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North-East Revisited

Nearly a year after we reported on PBC in the North East SHA, Kathy Oxtoby gives a progress report on the region.

Nearly a year after we reported on PBC in the North East SHA, Kathy Oxtoby gives a progress report on the region.

When Practical Commissioning looked at PBC progress in the North East last December, the area had the joint highest number of PBC commissioning plans agreed in England, according to a Department of Health survey. But relationships between GPs and PCTs were less positive, with 41% of respondents rating their PCT relationship as poor – the worst in the country.

The same survey in September 2009 showed a marked improvement in relationships, reflecting the SHA's determination to reinvigorate PBC in the region. Now only 29% of North-East respondents described relationships with their PCT as poor – although this was still above the national average of 20%.

The proportion of practices in the region that had agreed a commissioning plan had risen from 67% to 72% – above the national average of 64%. Respondents rating managerial support as good had also increased from 41% to 49% – just below the average of 50% for the rest of England.

A common concern for GPs in the region is that PCTs are exerting too much power over PBC and that budgetary cuts will slow or even stall its progress.

Northumberland and North Tyneside – good support

From its patchy performance last year, PBC north of the Tyne has made ‘strong progress', says Dr Stephen Blair, chair of the PEC across the three PCTs of Northumberland, North Tyneside and Newcastle.

Improvements have come about partly because a new director was appointed at the North of Tyne PCTs, who set up a central PBC management team. This is giving ‘robust support' to individual groups and encouraging better PBC engagement from GPs, Dr Blair says. Events have been held to get feedback from PBC groups to ensure ‘what they want to happen starts to happen', he says.

To speed up the approval process for small-scale PBC initiatives, the three PCTs have set up a commissioning decision panel, which includes managers and clinicians from primary care who meet monthly to discuss service proposals. Recent schemes that have been given the green light include a review of end-of-life pathways to give people more choice and support.

LMC secretary Dr Jane Lothian says six PBC groups in the county have negotiated a LES for commissioning – a move forward. But the possibility of cuts to healthcare budgets could be a step backwards, she believes.

‘It's frustrating that just as PBC is getting going in the area we're faced with public spending cuts,' says Dr Lothian. She believes GPs must present a ‘united front' to keep up the momentum to drive healthcare improvements.

Sunderland – improved PBC relations

Three PBC clusters in Sunderland are reaping the benefits of the agreement they drew up with the PCT last year. Its aim was to encourage good relationships, with commissioners promising to communicate with practices and be accountable, while the PCT pledged to be visible and provide a level playing field and management support. The survey showed a rise in those rating their relationship with the PCT as good from 66% to 77%.

Dr Iain Gilmour, a member of Sunderland PCT clinical executive and a GP in Sunderland, says the compact has ‘helped influence' operational plans of the PCT. ‘The PBC clusters have been involved in setting priorities for investment and will help deliver PBC objectives,' Dr Gilmour says.

One objective is to improve COPD care, and each cluster has responsibility for a different aspect. The work includes an integrated audit of COPD care so that clinicians can compare support of COPD patients, admission rates and the use of community resources. ‘We hope to ensure every practice is delivering the same standard of care and reducing unnecessary admissions,' Dr Gilmour says.

More schemes are being approved by the PCT, thanks to the introduction of fast-track commissioning scheme for small PBC-related projects.

In the past year there has been ‘more support for, and less lip service to PBC', Dr Gilmour believes. ‘Now that PBC is an integral part of World-Class Commissioning priorities for PCTs, we are getting much more management support,' he says. This includes the recent appointment of a data analyst to help deliver more accurate and up-to-date information to inform PBC groups' plans for service redesign.

County Durham – high on enthusiasm, low on progress

GPs in County Durham continue to be frustrated by poor information, stalled business plans and arguments over savings, says Dr Stewart Findlay, NHS Alliance lead for PBC in the North East and a GP in Bishop Auckland. In the survey 55% of Durham practices rated their relationship with their PCT in terms of PBC as poor.

The merger of five PCTs has halted PBC progress, he says. ‘We're still not seeing real change or PBC commissioners influencing the PCT's decision-making process.'

Cost savings remain a fraught issue – instead of budgets, PBC clusters have an incentive scheme, which Dr Findlay believes has removed the link between financial and clinical responsibility.

Despite these difficulties, there is still ‘good engagement' between clinicians and the six well-established PBC clusters, which are led by GPs who were on the PECs of the old PCTs.

Dr Findlay says the ‘big success' of the past 12 months was when the Durham Dales cluster won its bid to set up an integrated care organisation (ICO), linking GPs with County Durham and Darlington Foundation Trust. The ICO model will involve ‘front-ending' the acute hospital with GPs 24 hours a day, and moving outpatients and minor surgery to the community.

Dr Findlay's enthusiasm for PBC remains undimmed and he feels it has the foundations to work in Durham, ‘if the PCT would give more power to general practice'.

Newcastle – Gaining momentum

There has been ‘slight progress' over the past year, but the PCT still holds too much power, says Dr Mike Scott, joint chair of West PBC Group and a GP partner in Newburn, Newcastle.

However, Dr Scott says the ‘blight' caused by the merger of the Newcastle, North Tyneside and Northumberland's management structures is over and some successful schemes are running. These include a COPD early discharge team, which has reduced the number of unplanned admissions across Newcastle.

One reason there is greater PBC momentum in the area is that West PBC Group and Central PBC Group are jointly funding independent management consultants to help develop business cases.

‘We look at what is good clinically and they look at the numbers and see what is viable. It's helped to make the groups more business minded,' says Dr Scott.

These measures have made a ‘big difference', he says, but in general, GPs ‘feel frustrated that they are not given enough trust, power and cash from the PCT' to make PBC work.

Cleveland – lack of enthusiasm for PBC

Work pressures have left little time for GPs to get enthusiastic about PBC, says Cleveland LMC secretary and Middlesbrough GP Dr John Canning.

‘When you're under pressure you concentrate on treating patients,' says Dr Canning. ‘This is our priority, not PBC.'

There have been some successes, such as a service that is helping to manage heart failure patients in community settings, reducing referrals to secondary care. But overall, PBC ‘hasn't achieved much in terms of day-to-day practice', he feels.

PBC has been held back by the PCT, which ‘continues to hold the purse strings', and by "bureaucratic processes" that make it difficult to get schemes approved.

Four new health centres in Cleveland created under Lord Darzi's Next Stage Review programme continue to affect relationships between GPs and the PCT. Clinicians are concerned the new surgeries will compete with local practices, says Dr Canning.

For PBC to thrive, he believes ‘more doctors, more time and more resources are needed, so that GPs can carry out PBC while still giving patients a quality service'.

Stockton-on-Tees – hospital reconfiguration driving PBC

In Stockton-on-Tees, the hospital reconfiguration is driving practices to improve community services, says

Dr John Harley of the Woodlands Medical Centre. Gynaecology and DVT services and a minor injuries unit are some of the ideas being discussed to bring services closer to home so that patients are not sent from Stockton to Hartlepool.

But although practices see the reconfiguration as an opportunity to drive PBC, the approval process is proving frustrating for GPs, says Dr Harley.

‘It's like wading through treacle – not because people are dragging their feet, but because of the way the approval process works,' he says.

One of the first areas in the country to take part in the Improving Access to Psychological Therapies initiative, Stockton-on-Tees has developed ‘an incredibly useful service for all levels of mental health', according to Dr Harley. It was initially swamped by referrals because of an unmet need, but the service has now matured and is delivered by gateway workers and graduate mental health professionals who provide CBT and counselling.

The Stockton board of the North Tees PCT continues to recognise the value of PBC and develop good relationships with practices, Dr Harley says. But to re-energise PBC, he would like to see federations of practices with real budgets whose managers would look to any willing provider to run community services.

Gateshead – PBC progressing

When Gateshead PCT became part of NHS South of Tyne and Wear, joining with two others, GPs were cynical about opportunities for PBC development, says Dr Mark Dornan, chair of PBC consortium GatNet.

But because clinicians in the area were used to working together through the out-of-hours co-operative, he says there is a ‘lot more joint working in Gateshead than perhaps in other areas', which has encouraged PBC projects to develop.

GatNet has a ‘well developed network with a good relationship between practices, PCT management, providers and other partners', Dr Dornan says. Successful schemes include a clinical assessment and treatment service for knee pain, and a collaboration between the local hospital and PCT provider to reduce nursing home admissions to secondary care.

GatNet has also worked with the local authority and other providers to produce the Gateshead Information Network, which offers public service professionals a single source to access such information as clinical referral guidelines and details of urgent care services. ‘The site is helping to standardise care and improve quality,' says Dr Dornan.

But PBC progress could stall in Gateshead following a funding freeze on all new work because of pressures on the acute contract. Although practices have had indicative budgets since May, Dr Dornan says ‘we're not sure what to do with them'.

‘We need budgets to become actual or there will be no chance that practices will be rewarded for savings.'

Kathy Oxtoby is a freelance journalist

View from the boardroomView from the boardroom View from the boardroom

Dr Carl Parker, adviser on PBC to the North East SHA, stresses the organisation is ‘committed to PBC and sees it as the way to develop services'. After a year of ‘complete reorganisation' in 2008, Dr Parker says the past 12 months ‘have been about trying to re-embed processes locally'.This February, PBC representatives from all the North East clusters met with the PBC National Improvement Team to discuss how PBC in the region could be improved. Since then the SHA has set up a PBC development group chaired by Dr Parker. The group holds meetings attended by a senior commissioning representative from each of the four PCT clusters and PBC representatives from the region, to clarify the North East vision for PBC. ‘It's a great way to bring unity back,' he says. In his advisory role Dr Parker has spoken to 90% of PBC leads to get a flavour of PBC issues and how GPs would like work to progress. Current work includes looking at what is meant by any willing provider contracts in the context of PBC and making this consistent across the whole of the region so there is no variation between clusters.Dr Parker believes the Department of Health guideline setting an eight-week approval deadline for PBC business cases is starting to bite. While the implementation stage ‘still needs speeding up', he says the SHA is ‘committed to do this'. By 2010 he envisages that GPs will ‘feel more empowered.' as a result of PBC. ‘We're in a far better place than we were a year ago, and we are hoping for constant improvement.'

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