholson and Dr Peter Devlin Left to right: Dr Jonathan Sergeant, Zoe Nicholson and Dr Peter Devlin

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