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Improving diabetes care through a GP-led company

Dr Adrian Higgins explains how GPs set up a private company to shift diabetes care into the community

Dr Adrian Higgins explains how GPs set up a private company to shift diabetes care into the community

The appointment of an enthusiastic community-based diabetes consultant by our PCT has opened many PBC doors for us.

Tackling diabetes care was a number one priority for our practice because we had 500 patients with diabetes, the largest number for any practice in Southampton.

When I first heard about PBC I was inspired and hopeful it would offer us the chance to tackle important issues affecting patient care and influence service redesign for diabetes.

Patients with routine diabetes who had been referred because of a particular problem would typically undergo at least 10 follow-ups in secondary care over a five-year period.

41187772There were several frustrations with this follow-up appointment system.

The diabetes resource centre at Southampton University Hospitals NHS Trust often duplicated the work we did at the practice and the communication we received about a patient was poor and lacked the basic information we needed.

So in January 2005, our practice started to look into piloting some PBC initiatives and two months later I contacted the PCT, consultants and other healthcare professionals working with diabetes in secondary care to explain our ideas.

We wanted to have a monthly community-based multidisciplinary clinic at our practice and reduce the number of follow-up appointments to just one after the initial assessment. At around the same time the PCT had appointed a community diabetes consultant, Dr Patrick Sharp, and his reaction was extremely positive – he felt it was a ‘real boon' to work with a practice in developing a model and to have the support and facilities to make it happen.

Making the pilot happen

We organised a multidisciplinary meeting to discuss the proposed model and the practice agreed to pilot the service on a small scale. The monthly clinic would consist of a community diabetes consultant, podiatrist, dietician, practice nurse and diabetes specialist nurse.

We decided the consultant needed to see the following patients:

• those with an HbA1C greater than 10

• patients potentially needing initiation of insulin

• those with complex morbidities.

Setting up the pilot took just three months. Aside from writing letters and organising meetings to let people know what we were trying to do, it was a case of finding a morning where we could clear a few rooms where the consultant and diabetes team could deliver the service.

We identified which patients might benefit from being reassessed in the new clinic with a view to discharging them back to their GP. We wrote to patients about the service, explaining that we believed most diabetes care could be managed by them with our support.

There were no formalised start-up funds, but the PCT covered our costs during the pilot phase – about £800 per monthly clinic – which helped fund the consultant, nurse and other team members' time as well as providing a small amount for our own overheads, such as administration and reception support.

The practice didn't need to employ new staff, but the role of our diabetes specialist nurse changed. She now participated in the consultant-led clinic and in team reviews of patient cases.

We ran the pilot for about 12 months, during which time we evaluated the service and found that, of those patients who needed to see the consultant, an initial assessment and one follow-up appointment was needed before they could be discharged.

Using PBC to roll the pilot out

Six months on, the new Southampton East Commissioning Consortium, made up of 13 practices in the locality including our own, held a meeting and agreed to roll the service out to the combined population of 90,000. This included some 3,000 diabetes patients, 500 of whom were regularly attending the acute hospital clinic.

We realised our Chessel practice couldn't be involved in being both a commissioner and a provider, so in 2007 I helped set up a separate provision company, Solent Medical Services Ltd (SMS), which is a company limited by share. We invited share applications from all 13 practices from GPs, practice managers and other staff.

SMS has 60 shareholders who invested about £80,000 to set up the company.

There is a specialist PMS contract between the PCT and SMS to provide the service on a tariff-based arrangement, with a reciprocal arrangement for SMS to remunerate the PCT for use of its staff.

Having helped to establish the diabetes model, I became involved in setting up dermatology and ophthalmology community-based services, which were delivered by SMS. Then I was appointed PEC chair, which meant another conflict of interest, so SMS recruited Claire Wheeler to take on the company's day-to-day management and I resigned from SMS and sold my stake in the company.

SMS now runs weekly clinics from the Chessel practice, where up to 12 patients will see the consultant, a specialist nurse or another member of the team. As well as seeing patients, the consultant gives diabetes advice to practices in the locality, engages his colleagues in the outpatient department to make them aware of the value of the service, and takes an active part in looking at how the model can be expanded across Southampton.

The biggest difficulty we faced was how to extract people from outpatient clinics into our service. It was hard to get information from these clinics because we were seen as being a competitor and this has taken time to resolve. Now we have an agreement with the acute trust that it should no longer provide routine outpatient diabetes care.

Analysing the results

Despite the challenges the work has been worthwhile. The service has reduced reliance on secondary care. Unfortunately, our information systems and access to them continue to defeat us in our attempts to prove the exact extent of this change. But we do know the average follow-up rate for every new patient has fallen from 10 to two appointments.

As for the financial benefits, the rate for new first appointments in secondary care for diabetes patients is about £260 and follow-up costs are £87. SMS charges a lower tariff rate for first appointments at £110. Although the follow-up cost is also £110, because there are fewer of them, there is a much reduced cost overall.

The approximate annual cost of providing diabetes care for the locality was £200,000. We estimated our service would generate £30,000 savings per year, if the model were applied fully across the locality. But the model we developed anticipated a slower transfer of work, which would begin with a smaller capacity, so the service saved £10,000 for the PCT in its first year.

Under the rules of PBC there is no ringfencing of budgets and the overall budget is overspent because of the inflationary effect of Payment by Results, so the PCT has not actually received any savings to reinvest. But in its first year, SMS covered the £53,000 costs for providing this service and is likely to make a small surplus.

Most patients have welcomed the change because the community service is more personal and closer to home and they see the same consultant.

Waiting times have reduced to an average of four weeks. GPs know a senior clinician is at hand who is happy to discuss the patient's condition and talk through the treatment options.

The future is about continuing to shift care and consultant provision into the community and, long term, it's crucial that patients take on more aspects of their own care, supported by GPs and consultants.

Working with a consultant to improve care is extremely do-able, but establishing a service is more complex than it seems.

You can go a fair way on your own but it's essential to develop the skills for writing commissioning plans and business cases, and that means getting support from consortiums and PCT commissioners, as well as working through the nitty-gritty of who will actually provide the service.

We discovered that with PBC you can achieve things using an approach that borders on bluffing. You create a belief that you can make a change – and if you can convince enough people to get on board, change really can happen. There do, however, remain considerable blocks in the system.

Detailed information continues to be difficult to access, transferring patient care from one setting to another is not straightforward and the financial mechanisms and incentives remain complex and difficult to negotiate.

Dr Adrian Higgins is a GP in Southampton and PEC chair for Southampton City PCT

By chance the PCT appointed community diabetes consultant Dr Patrick Sharp (seated) at around the same time as Dr Adrian Higgins (standing) suggested a new diabetes model. Community diabetes consultant Dr Patrick Sharp (seated) and Dr Adrian Higgins (standing) 60 second summary

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