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GPs buried under trusts' workload dump

North-West revisited

Last October we looked at the state of play with PBC in the North-West – Kathy Oxtoby reports on whether progress is being made in this part of the country

By Kathy Oxtoby

Last October we looked at the state of play with PBC in the North-West – Kathy Oxtoby reports on whether progress is being made in this part of the country

When Practical Commissioning put PBC in the North-West in the spotlight last October, a Department of Health survey on PBC carried out two months earlier had suggested that 79% of practices had a good relationship with their PCT, compared with the national average of 75%. According to that survey, 49% of practices had agreed a commissioning plan with their PCT, and 50% rated the quality of managerial support for PBC as good, compared with a national average of 53% and 44% respectively.

The same survey in July 2009 showed an improvement in practice relationships, with 81% of North-West respondents now describing them as good, above the national average of 75%. Practices in the region that had agreed a commissioning plan had risen to 55% – still below the national average of 62% – but those rating the managerial support as good had risen to 56%, well above the average of 48% for the rest of England.

As with the rest of the country, GPs in the region say their experience of PBC varies, with plans for service redesigns progressing or stalling depending on the attitudes and priorities of PCT management.

Manchester – winning hearts and minds

Since announcing plans for the South Manchester Hub consortium to form a legal entity last year, consortium chair Dr Bill Tamkin says: ‘We've been struggling to win the hearts and minds of the PCT to take on the idea of our having more autonomy.'

These efforts eventually paid off and in June this year, the hub – with 26 practices serving 155,000 patients – was given the green light by NHS Manchester PCT to form a social enterprise, due to go live in September. It will run along the lines of an Industrial Provident Society – as a co-operative for the benefit of the community – and have clear accountability for its commissioning role with the PCT.

In 2008 the group undertook two major service redesigns, which have had very different outcomes. The hub's community-based minor surgery service is thriving, and it is hoped that soon 1,500 cases will have been ‘pulled out' of the secondary sector. But its community gynaecology service ‘could not be sustained', Dr Tamkin says. ‘There were tensions between the PBC group and the provider arm, which did not share the same vision as PBC commissioners,' he says.

Protectiveness from service providers about the work they do can inhibit PBC, he warns – ‘and if we can't get the services we want for patients we will commission elsewhere'.

But GPs are still positive about PBC, Dr Tamkin believes. The approach has encouraged mutual support between communities and gives clinicians ‘a large corporate voice to support individual practices – there's definitely strength in numbers', he says.

A frustration yet to be addressed is the wider policy role of PBC. ‘The DH has yet to clarify how much ownership of health service problems they want us to have. There's a lot of rhetoric about strengthening PBC, which I'm all for, but it's hard for PCTs to know how much responsibility to devolve and how much support they should be giving us.'

PBC could be boosted by the credit crunch, he suggests, because ‘strengthening the role of the gatekeeper in the commissioning process is the only way to manage the burgeoning cost of healthcare'.

Cumbria – PCT relationship satisfaction hits 100%

The DH survey suggests 100% of practices rate their relationship with their PCT in terms of PBC as good. Dr Peter Weaving, a locality lead for Cumbria PCT and Practical Commissioning's diarist (see page 12), believes this achievement owes much to the PCT's efforts to encourage clinical engagement, which includes having clinicians working in senior management roles at the PCT.

Cumbria is divided up into six localities that fit with the county council footprint, each of which is headed up by a GP, and has a representative from each of the constituent practices. That practices feel supported and involved in PBC is shown by the amount of innovative work that is being carried out in the county.

Cumbria was chosen to take part in one of the 16 DH integrated care pilots selected by the DH in April. Because of the challenges of Cumbria's geography and dispersed population, the pilot will test two models of integrating care. The first is based on a whole locality, South Lakeland, with a population of about 100,000 and 22 practices coming together to work in a co-ordinated way. The second is a smaller model covering population sizes of between 15,000 and 20,000, with two or three practices working together, and is centred on small market towns in the Allerdale locality, West Cumbria.

In Kendal, Westmorland Primary Care Collaborative – with 21 practice members and a population of 110,000 dispersed over 600 square miles – has redesigned urgent care services. Urgent care delivery so far includes a 51-bed GP-led inpatient unit in Kendal after the closure of three acute medical wards and the coronary care unit and a rapid access case management team now integrating with the intermediate care (rehab) team.

It also features a primary care assessment service, a £250,000 investment in generic home care and a community respiratory team. Between July 2008 and August 2009, the area has seen a 1.5% increase in non-elective admissions, compared with a 5% increase across the North-West.

Last year, the six localities were given £6m to invest in projects at a local practice level, which was invested in community projects in ophthalmology and dermatology. Now, along with other areas, Dr Weaving says PBC in Cumbria is facing a financially challenging year and that less money will be available to make savings.

‘The good times are over. But we need to make the best of things and use this financial crisis to be innovative,' he says.

Lancashire – service redesigns caught up in red tape

Last year, the Wylde consortium in north Lancashire was in the early stages of analysing data and planning projects. Since then, consortium chair Dr Tony Naughton says little progress has been made because of PCT red tape. ‘It's been a year of wading through treacle. We've got lots of ideas, but the approval process is complicated and long-winded, and the rules about procurement methods for a new service seem to change on a regular basis,' he says.

A project to move diabetes care into the community that Dr Naughton expected would be rolled out last year has yet to get off the ground. And a scheme to develop a new musculoskeletal pathway, so patients only end up in the orthopaedic department if they really need to, has been under review for 18 months. These delays could explain why 54% of practices rated their relationship with the PCT in terms of PBC as ‘poor'.

Plans to employ pharmacists to work alongside practices to reduce their prescribing costs were also stalled because now, as purchasers rather than providers of services, the PCT did not want to employ them. The consortium went to the acute trust, which has agreed to act as an employer and it is hoped that pharmacy posts will be advertised this autumn.

Despite these difficulties, Dr Naughton is hopeful that the situation will improve. He says senior PCT staff recognise the need for a much faster approval system ‘and are doing their best to speed up the process'. The PCT has employed a project manager to drive forward PBC projects and is working closely with the consortium to ensure their plans are given priority.

The financial difficulties the NHS is facing will give PBC more power and influence, Dr Naughton predicts. ‘The PCT will look at PBC and say "well here's a tool we can really use".'

Merseyside – needs to accelerate progress

Dr James Kingsland, president of the NAPC and a GP in Wallasey, says PBC has made headway in the area – but not fast or far enough. ‘More PBC groups are saying they are getting the tools to do the job, such as more accurate data, more timely budget information and greater ownership of the health agenda.'

However, he says this is still only happening in small pockets, which can be discouraging for those who want to get involved in PBC. Much of PBC work in the area is still PCT-driven, which continues to frustrate GPs.

Wallasey Health Alliance, Dr Kingsland's consortium of 12 practices, was the first in the Wirral to form a legal entity last year, and he believes this is the future of PBC. He says having an independent management structure means the organisation can determine how to develop partnerships. It also gives it a stronger voice with the PCT, and has boosted healthcare staff's enthusiasm for PBC work.

Service redesigns in their early stages include a project looking at preventing admissions for patients with COPD. At the two practices where the pilot scheme is being conducted there has already been a significant difference to the quality of life of patients. The risk of hospital admissions and readmissions following discharge has also been reduced.

Much work needs to be done to really ignite PBC, Dr Kingsland believes, saying ‘we would have very few problems' if only the recommendations of Clinical Commissioning: Our Vision For Practice-based Commissioning, published by the DH in March this year, were adhered to. But although he says PBC still has a long way to go, he is hopeful progress will accelerate over the next 12 months.

Cheshire – finally moving forward

Enthusiasm for PBC was initially hampered because of PCT reorganisation and overspend, but now projects are moving forward, albeit slowly, says Dr Philip Milner, vice-chair of West Cheshire Health Consortium.

The consortium comprises 38 GP practices and covers a population of around 250,000 patients. It secured £200,000 of freed-up resources (FURs) in 2008/9 from savings made on its prescribing budget.

Investment priorities include developing enhanced diabetes services

in primary care to enable more patients to be cared for out of hospital, and ophthalmology, where there are plans for an intermediate tier to assess patients referred from high-street optometrists.

FURs are also being used to invest in business management skills to ensure that further savings are made from the prescribing budget in 2009/10.

A significant challenge will be to manage the £20m outpatient budget, as along with many other areas, Cheshire has seen significant increases in outpatient referrals. One of the consortium's practice members has implemented a system whereby it publishes within the practice individual GP referral rates per consultation. This model has been presented to all 38 member practices, to show how variation in referral rates can be reduced simply by publishing and talking about these differences.

Although PBC is moving forward, Dr Milner says getting approval for schemes from Western Cheshire PCT remains ‘a complicated process'. This is shown by the fact 90% of practices say they are not providing more services as a result of PBC, compared with a national average of 39%.

Dr Milner also anticipates that in the months ahead, ‘introducing innovative schemes will prove increasingly difficult as we face working in an environment focused on making cost savings'.

Manchester Cumbria Cumbria Lancashire Lancashire Merseyside Merseyside Cheshire Cheshire North West SHA North West SHA View from the SHA boardroom View from the SHA boardroom

Dr Steve Henderson, associate director for clinical engagement at NHS North West, says the DH July 2009 PBC survey supports the SHA's belief that PBC in the North-West has been ‘strongly embraced' by GPs.

‘We've always had a high rating. That has remained strong, and overall the results are very encouraging,' he says.

Building on its higher-than-average result for practices that have a good relationship with the PCT, the SHA has launched a PBC and PEC chairs joint network, which means the lead clinicians from PBC and the PCT now meet regularly. ‘This gives them an environment where they can discuss emerging issues, talk about successes and learn from each other,' says Dr Henderson.

As a GP in Wythenshawe, south Manchester, who sits on the board of South Manchester Commissioning Consortium, Dr Henderson also uses his knowledge of what is happening on the ground to inform what needs to be done strategically in clinical commissioning.

With some of the worst health statistics in the UK, he says GPs in the North-West are focusing on broader commissioning rather than local services. In Trafford, discussions are under way to see how GPs and hospital clinicians could work together as an integrated care organisation to solve healthcare problems in the area.

Innovative PBC practice in the region continues to develop. The Stockport Managed Care Commissioning Company, a social enterprise wholly owned by all 54 surgeries within Stockport PBC consortium, has control of its PBC budget. It has been commended for good practice by the DH in its publication Transforming Community Services and World Class Commissioning.

The region is also setting an example of shared leadership with clinicians and managers through the SHA's clinical leaders network project, which involves medics, pharmacists, nurses and health professionals meeting monthly to look at policy areas and strategies and meet with national and regional leaders.

As SHAs face a tougher financial climate, Dr Henderson says that if any area is prepared, it's the North-West. This is because GPs who understand local health needs will be at ‘the heart of discussions' when changes are proposed, ensuring they have ownership and influence over how to use resources – and, as he points out: ‘Who better to do that than clinicians?'

PBC Masterclass

PBC Masterclass: Regional events

What: These regional PBC events are designed to equip you with the sophisticated skills needed to overcome barriers and push on towards PBC success.

When: 10 individual events running from October 2009 to January 2010

Where: 10 different regions throughout England. Each event has been tailored to address the learning priorities highlighted by practice-based commissioners in that area.

Next steps: Find out more and book

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