Learning the lessons from pbc pilots
Five key themes have emerged from wave one of the PBC development programme run by the Improvement Foundation, write Jacquie White and Beverley Slater
Five key themes have emerged from wave one of the PBC development programme run by the Improvement Foundation, write Jacquie White and Beverley Slater.
In October 2005 the Department of Health commissioned the Improvement Foundation to deliver an ambitious development programme supporting the implementation of practice-based commissioning in England. In December 2005, 28 sites considered ‘most ready' were recruited to the first wave of the programme.
This was followed by a second wave in April 2006 and a third in October 2006. By the end of 2006 the programme had engaged 106 PCTs covering 2,450 GP practices serving 23 million patients.
Each site comprises a local implementation team of PCT managers and five GP practices or clusters, plus other local stakeholders. Each practice is required to identify one area for service redesign. Practices may focus on either scheduled care or unscheduled care – but the team as a whole must cover both.
This article describes the service redesign that is taking place in the 28 first-wave sites, and identifies barriers and enabling factors that will influence how PBC is likely to progress in the future.
What services are being redesigned by pilots?
An audit of the areas of redesign being tackled by wave one sites was undertaken in October 2006. It shows a varied picture of service redesign, ranging in scope from covering a whole service across a whole PCT, to covering a specific clinical area in one practice.
Some of the service redesign was already in the pipeline and has been adopted and/or adapted under PBC; others are completely fresh initiatives. Some of the initiatives are already being implemented, whereas others are at the stage of developing a business case.
All service redesign is responding to a local context of health needs, skills and interests, but the overall audit nevertheless demonstrates five clear areas of focus for PBC.
1 PBC can be a tool to implement acknowledged, better models of care
Some of the more popular initiatives for taking forward (including musculoskeletal triage and treatment services, anticoagulation services, diabetes services, COPD services) are those services that are fast becoming established ways of delivering effective healthcare in the community.
PBC is an opportunity for those sites which have not yet developed community services in any one of these areas to startt o implement these, and, building on the experience of those who have gone before, expect to realise some efficiency gains.
Hospital services are likely to be happy to support and work with primary care on these more established areas, providing that there is good clinical governance processes in place. Clinically there is a good case and the net result for hospitals is to prevent patients with low-level needs (and relatively low treatment tariffs) being added to their waiting lists.
Case study: Two localities in east Southampton implemented a locality diabetes model from June 2006, using a multidisciplinary community team supported by a consultan tin diabetes care jointly employed by the PCT and the local hospital
2 Quick wins for PBC include in-house review of referral and prescribing
A quick and easy impact can be made by putting in place good systems for managing referrals and prescribing. In-house review of referrals has been a successful strategy for some practices, to ensure that secondary care referrals are used to best effect.
Prospective review of referrals is the ‘hard-line' version where any referral has to be agreed by colleagues, but retrospective review is also a useful model to share knowledge about how patients can be managed using existing community services, or identifying a gap in community services that can be addressed (see article by Dr Richard Jenkins in the February 2007 edition of Practical Commissioning).
Strategies for ensuring that prescribing is efficient and effective can have a big budgetary impact, and hence these are useful PBC strategies, but may tend not to be reported under the PBC banner.
Case study Several practices in Derbyshire have been trialling internal peer review of referrals. The impact is to highlight appropriate community pathways that partners may not have been fully aware of, for example community continence service rather than urology referral; extended scope physiotherapy rather than orthopaedic referral.
3 Reducing emergency admissions is a ‘big win'
Pilot results from some sites demonstrate big savings on indicative PBC budgets by shaping existing health and social care resources to proactively meet the needs of complex patients and prevent emergency admissions.
Finding ways to do this that work in your local area has a substantially greater impact than work in any one disease pathway by itself. A system of primary care assessment beds to reduce secondary care admissions is a possibility that four of our sites are exploring.
Case study One practice in London has reported an estimated £60,000 saving on emergency admissions after undertaking a three-month pilot of ‘Unique Care', involving a community matron and a social worker spending seven hours a week each on managing patients at high risk of admission and preventing excess bed days.
4 Triage and treatment services need careful business cases
Sites are developing triage and treatment services for gynaecology, minor surgery, ophthalmology, dermatology, urology and ENT, in primary and community settings using GPSIs and other professionals. The business case for providing particular services into the community depends on skill mix, case mix, patient flow and set-up costs. In some cases there may be no efficiency gains.
Commissioners also have to be aware of the potential for these services to stimulate further demand and put in place strategies to prevent this.
Case study: A systematic process of developing extended primary care services has been developed in south Manchester. A clinical lead is funded to help the development of the service through all the stages including an initial referrals review, engaging with secondary care and other clinical professionals, developing a service specification, agreeing the service specification with all the practices in the consortium and working with the PCT on the business plan. The PCT undertakes a risk assessment and leads contracting negotiations. In this way, highly robust business plans have been produced for services including gynaecology, minor surgery and ENT.
5 Other quick strategies for demand-management
Other quick strategies around demand include developing ‘advice only' protocols with hospital consultants to avoid unnecessary hospital appointments, and working with the PCT to put in contract clauses to validate and reduce consultant-to-consultant referrals.
Case study In Northamptonshire, arrangements are in place for GPs to use Choose and Book to send referrals for ‘advice only' in a range of specialties, including general surgery, obstetrics and gynaecology, urology and orthopaedics.
What can PBC achieve in the future?
There is clearly the potential for PBC to unleash a lot of change. However, engagement in PBC is still a fragile commodity.
For PBC to be sustained there needs to be attention to removing the barriers to development. Barriers include: not seeing rewards; feared loss of power for PCTs; acute trusts losing mechanisms for releasing efficiency gains; and reorganisation. Practices and PCTs are only now beginning to get their heads around the new roles and relationships.
This, in turn, means that, as yet, the common agendas between primary care and secondary care, and between primary care and social care, have yet to be fully explored. The opportunity to work together with hospital services to deliver the 18-week pathway by December 2008 is primary care's chance to help hospital services understand the power of PBC and to find some win-win solutions to development of services.
GPs and other primary care professionals also need to build on effective ways of working more closely with social care and local authorities (as both commissioners and as providers) to continue to integrate services around the patient.
As the recently published Commissioning Framework for Health and Wellbeing makes clear, this will continue to be the long-term direction of travel.
Jacquie White is PBC development programme director and Beverley Slater is learning development lead at the Improvement Foundation
Where the pilots are concentrating their efforts
1 Emergency care and long-term conditions
The majority of wave one sites were aiming to stem the increase in emergency care costs by providing better and more comprehensive proactive services for patients with complex or long-term conditions:
• Half the sites (13) were doing work with their community matrons and district nurse teams and a substantial proportion of these are exploring the ‘Unique Care' approach
• Eleven sites (more than one-third) report concrete developments in COPD
• Seven sites were working on providing more diabetes services in the community
• Six sites were working on re-provision of anticoagulation services in the community
But some were aiming to provide emergency care services differently:
• Four sites were developing minor injuries services
• Five sites were at different stages of looking at providing GP assessment beds
• Five sites were exploring a form of GP liaison in A&E
• Three sites were targeting specific emergency conditions (catheters, cellulites, and paediatric pathways)
2 Planned care
The most common areas of planned care specialties targeted were:
• Musculoskeletal services (10 sites)
• Dermatology (nine sites)
• ENT (six)
• Minor surgery (five)
• Urology (five)
• Ophthalmology (four)
• Sexual health services (four)
• Mental health (four)
3 Management of care
A number of initiatives were targeted at ensuring that the existing tools for avoiding unnecessary hospital visits functioned properly:
• Practices in six sites have started to implement some form of peer review of referrals, with encouraging results
• Three sites are working on enforcing clauses in contracts for reducing hospital doctor-to-hospital doctor referrals
• Three sites are setting up systems to refer to hospital consultants for advice only
• Two sites were looking at systematic ways to reduce outpatient follow-ups
in-house review of referral and prescribing can lead to quick wins