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Sharing a vision for eye services with consultants

GP Dr Peter Godbehere explains how two consultants have taken a leap of faith by leaving their NHS hospital posts to join his eye service.

GP Dr Peter Godbehere explains how two consultants have taken a leap of faith by leaving their NHS hospital posts to join his eye service.

About 18 months ago a local ophthalmology consultant and GP met socially and discussed how, in an ideal world, they would improve the service to patients and make it more local. It was a conversation the consultant had had many times in the past but his efforts to change the service had always been in vain, swamped by various layers of committee and paper.

The GP, who knew practice-based commissioning was being rolled out and had been invited to join a new local commissioning group, put the consultant in touch with another GP who seemed to understand how this all might work.

That second GP was me, part of a commissioning group of four practices. From my initial talks and meetings with the consultant, it was clear we both believed we could improve on the current service.

Traditionally, GPs and some opticians referred patients with eye problems to hospitals. Waiting times for a first appointment ranged from 7-13 weeks. At one clinic, there had been no consultant in attendance for 18 months. We were told it was consultant supervised, but it seemed to be very much from afar and more like a clinic run by a junior hospital doctor.

Aiming for a first-class service

Our new plan initially involved a simple patient pathway for cataract surgery, whereby consultants from a local acute trust would work with us to deliver care closer to home through practice-based clinics and operations in a community hospital. The pathway was drawn up in conjunction with an active patients group and committed to gold standards of care.

We then undertook the more complex financial modelling, using GP surgery costs as a benchmark for potential costs of delivering the pathway. Every aspect – the cost of a phone call, heating the rooms, renting the rooms, staff, paper and so on – was covered. We wanted to avoid a mistake many make when setting up a new primary care service by ensuring existing overheads were also considered.

At this stage we also had to address probity and conflict of interest, as our commissioning group of four practices would also be the provider of the service.

Several issues were considered. Given that we already undertook enhanced service contracts where we controlled the demand and hence the remuneration, weren't we already faced with this conflict of interest accusation, but for lesser volumes of work? It was clear a GP and patient would be happy using a service only if it fulfilled the needs of service, quality and cost.

We established separate committees for commissioning and providing. We also decided it was vital to establish criteria for entry into the service wherever appropriate, as well as benchmarking to compare volumes within the new and old service models. Finally the PCT, as the contracting body, had to be comfortable with the potential for ‘internal' referral. Again, benchmarking seemed the best method.

Initial conversations with our PCT were very positive. It was seen as a win-win situation, with an improved service at reduced cost. But it also depended on an extensive and detailed clinical governance framework. As GPs, we already understood expectations around sterilisation, note-keeping and measuring quality, and we were able to work through other governance issues in talks with the PCT.

Meeting hospital resistance

The main stumbling block, as it turned out, was the hospital that employed the consultants. Obviously any acute trust will be reluctant to lose work, but we were under the impression from the hospital's senior management that they understood the policy environment and would do what they could to release the consultants' time. But despite many months of discussions, this failed to materialise. In the interim, the business case and clinical governance framework was passed by the PCT.

We were at a crossroads. Without the support of the hospital, the process was dead. It was at this stage we made the decision to look at a total ophthalmology service model, beyond just cataracts.

In truth this was only a modest step from our original plans, given that the booking processes, theatres, many elements of staffing and so on were already in place. Even the financial models were in the large part applicable.

The main difference with the total service model was that there would be sufficient work to pay to take consultants out of secondary care altogether and offer them a primary care-based contract.

Employing consultants

The main risks were now stability of employment for the consultants; financial risks to the practices, who had agreed to underwrite necessary borrowings to deliver the service; and the PCT risking losing a service if the new provision could not be sustained. But the only alternative was to maintain the status quo.

So a new bid was put together, new clinical governance and risk assessment registers were compiled, and finance was recalculated. After many months of work the bid was agreed by the PCT and planning for launch started.

Now the real work began. A private limited company – Wisbech Health – was set up to act as the mule on to which separate components could be added.

A director was appointed from each of the four practices and a snapshot of each practice's list size was taken. Shares in the company were issued according to the list size.

All set-up funds as well as any profit payments would also be made according to the list size.

In each practice an addition to the deed was made to reflect one GP holding a share on behalf of the other partners in the surgery, to make coming and goings within practices much simpler to manage. A three-year financial plan was put together and, most importantly, a high-quality manager was employed to move the service forward. We also took out lease and hire purchase agreements via the company.

Putting up start-up funds

The start-up costs provided directly by the practices were considerable (and are being kept confidential by the company). We felt

it inappropriate, given the nature of our provider vehicle, to request any seed funding or support from the PCT as the income per case should eventually cover our costs. The practices have also underwritten the salaries of the consultants and of those primary care staff who have been seconded to the eye service. Secondment preserves employment and pension rights and allows for flexibility in capacity.

The service was always set up in partnership, with the consultants bringing expertise and the GPs bringing infrastructure and finance. However, given that the service would be in debt for some considerable time, it was felt unfair to the consultants to ask them to carry a burden at the beginning. So they have their pay underwritten from the beginning but as soon as the company breaks even, they will receive a share option of about 50% of the business.

A special mention really needs to be made about the consultants. All along we all firmly believed in what we were hoping to achieve – the best possible patient service and care in partnership with each other.

But in the end the consultants were faced with massive pressures from their employing hospital and leaving those posts became the only option to make this service work. The GPs underwrite the salary but this is not an open-ended arrangement. Trust is a vital part of any business and we trust each other in both the service and the finances.

Going live

We went live on Monday, 17 September 2007 for referrals. We expect to fill 14 sessions per week by the end of year one. We take all referrals, excluding general anaesthetic work, diplopia, children, diabetes screening and – initially at least – laser treatments. We also see acute patients within the scheme and hope to introduce an educational element.

The idea is, when the sessions are frequent, a GP will have the luxury of seeing a patient with the consultant together in their own surgery.

Referral is made either direct from the optician via a central access point or alternatively GPs can refer by telephone. The consultants are always available to give GPs advice or alternatively the patient is just booked into the next appropriate clinic.

Every patient is contacted personally to discuss their preferred point of contact, their appointment time and venue, backed up in a letter. GPs are also fully aware of the obligations to discuss choice of provider with patients.

We aim to see all patients in two to four weeks as standard once the service is fully established. We plan to ensure that any surgery will follow two to four weeks afterwards. We also plan to increase skills through training as opportunities arise.

We hope to save about £80,000 in our commissioning budget, rising to £120,000 by year three – to be reinvested in patient care, of course.

Learning the lessons

We believe patients will receive all the things they asked for – a high-quality, local, familiar service, and at reduced cost.

So what lessons have we learned? Certainly that you need to share a vision and trust each other to be able to deliver on it. You need to have patients on board and not settle for second best where service is concerned. The process is long and hard and will be taxing. Be prepared for the conflicts, not just internally but from outside.

Where clear government policy is resisted through issues of self preservation, personal politics and even plain envy, it is important to keep your nerve.

Dr Peter Godbehere is a full-time GP in Wisbech, Cambridgeshire, and a director of private healthcare provider Wisbech Health

Dr Peter Godbehere Dr Peter Godbehere

Be prepared to face resistance motivated by personal politics, self-preservation and even envy

60 Second Summary 60 Second Summary

The launch of a community-based ophthalmic service by a GP-run private company, offering outpatient clinics in practices and surgical procedures in a community hospital for NHS patients in a rural community

Preparation time
18 months

Two consultants (1.5 full-time equivalents) who have left their NHS hospital posts to work for the company

Service aims
Reduce waiting times for first appointment to between four and six weeks and reduce waiting times for surgery from first appointment to two weeks

Potential cost savings
£80,000 in year one, rising to £120,000 in year three, based on a 15% saving to the PCT on the previous hospital contract

Hold your nerve in the face of strong resistance from traditional secondary care providers

Email Dr Peter Godbehere,

Dr Peter Godbehere (left) says success is down to mutual trust and a shared vision with surgeons Neil Johnson (right) and Cliff Jakeman Dr Peter Godbehere Eye test

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