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At the heart of general practice since 1960

PBC innovation through creating a new company

Dr David Morris and Dee Kyne explain how they remortgaged their practice to kick-start the process of PBC innovation in their area

Dr David Morris and Dee Kyne explain how they remortgaged their practice to kick-start the process of PBC innovation in their area

When I came into general practice in 2000, I found it immensely frustrating that patients would come back time and time again with the same problems. Faced with a 20-month wait before they can do anything for them, their GP can feel powerless. And so we began to look for a way to have more control and to find a better, more efficient and more rewarding way of working.

Accessing the right person in the health service is difficult at the moment and often requires several steps. We wanted to create a service that would ensure efficient and streamlined access to the right person at the right time in the right place, and would take the surgery to the patients – rather than the patient having to come to us.

All change needs a driving force and models of successful innovation, but few are willing to take the necessary risks. PCTs tend to be risk averse as their priority is to make the finances balance. GPs often feel they should be insulated from risk and PBC clusters are often defined by geography rather than attitude to risk and willingness to innovate. The other 22 practices in our PBC cluster weren't ready to take the next step. So we took it alone.

Setting up the social enterprise

We decided the best model to adopt would be a social enterprise so we could take the risks necessary for successful innovation, which others could then follow.

In 2006 we decided to establish a community interest company, which we called Pathfinder Healthcare Developments (PHD). We decided on this approach so that we could access funds and prove we had a strong governance framework. We reinvest our profits and assets for the public good. The idea was initiated by Dr Niti Pall, a partner in our practice and PEC chair at the time, and took about a year to develop. The company started in 2007, then took around nine months to really take off. The company is now owned by the practice along with business development director Dee Kyne, who was brought in to set up the social enterprise. The company was initially run separately from the practice. It now covers three practices.

The 11 partners invested £34,000 of their own money (about £3,000 each) to start the company and support initial staff salaries. As the company has grown, it has been able to pay the current 12 staff salaries out of its turnover.

A further investment to fund redesign of our primary care services came in a £200,000 loan from the Big Issue Invest – a fund that invests in groundbreaking social enterprise. We were its first health investment. The partners took the risk of underwriting the loan by remortgaging the practice premises.

PCT involvement

At this stage, our PCT, Sandwell, had not invested in the company. We started on a programme of redesigning our services using the £200,000, focusing on preventive care and early intervention, which is where we will eventually make the most significant savings.

Once the PCT could see what we were doing, it came on board and in various ways has invested around £400,000 of its own money. It has paid for us to run the community aspect of its CVD programme and contributed to the risk stratification analysis (see right) and workforce development for both clinical and non-clinical health professionals across the cluster. (We had already funded this with some £25,000.) The PCT invested a further £35,000 to develop a supervision and medical mentoring programme for the cluster.

Some of the money has also come from the PCT's innovation fund. It is very supportive of what we are doing and has given us almost total freedom. The social enterprise has put us in a strong position to bid for contracts such as PMS Plus, APMS, LESs and DESs.

We work with the PCT collaboratively – we don't have to ask for permission. It's a healthy relationship – the innovators push the agenda and hold the power because we are the providers and we are very close to the patients. A PCT is more restricted in this area because it is trying to be a good banker.

PBC involvement

Although PHD has no immediate direct link with PBC, we're using the practice development as a pathfinder-incubator company for areas in PBC. What we're trying to do is linked very clearly with the set aims of PBC: improving primary care access, moving more services to primary care and minimising unnecessary use of secondary care.

Having an incubator company in the cluster enables us to test innovation. We have taken huge gambles to see if we can restructure the way we offer primary care services. That then becomes available to the PBC cluster and sets the tone for what may be achieved as a collective. Others in the cluster have access to everything we're achieving, such as IT innovation and risk stratification of the managed population.

Data

We have worked with Aetna, which is one of the Government's Framework for External Support for Commissioners (FESC), to develop a robust risk stratification tool.

This uses primary and secondary care data to establish how our patient population is at relative risk of becoming unwell and allows us to become a very effective health population manager. This is being used though the cluster and is supported by the NHS Evidence Centre.

The data has dispelled some myths about how our patients access healthcare and has shown us the areas we need to change.

For example, when we started out we believed diabetes and mental health were our ‘low-hanging fruit'. But when we risk-stratified the population, the high spenders turned out to be asthma in young people and people who had two or more long-term conditions. Interestingly, the latter group was any combination of any two conditions. So we realised that no single condition drives urgent admissions and therefore that care management that focused on specific disease areas would not meet patients' needs.

This information showed us the way forward and led to the development of a model of work that will ultimately reshape services to the benefit of everyone.

Our aims became:

• to redesign services to improve access in primary care

• to keep people well who are currently well and reach out to those we don't normally see

• to maximise the health of those who do have illness in a targeted way, focussing on those with more than one illness through a care management programme

• to develop staff and personnel in a very positive way

• to provide value for money – not just providing cheaper services but making sure costs aren't multiplied by ensuring patients are seen by the right person at the right time.

The service redesign model

The service redesign model we have developed comprises various elements, as follows.

Self-care

We are developing personal care packages, working with people in their homes and looking at how technology can help them.

This service promotes confidence in self-management and provides an opportunity for community members to develop skills that improve the health of others in the community. We are also exploring using telemedicine.

Outreach/inreach

Working within communities that have not until now been contacted proactively, for example church communities, Gurdwaras, mosques, pubs and shopping centres.

We have carried out mid-life health check sessions in supermarkets, connecting with more than 500 people. By actively looking for patients at risk of ill-health this service will reduce inequalities in health.

On behalf of the PCT we carried out the community aspect for the CVD programme. We were so successful in engaging members of the community that we now have a 45-strong volunteer force who have become health champions. This has rolled out into the cluster and is now operating across the whole of Sandwell.

This group now forms the bones of

a patient reference group, which will be

an important part of everything we do in the future.

Fast-track referral and treatment

We have triage and clinical assessment teams working closely together to ensure people are no longer slowed down by the system. Clinicians and support staff are streamlined into effective multidisciplinary teams.

Signposting

This aims to identify all the resources locally that can help to improve people's health – whether this is simply identifying a local ramblers' club, or putting someone in touch with the Citizens' Advice Bureau to discuss housing needs.

We set out to bring together the information on a single website to make it as up to date and easily accessible as possible. We anticipate it will go live at the beginning of 2010.

Group consultations

This is a new style of consultation, for practice staff and patients with long-term conditions or recurrent acute conditions, delivered at the practice. It means a reduction in the use of primary care resources as well as better use of the most appropriate clinical expertise.

Diabetes and asthma group consultations are now a part of daily life at the practice. We will be launching other groups shortly, including back pain and hypertension.

Outcomes

Our model uses primary care as an agent of regeneration and raises expectations in a community that traditionally has low aspirations.

At this stage we are creating our own freed-up resources through redesigning primary care so we can then focus on innovation in secondary care redesign with our secondary care colleagues.

We have seen a slight reduction in non-elective procedures but can't at this stage say it's because of what we're doing. We are now 13 months into our new way of working and all the financial modelling we have done suggests that by year five we will have made a saving of £40 a patient – £400,000 for a population of 10,000 through keeping them out of secondary care. The big win is that this money will be reinvested into NHS services.

We have taken this risk to get us where we need to be for contract reviews. We now have the power to negotiate and develop services. If we'd taken no risk we wouldn't be in that position.

What we get from this is autonomy – developing the level of services we believe we should be developing.

The future

We talk in terms of becoming a health management organisation that would manage the whole of the patient's capitated budget – the natural evolution for PBC.

We would like to call ourselves a social

HMO and bring together a lot of the social public health services that impact on our patients' lives.

We are working towards holding our own budgets to provide outstanding excellence in primary care, with full control over the health economy spend of the patients we have responsibility for and delivering that as effectively and efficiently as possibly. We will take on the real budget risk with the PCT.

Once we move into a more sophisticated system of earned autonomy we intend to set up an effective discharge-planning programme and support service.

Dr David Morris is a GP partner at Smethwick medical centre, West Midlands, and partner in Pathfinder Healthcare Developments

Dee Kyne is business development director of Pathfinder Healthcare Developments

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