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How we saved our community hospital

Liam Williams and Dr Martin Gibbs explain how GPs came up with a PBC plan to save the £1.2m needed to keep a community hospital open – and improve services

Liam Williams and Dr Martin Gibbs explain how GPs came up with a PBC plan to save the £1.2m needed to keep a community hospital open – and improve services

Practice-based commissioning was not a new concept for GPs in the Forest of Dean, who have always considered themselves the key stakeholders in delivering healthcare to the local community.

By April 2006, the Forest of Dean PBC cluster was made up of nine of the 13 practices in this rural area. The cluster covered 45,000 patients and had an indicative budget of about £40m. The cluster steering group comprised a lead GP from each practice, a lay member and a nurse, each with an equal vote.

Under threat

During 2006, West Gloucestershire PCT was required to make substantial savings to balance the books, as were many PCTs across the country. One proposal was to consult on the closure of Dilke community hospital, with the promise of significant investment in community-based services. As is common when a community hospital is threatened, the local community reacted strongly.

The Dilke Memorial Hospital, one of two community hospitals serving the Forest of Dean, opened in 1923 and was paid for by grants and voluntary contributions, many of them from miners. Its running costs were met by subscriptions, and subscribers received free treatment before the transfer into the NHS in 1948. Some older Foresters clearly remember their families' subscriptions. This historical context is critical in understanding the strength of feeling among the local community about ‘owning' the hospital.

Community leaders and political representatives, supported by the district council, launched a high-profile political and media campaign to save the hospital. There were marches and rallies, political lobbying at Westminster and a campaign website. Somewhat unusually and for reasons not fully clear, a camel took part in some of the rallies!

In a separate development, other prominent members of the local community came together to form a steering group to consider how the feeling of community ownership of the hospital might be exploited. Benefactors came forward who committed to fund work required on the old parts of the estate and independent assessments were undertaken to verify the state of the buildings. The steering group submitted a successful bid to the Department of Health to develop a business case for a Social Enterprise Trust (see box, page 40). The SET steering group has continued to work with the PCT to determine a company structure and the range of community services it wants to provide, although there are currently no implementation plans in place.

The GP community is supportive of the social enterprise trust but engagement with it has been limited as GPs in the cluster have concentrated on developing commissioning capacity. The GPs realised that without a robust commissioning plan in place, that set out how significant savings could be achieved, there would be little chance of persuading the PCT that the community hospital could be run cost-effectively.

An alternative approach

A tense meeting took place between West Gloucestershire PCT's chair and chief executive and the Forest of Dean PBC cluster. It was agreed that if the cluster developed a credible alternative commissioning plan that made the £1.2m savings required, the PCT board would consider it. The local commissioning manager would continue to support the cluster and as the plan was developed, additional finance and information support would be made available from the PCT.

The development of an alternative commissioning plan meant revisiting PCT intentions and challenging the provision of existing services that caused frustration among primary care clinicians.

The commissioning plan was broken into three key areas, which together with

a £329,000 saving from the PCT via integrated service improvement, would make up the total £1.2m saving:

• inpatient non-elective care – £648,000 saving

• elective care – £34,000 saving

• prescribing – £188,000 saving.

The main incentive for GPs to engage with the changes was to retain local services – and the only real sanction was peer pressure, from GP colleagues.

Non-elective inpatient care

This was the area that was felt to offer greatest potential for reducing acute hospital spending and would make best use of community hospital capacity. Non-elective inpatient activity for 2005/6 was thoroughly reviewed and broken down independently by several GPs to identify whether a community hospital could provide the care required. This review covered more than 250 HRG codes and the GP responses were highly consistent.

It was this exercise that led to the single largest change in proposed service delivery from the Dilke community hospital – covering ownership, bed numbers and case mix.

To make the hospital financially viable,

it was proposed that the 36-bed unit, with mixed primary and secondary care ownership, should be reduced to a 26-bed unit wholly owned by primary care.

There was also a requirement for the case mix of the inpatient unit to be changed. The unit traditionally treated older people requiring rehabilitation or acted as a facility for patients awaiting complex social care packages or residential care. The activity review and financial modelling using the Payment by Results tariff indicated that case mix should be based on 30% rehabilitation and 70% sub-acute care patient occupancy.

A change in medical care was also needed to ensure the community hospital could provide high-quality care to sub-acute patients. To facilitate this, GPs agreed to give up their admission rights and associated income for managing the beds so a more robust model of care could be provided.

A service specification was developed in partnership with therapy, nursing and social care colleagues and a tendering process undertaken by the PCT and cluster led to a local practice being awarded the contract to provide the care.

Alongside the focus on the use of community hospital beds, the cluster continued to ensure that non-elective demand was proactively managed using other services. Case management had already been implemented and was highlighted as a priority for primary and community clinicians; blood transfusion and IV drug infusion services were set up and included a community based IVAB service; a local COPD management plan was developed and implemented by all practices; and intermediate care provision was increased.

Elective care

The biggest sources of savings envisaged in elective care were from switching follow-up from secondary to primary care for conditions GPs felt should be managed there, and a significantly more robust approach to peer review of referrals.

The PBC cluster had already developed primary care-based diabetes, dermatology and orthopaedic services and the alternative commissioning plan proposed to increase the work undertaken by these services.

The figures put forward for reducing new referrals and shifting follow-up to primary care were based on the PCT's practice-based commissioning DES targets. However, it was anticipated by many GPs that with greater use of peer review the savings target could be exceeded.

Prescribing

This was probably the most contentious area to make savings within the cluster, particularly as all but one were dispensing practices. There were differing views between the cluster and PCT as to the level of savings achievable and the accuracy of budget setting. However, the political imperative for the GPs to demonstrate

a commitment to reducing pharmaceutical spend was critical. This led to a debate with the local community and some patients being informed that, to support local services, they would be asked to change their drug regime. This was overwhelmingly supported and a prescribing action plan was agreed setting out the savings achievable at practice and cluster level.

Progress report

The PBC cluster's alternative commissioning plan was approved for implementation

in September 2006 after a comprehensive review by the PCT board, thereby securing the future of the community hospital.

Regular progress reports have been generated by the PCT information and finance teams.

The inpatient service redesign took longer to implement than expected as a result of the national tendering process that was put in place. Expected savings for 2006/7 were therefore not fully achieved and although significant savings continue to be made, the first-quarter report for 2007/8 has demonstrated the need for some of the assumptions to be revisited. In particular, the sub-acute bed utilisation rate appears to be overambitious.

Elective care targets were all achieved and exceeded, with service redesign also improving local access to services. Peer reviews undertaken at practice level did reduce demand and the sharing of clinical expertise via protected learning time remains a feature of the cluster practices. There was a 3.31% reduction in outpatient activity in 2006/7, with a 5.44% reduction in spending.

But many of the cluster GPs are frustrated at the obstacles they face in shifting appropriate follow-up care from secondary to primary care. There is constant discussion with the PCT to identify how

the contracting process can be used to aid this.

Prescribing savings have not reached their expected levels although considerable effort has been made by most practices to reduce spending. A sub-group of the cluster is now working with the PCT medicines management team to identify areas for future work. One challenge the cluster has struggled with in this area is the time lag between agreeing a plan and the associated savings being realised – although the latest data does suggest the cluster will achieve its £188,000 savings target.

Lessons learned

The PBC cluster has undertaken substantial service redesign within the Forest of Dean, achieving significant savings and securing future community hospital provision in the area. However, it did not achieve its entire savings plan and work continues to ensure this is achieved in 2007/8.

We do feel that our experience shows that by working actively with the commissioning arm of the PCT, GPs can genuinely influence service commissioning and provision. In this case, GPs' input into service redesign has made it possible to provide a high-quality financially viable service in line with local priorities and local ownership.

Along the way, we feel we have learned some important lessons (see box, page 39) to pass on to other GPs who are at an earlier stage of PBC.

Liam Williams is head of commissioning for Forest of Dean & Stroud at Gloucestershire PCT

Dr Martin Gibbs is a GP in Blakeney, Gloucestershire, and steering group member of Forest of Dean PBC cluster

Key lessons for pbc success

1 Spend time developing positive relationships with the PCT management and local stakeholders, as well as with each other. Remember public consultation and engagement can be challenging but hugely influential.

2 Never assume your peers are in the same place as you – discuss issues explicitly to ensure mutual understanding – and remember that the lead PBC GPs are not necessarily representative of all their practice peers.

3 Most areas of service redesign have an impact on community-based colleagues in other organisations, such as district nurses. Consider how they can be actively engaged in the commissioning cluster and empowered to assist the service redesign and development process.

4 Spend time understanding the data provided and work with the information and finance teams to identify improvements to presentation format or content.

5 Do not concentrate on the areas that will generate minimal return for time invested. Identify trends of high use or costs and work with the PCT and colleagues to consider all the relevant issues before undertaking any service redesign.

6 Identify key dates in the contracting process between the PCT and its providers. Ensure business plans take account of notice periods and the LDP process.

7 Identify what you can really influence before you spend valuable time on service developments.

8 Get actively involved in the PCT monitoring of the quality of acute trust service provision. Do not underestimate the influence you should be able to have in improving the quality of patient care through this process.

9 Remember the PCT may still be developing its approach to policy initiatives. Ensure you fully understand its internal contracting and commissioning processes when developing your business cases.

10 Although the intention may always be to reach a consensus on decisions, ensure that your accountability agreement sets out the process for more contentious decision making.

Social enterprise trusts


• Social enterprises are organisations that are run as businesses but where profits are reinvested into the community or service developments.

• There are a number of different forms of social enterprise trust, such

as co-operatives, trusts, community interest companies, and it is estimated there are at least 55,000 in the UK – the best known being the Eden Project.

• Health and social care-based social enterprises should involve patients and staff in designing and delivering services, improving quality and tailoring services to meet patients' needs.  • Many feature partnerships with third sector organisations, such as voluntary and community groups.

• Third sector organisations can have advantages in terms of better relations with particular groups, expert knowledge in a specific area, or expertise in a specific type of care.

• In June 2006 the Department of Health sought submissions for sites to act as SET pathfinder sites, working with the NHS as potential providers of services.

A Department of Health-funded Social Enterprise Unit has been supporting successful sites develop plans.

The community reacted strongly to proposals to close the hospital Community hospital

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