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GPs go forth

PBC at the core of commissioning local lifestyle services

Dr Peter Ilves on how his PBC group is being given responsibility to pull together primary prevention services and identify the gaps

Dr Peter Ilves on how his PBC group is being given responsibility to pull together primary prevention services and identify the gaps

41207562In late 2007 we suffered a PBC break-up. We had been in a cluster with neighbouring practices from Putney for two years, but the differences between the health needs of our populations could no longer be overlooked.

In broad terms Putney is a healthy, prosperous area with high levels of education and employment whereas here in Roehampton and West Hill we have the second highest index of multiple deprivation and self-reported long-term illness of all the wards in Wandsworth PCT. The table on page 41 gives more detail on the differences in needs between the two different clusters.

The split meant our cluster was now made up of just seven practices, nine partners and 11 salaried doctors, covering a patient population of 34,000. And our FURs for the first year were just £110,000 of which 70% was split between the individual seven practices to reinvest in their practices and 30% was in the central PBC fund.

However, the split left us with an acute awareness of what our population's needs were in this part of south-west London and that they would not be greatly addressed by the more traditional models of PBC that often entirely focus on care closer to home, at a cheaper rate with shorter waiting times.

To make an impact on the health of our population we would have to work with all stakeholders to influence the many and varied factors that contribute to their ill health.

We have a very mixed population with a wide variety of racial groups including large numbers of refugees from multiple countries around the world.

The core population is also of low socioeconomic status with a high level of deprivation and the older members of the community are displaced East Enders, rendering RoeHill very much an inner-city population.

There is, however, a great sense of community and pockets of support structures in place within family and ethnic groups.

The number of people registered with CHD in Roehampton is significantly higher than west Putney (639, compared with 266) and well above the rate for Wandsworth as a whole (30 per 1,000 in Roehampton compared with 18 for Wandsworth).

The box (bottom) explains more about the local situation.

New beginnings

The feeling of the newly formed PBC board was buoyant and positive despite the cluster split, but it was evident that communication and processes were simply not working effectively at the PCT leads meetings.

The monthly meetings demonstrated participants pulling in multiple directions, slowing down opportunities. Many people simply felt quite tired.

GPs, so used to working within self-employed status and running independent businesses, were busy fighting little corners; the PCT, with an increasing sense of autonomy, only too aware of NHS bureaucracy and systems, was battling with impossible rules; conversations were in several languages – a tower of Babel with no deity to establish a common dictionary. There seemed to be a lack of common understanding.

41207563A turning point came when the PCT noticed common understanding was what PBC truly needed for collaborative working and to deliver the PCT's own commissioning strategy plan (see box left). Indeed, when we achieve our common goals we will tick all of the PCT's objectives.

A PCT manager facilitated some workshops between the PBC, PCT and public health leads to discuss what PBC is, what it could and couldn't do, and asked

us to set an agenda and remit to achieve our goals which resulted in five pan-Wandsworth themes – urgent care, community nursing review, children's services review and a collation and access methodology for lifestyle services in Wandsworth.

To facilitate this last goal, it was agreed to develop a lifestyle services umbrella organisation concept, and this work would be run by PBC leads and PCT and public health commissioners.

The concept would then lead to a service to be commissioned.

The PCT has allocated £50,000 to this ‘board' so that it can get to a point where it can procure a provider organisation to come in and run such a single overarching organisation to co-ordinate public health services in our area.

The £50,000 will pay for management, PBC time, possibly an additional public health manager and other running costs to get us to that procurement position.

The vision

There is already a significant amount of primary prevention and education activity going on in Wandsworth via public health, primary care, community services and the statutory, voluntary and private sectors. However, co-ordination of this activity is questionable and so services have existed and developed in silos with little understanding of each other's roles and activities.

The other major challenge we faced was how to get beyond the ‘worried well', who traditionally access lifestyle services, and reach the patients who most need it.

The PCT and public health managers have recognised that practice-based commissioners have a significant insight into the population's needs and can commission and enhance services for our patients in a way that a single PCT director of commissioning or public health could not.

The aim of the umbrella organisation is that it will develop a single database for the general public and clinicians to access, detailing what services are available in this area.

Health trainers will play a central role in facilitating the database. Possibilities include a single telephone number that GPs and patients can call to get advice from the health trainer on the most appropriate services for their needs.

We also see health trainers, ideally drawn from the local community, as having another key role in ensuring people engage with services. The DNA rate for some of the existing services is extremely high.

For counselling services from my population, for example, the DNA rate was 45% to 55%. In part it may be the fault of referrers not making a wise choice about what these patients needed but was also about the recurring themes of patients having low motivation, not perceiving their own self-worth and so not engaging with what was being offered.

These are people with complex lives so they need that little bit extra – someone who takes them under their wing and who helps them to identify their true health needs.

A positive facilitator who helps them by introducing them to the appropriate service and then follows them through that ‘journey' with a gentle phone call, text or email to see how they're doing.

That is one aspect of what we want that we think health trainers can do.

By creating a defined project group made up of representatives from the PCT, PBC group and public health, the aim is to create a more unified voice when communicating to agencies beyond the local health environment.

Through mapping out what services are available in the area this organisation will also be able to fill in the gaps and commission new services. This will move the commissioning power of PBC to a new level because we will be able to encourage the development of existing providers and stimulate new ones as we can communicate what is needed and advise how to fine-tune those services to suit.

These are much easier things to do when the PCT knows exactly what it wants to commission.

Early wins

The discussions we have had with the public health representative to get to where we are have opened a new channel of understanding into a health sector that was working hard to achieve similar goals.

To date, despite the slow progress of the lifestyle project itself, I have found that by simply talking to people, departments, specialist units, colleagues, local managers, community services and so on, things start to happen. So many services have been performing quite reasonably for many years with good outcomes but are not progressing, are overstretched and not able to develop or change.

With a PBC hat, attitudes change as soon as you step through the door. You can then listen and influence and guide their progress knowing patients' needs for your locality.

A pilot service called Footsteps came to the PBC clusters' attention. This was a public health provider organisation that offers a five-item menu of stress management, smoking cessation, an exercise programme, healthy eating and weight management.

Yet it wasn't being used. So we invited the founders to a PBC meeting to discuss how we could engage with it. GPs in the cluster are now referring patients to it and Footsteps is just about to begin accepting self-referrals.

As cluster lead I was also able to hold a meeting with the existing psychological therapy providers to address the high DNA rate for counselling and look at outcomes.

As a result of these meetings, graduate mental health workers now lead the service as a single point of access where every referral goes to them to ensure it is appropriate and they make contact with the patient to explore their needs further.

The best conversations are often had when there is a shared purpose simply to make something happen.

When that is the case things do happen: three conversations and a local radiology department creates extended hours to include weekends, opens up CT of the head within a week, introduces fast-access ultrasound, works up a business case for high-quality DXA scanning and more. Low cost – just conversation and thought.

The health shop

Another existing public health project that the PBC has been able to get involved with is the development of a health shop.

Being able to access lifestyle services without needing to go through a GP has been identified as a major obstacle that has to be overcome if we are to make contact with hard-to-reach groups.

The health shop will be open to passing trade and have a visible presence with a front desk and access to health trainers on site with multiple information sources. Associated with the shop would be other units such as a cafe/shop that will deliver a healthy-eating message, offer education packages and hands-on experience, and sell foods.

We are also exploring the idea of having a unique type of gym set up with Nintendo Wii consoles – the Wii Fit Gym. Why is it that our overweight teenagers are getting fatter?

Most have just not found exercise that they would do – especially true for embarrassed, overweight children who avoid visibility at all costs. Imagine a gym comprised of games consoles lined up ready to use, competitions to be had and fun stuff to do while getting fit. I am running the idea past my teenage patients and they are all saying ‘yeah, that I would do'.

We also hope to introduce a bike hire company as a component of this project.

In Roehampton we are adjacent to Richmond Park, which is an ideal place to spend time on a bike. Bikes could be hired as part of an exercise project, but also for general use to encourage daily exercise in the population, and there are numerous students locally at the university who could benefit.


In taking on clinical lead for the RoeHill cluster I truly had no idea what to expect. There were so many descriptions of what PBC was going to be. I think it is true to say that in most people's eyes the RoeHill cluster has not followed the traditional route and our relationship with existing providers has been closer than the norm.

However, I would emphasise that because of these relationships, we have already successfully enhanced services and we will be spoilt for choice when we come to tender services in future.

We simply want better for our patients and this has happened; no business plan needed. Also, what is evident is that taking on lifestyle services as a commissioning intention, working with public health and being part of the process to develop the concept I have outlined will be extremely satisfying .

One can see how this will affect large numbers of the population now and into the future.

Dr Peter Ilves is a GP in Wandsworth, south-west London, and clinical lead for RoeHill PBC cluster

Dr Peter Ilves: hopes to introduce a bike hire company into his local health project Dr Peter Ilves: hopes to introduce a bike hire company into his local health project 60-second summary Commissioning strategy Differences in adjacent clusters Local situation

Wandsworth public health report

General public health issues identified areas for Wandsworth (based on Public Health report, 2005/6)
• The Wandsworth survey of smoking, alcohol and drug use in school children 2004 shows high levels of abuse for all three categories
• Obesity: there are 65,000 individuals in Wandsworth who are obese and a further 100,000 who are overweight; obesity has grown by almost 400% in the last 25 years and on present trends will soon surpass smoking as the greatest cause of premature loss of life (House of Commons 2004)
• Particularly a need to target obesity in young people
• Excess alcohol consumption and illegal drug taking affecting high A&E attendance, cardiovascular disease, some cancers and mental health issues
• STIs and high attendance in clinics and A&E
• High teenage pregnancy rates
• Inequalities in health service delivery and provision

We simpky want better for our patients, and this has happened - no business plan needed

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