We check in with one of the first pathfinders to find out more about their background and discuss the challenges they anticipate having to overcome. This month we talk to Dr Neil Kerfoot of South Gloucestershire consortium
What's the story leading up to you becoming a pathfinder?
There were originally three separate localities within South Gloucestershire PCT – Kingswood, Severn Vale and Thornbury and we came together as one PBC consortium in 2008. Our population is a mix of urban and rural with some pockets of deprivation in each area.
We came together with the help of an external facilitator after we all became frustrated by our attempts to kick start PBC in much smaller consortia. Our PCT was finding it difficult to work in a co-ordinated way with many mini consortia and we began to see the bigger picture of how to improve patient care and treat patients nearer to home, which was something patients clearly wanted. We were also conscious of the need to address the tight budget position for the whole of South Gloucestershire. The three clusters merged and became co-terminus with the PCT and local authority.
Our board is made up of two GPs and a practice manager from each of the localities and a co-opted practice manager. We feel practice managers are an essential part of GP led commissioning. To leave GPs in total charge would be a recipe for disaster!
The first year mostly involved finding our feet and deciding objectives with focus on elective referrals which, like the rest of the country, were on the increase and how to bring services closer to home. Our PCT worked with us and agreed to provide funding to remunerate practices for the work they undertook towards achieving what we laid out in our commissioning plan for the year.
By the second half of 2009/10 we saw a downturn in GP elective referrals to secondary care and our latest year to date compared to the same period last year shows a decrease of -3.35%. (See box below).
Why did you decide to become a pathfinder?
When we read the document that came out last year following Andrew Lansley's announcement we realised the way we were now set up meant the possibility of progressing to a GPCC quicker than the timescales set out in the white paper. It made sense to apply especially as there was some money associated with becoming a pathfinder which may help fund the work required to progress at pace.
Why did you choose to remain a consortium of 27 practices when you applied to become a pathfinder?
GPs here like working in this 27 practice consortium and it feels comfortable. However all GPs in and around our consortia do not think this should be the final size and that we should eventually become bigger. They may be right but to the PBC exec in South Glos it feels better to remains local but work wherever possible in commissioning secondary care or in organising backroom processes like HR, IT, payroll, estates etc with a wider group across the Bristol health community.
What sort of financial situation are you inheriting from your PCT?
It's a fairly challenging one but we are working together using QUIPP to hopefully achieve financial balance by year end - just. We certainly require both primary care and secondary care to work in a slicker way next year and for them to fully commit to QUIPP.
What are the main challenges ahead?
The biggest challenge is engagement – getting everyone on message that we need to improve care but move away from the traditional approach of primary and secondary care. Patients don't like going to hospital in the most part and we are speaking to our acute trust about pathways that facilitate care closer to home.
While the efforts of GPs have managed to reduce elective referrals, and to a degree non elective referrals, we've not yet realised a reduction in the amount of spend we are incurring in secondary care which hasn't really changed.
This is what we are currently talking to the hospital about, for example the consultant to consultant referral rate has gone up and so we need to look at how we change that and this will require GPs talking directly to consultant colleagues.
I also think challenging how patients treat A and E like an alternative GP clinic will, need to become a key workstream. When asked why they do this, patients inform us that they perceive access to general practice to be difficult and we need to address this in the next 18 months.
Making all GPs realise commissioning must become part of our core work within (the) general practice is another challenge. We feel by working as a team to inform and educate our colleagues in general practice over the past 2 years we have progressed this challenge.
We also need to make sure consultants have the confidence to discharge patients and know the care and expertise in managing chronic conditions is present within general practice. There is almost a nervousness at the moment about giving their patients back to us GPs. Again the way to change that is for us to sit down with the consultants and demonstrate to them we have the systems in place to continue the management of our patients and follow any detailed plan of care provided by the secondary care clinicians in primary care.
In the last 3 months we have also begun working with neighbouring consortia (Bristol and North Somerset) to see what we need to work on collectively – for example we all refer into the same provider trusts in Bristol and so it makes sense for GPs locally to agree what is required when commissioning from the provider trust and commission with one voice. However going ‘global' like that also presents a challenge of how we keep the focus local, which is what our constituent practices like and want for their patients.
How will you avoid your consortia becoming just another PCT?
I think the fundamental difference about GP commissioning consortia (GPCC) is that GPs are at the forefront with management support, rather the past where it was PCT management with GP support. If commissioning becomes part of GPs' core work and every practice is working towards a common good then that's very different to a PCT as we truly own the agenda having taken on responsibility for writing the commissioning plan. There will of course be some statutory functions we have to do too.
What are the biggest potential pitfalls?
For us, it's the (acute) trust not playing ball with us. Locally we have engagement and dialogue evolving with the trusts but we need them to make wholesale changes in their approach to care. This will mean a trim point at some stage where hospital provision must reduce to allow money to move within the system to support improvement of community services. There is obviously a nervousness with secondary care that if they reduce they risk being caught out if demand rises again and we need to work through this with them during this transitional period.
The big financial challenge is to ensure we don't go over budget, in fact we are challenged to make in year savings over the next 5 years. Wholesale system change in this tight financial market is a daunting task.
Do you plan on buying in external support?
We work very closely as an executive team. As we developed our initial commissioning plan we recruited a project manager, Beverly Stretton-Brown who has vast experience of working within the health service in the south west. She has been a key driver as she has dedicated time to devote to this work. We have strived to support practices with a clear commissioning plan, regular monthly newsletters and bimonthly meetings which keep practices up to date with how care pathways are changing. Hopefully practices feel they have some input during these meetings into how things change and this ownership of the change process encourages engagement.
We are looking at which skills we will need to move from PBC to GPCC and the structures we need to do that, so it's too early to say exactly what external support we will require. The recent HR strategy indicates that we must endeavour to utilise existing PCT staff in our support structure. Within South Gloucestershire we realise we are lucky to have a supportive PCT with some very committed individuals which is not always the case in other PCTs.
What will success look like in three years' time?
In my magical world of perfection the health community works in a seamless co-ordinated way and patients pass smoothly from home - GP - specialist opinion and home again mostly without sitting in a hospital bed. Patients are referred to hospital with a well structured letter including all relevant details to allow appropriate triage so the right person sees them first time. Patients are discharged predominantly back to GPs with a full management plan and detailed of further investigations required. The use of beds in the hospital has reduced freeing up clinicians to work in the community so care closer to home becomes the norm.
In reality - if we are all still speaking to each other in a civil way, no trust or GPCC has gone bankrupt and we are in financial balance as a health community we will have done very well!
Tackling referrals and avoiding admissions
We managed to achieve a decrease in admissions by:providing practices with information about their referrals, funding a PBC lead in each practice to champion the cause,encouraging in house peer review of all outgoing referrals to ensure the correct care pathways were used at the outset.Sharing comparative data with practices to allow them to benchmark their work with their neighbours.Working with our local provider trust we have also introduced some ‘hot clinics'. When a GP sees a patient with an acute respiratory problem or abdominal pain the traditional route is to admit to a secondary care bed. But now GPs can fax the ‘hot clinic' and the patient is seen, on the same or next day if safe to do so, by a consultant as an enhanced outpatient rather than as a hospital admission. We are looking to set up further ‘hot clinics' and are speaking to acute trusts about what's possible. The outcome of these hot clinic appointments is patients get timely consultant led investigation and treatment, without having to be admitted. Patients appreciate this, as does our commissioning budget as the enhanced outpatient tariff is considerably less than the cost of a non elective stay.The PCT provider arm for community services has employed eight emergency care practitioners to allow more patients to be managed at home. We also have an intermediate care team made up of nurses, physiotherapists, occupational therapists and social workers' input to support patients at home. Our provider service also employs community matrons that work alongside the district nurses to assist GPs in managing the chronically ill housebound cohort of patients. GPs can refer acutely ill patients to the intermediate care service who also accept patients deemed fit enough for early discharge from hospital. They do this via a SPA (single point of access) that takes the details of the problem and passes it onwards to the relevant community service.
