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Profile of a pathfinder

We check in with another first wave pathfinder to find out more about their background and discuss the challenges they anticipate having to overcome. This month we talk to Dr Nigel Guest, chair of Trafford Commissioning Consortium.

We check in with another first wave pathfinder to find out more about their background and discuss the challenges they anticipate having to overcome. This month we talk to Dr Nigel Guest, chair of Trafford Commissioning Consortium.

What's the story leading up to you becoming a pathfinder?

North and South Trafford PCTs came together in 2006 to form a single unit covering different socio-economic groups. The north of the area tends to be less affluent, so there is quite a lot of diversity. Initially GPs in the two commissioning clusters functioned separately but with there being one PCT, there were a lot of shared agendas. Around six months before the White Paper came out we thought commissioning would be more effective, and that it would be sensible for the future, if we were co-terminous with the PCT and the local authority .

There was a consultation process and we went to GPs to see if we could get a mandate to explore setting up a GP consortium - which is what happened from April 2010 with a view to working towards forming a merged commissioning organisation by November 2010. It all works together: there are two main secondary care providers - Trafford Healthcare Trust in the north and University Hospitals South Manchester Foundation Trust in the south - and already before the White Paper, a separate GP provider company, limited by shares, Trafford Primary Health set up in 2009 - a vehicle to carry out GP provision while all the joining up work was being undertaken.

The then director of commissioning had started to develop an integrated care services strategy - again coterminous with the PCT covering primary, community, social and secondary care (see box) - which ties all of this together. The consortium was virtually in place by the time the White Paper came out last summer and we already had inter-practice agreements, financial agreements and governance agreements with our PCT. As a commissioning group, we had made more than a million pounds in savings so there was an element that this had already been tried and tested. I was still really pleased and encouraged to see the GPs come together in this way.

Why did you decide to become a pathfinder?

Because of all that had happened before, we had already achieved a lot. We´d set up a transformation change group with representatives from the PCT, local authority and lead GPs looking at six strands via a steering group - how the consortium should be constituted, how to create support, local democracy, public health, finance and delivery of QIPP. So we felt we were moving forward and wanted the momentum to continue. As with anything in the NHS, it´s usually beneficial to be in the first wave. You can help shape the future as well as learn from others and get significant support. I was a second wave fundholder previously and was also part of the Ellesmere Port total purchasing pilot in the 1990s, for those who can remember that far back.

How did you decide on the size of your pathfinder? The size is already established. It´s 37 practices and 221,500 patients.

What sort of financial situation are you inheriting from your PCT? Our PCT is on schedule to deliver a small surplus so we´re hoping not to inherit any deficit. A lot of people must wonder how they are going to manage, but the saving grace for us is the Integrated Care Services strategy, which we are all immersed in. We think it will change the system permanently, becoming more efficient and, importantly, better for patients.

What are the main challenges ahead for your pathfinder?

I think the main challenges will be organisational. There is a lot of guidance to follow and it's a complex transition process. We also need to ensure that all GPs are engaged with and able to help shape the service amid challenging financial pressures. Finally, everyone involved will need to undergo behaviour change. For example, there is now a really strong emphasis on patient consultation. So we´re in a very different environment.

How will you avoid the consortium becoming a PCT with another name?

I think the ideas for change have to come from deciding what our functions are, and then by creating the form around those functions. Of course we are discovering all kinds of aspects of the PCT that we didn´t know about before. We have got to work hard to achieve the most important aspects of the commissioning job, and we also have to look at what local authorities have been doing and make sure there´s no duplication occurring.

What are the biggest potential pitfalls you need to avoid?

I think the biggest pitfall we face as clinicians is for us to imagine that we have to do everything. In reality, having picked the right team, we should be able to concentrate on what we´re good at - getting the right care for our patients. You have to be able to concentrate on the day job, which is actually what gives you the credibility you need with patients. Another challenge is freeing up clinical time from as broad a range of GPs as possible to get them involved in a very focused way. It´s about facilitation - how to get them involved in commissioning without using up lots of time. And one way to do that is going to be through things like electronic communication, teleconferencing and having really good back office support.

Are you buying in external support?

It's too early to say on this, and we are still working through processes around this. We are currently using combined resources to ensure we have the most appropriate and best level of support.

We're also organising a process and formal structure for how we work more closely with the local authority.

What will success look like in three years time?

Success for us will be the shift to a fully integrated healthcare system using secondary care appropriately. It will be better for patients and will enable viable care to take place. A smoother patient care system will also make our working lives better and be more cost effective.

Trafford Integrated Care System

The integrated care system in Trafford was formed out of the 'burning platform' of financially and clinically unsustainable local services. This led Trafford PCT to seek an alternative based on the following six design principles:
* general practice should be the locus of integration - with the GP list as the cornerstone of the system
* consultant opinion is an essential component of effective integrated services
* the delivery of integrated services will rest on extended roles for nursing and allied health professionals
* integrated services will be enhanced by the involvement of social care
* future integrated services would bring together the full range of primary services
The system - funded by the PCT to the tune of £2 million in the current financial year - involves community-based physicians being appointed to nine or ten local practices with a brief to focus on caring for patients identified as being at high risk of hospital admission, to oversee the introduction of telehealth and develop the approach to population risk management. Alongside vertical integration of general practice, office medicine - community-based and -focused primary/secondary and outpatient specialist and diagnostic care - and acute medicine, the Trafford system includes scope for horizontal integration for surgery through the merging or networking of services into larger provider units. Because of its historical financial problems, North West SHA has asked Trafford Healthcare Trust (Trafford General) - incidentally the hospital visited by Nye Bevan on the first day of the NHS in 1948 - to look at partnering with one of the other local secondary care providers. Dr Guest said it was necessary for the success of the integrated care system to find a solution: 'The relatively small size of the hospital trust compared with other organisations makes it increasingly difficult for it to meet the financial challenges faced by the economy, and so it must seek to join a larger NHS organisation.'
Trafford Commissioning Consortium and the PCT are working closely with the hospital trust, NHS North West, and partner organisations to ensure services are not affected during this period of change, and so that residents in the borough continue to receive high quality health services.

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