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South Central England revisited

Nearly a year after we last looked at how PBC was progressing in South Central SHA, Kathy Oxtoby reports on the state of play in this region

Nearly a year after we last looked at how PBC was progressing in South Central SHA, Kathy Oxtoby reports on the state of play in this region

Last November, when Practical Commissioning discussed PBC progress in South Central SHA, the region had scored well in the August 2008 Department of Health PBC survey. It held joint top place in the country for practices having agreed a commissioning plan with their PCT (67%). The survey also suggested that 78% of practices had a good relationship with their PCT compared with the national average of 74%, and 44% of practices rated the quality of managerial support for PBC as ‘good', matching the national average.

The July 2009 survey showed a slight improvement in practice relationships, with 79% of South Central respondents describing them as ‘good ', above the national average of 75%. Practices in the region that had agreed a commissioning plan had risen to 70% – higher than the national average of 62%. However, the number of practices rating the quality of managerial support as ‘good' had fallen slightly to 42%, below the average of 48% for the rest of the country.

Although enthusiasm for PBC continues, many GPs feel that a lack of capacity to make projects happen, together with financial constraints, continue to impede its progress.

Buckinghamshire – deficit still a barrier to change

Last year, PBC was being severely restricted by the PCT's multimillion-pound deficit. Dr Johnny Marshall, NAPC chair and a GP in Buckinghamshire, says little has improved and that the financial situation is still largely dictating PBC progress.

The PCT is ‘still struggling to plan its way out of the financial deficit', while work being done to shape service redesign in the future ‘hasn't delivered any significant change', says Dr Marshall, who is also chair of PBC collaborative United Commissioning.

Having three large PFI hospitals in the area makes it hard for PBC to thrive. ‘We are hamstrung by the PFIs to a large extent. It is difficult to disinvest in the acute sector and then invest in the community – that's not something that can happen overnight,' says Dr Marshall.

He believes other barriers to PBC progress are that Buckinghamshire is ‘still suffering from the legacy of PCT reorganisation when key people left', and that data to help inform GPs about which services should be redesigned remains ‘poor'.

There has been some progress in service redesign, such as the setting up of a community-based musculoskeletal service. The area continues to work towards an integrated patient pathway-led NHS for Buckinghamshire, which includes a board that brings together the main provider trust, the PCT and the collaboratives. By March 2009, the collaboratives had released about £2m savings in prescribing cuts.

But the current economic climate demands much more significant service changes, Dr Marshall believes. ‘To do this requires the right information on which to base that change and the capability and capacity to turn it into delivery.

‘There's the will to make things work, but we don't have the tools, the time, the capacity or the capability – and unless something significant changes this year, we'll be having the same conversation in 2010.'

Isle of Wight – united in making PBC work

When the idea of PBC first emerged, GPs on the island who had been working together for years wanted to have one locality to continue those relationships, and so they formed a single Isle of Wight PBC forum. Chaired by Dr Graham Gent, the forum is made up of 17 practices covering 140,000 patients.

In terms of financial risk, it was agreed that the forum would have an overall supervision of practices' budget and that the losses and gains would be shared by the organisation.

Initially, Dr Gent says, there was not much enthusiasm from GPs for PBC, but they have ‘knuckled down and made it happen'. Now 80% of practices back PBC, making the Isle of Wight the biggest PBC supporter in the South Central region.

Several projects have been funded with varying degrees of success, he says. A community anticoagulant service is saving patients visits to the local hospital. Minor surgery was traditionally only funded to a certain level by the PCT so the forum has financed the cost of removing the cap, and practices are now able to carry out whatever level of minor surgery they choose.

Part of the island culture is that ‘everyone gets on with it' and works together, explains Dr Gent. Unlike some areas, ‘it is not open warfare between health and social care', he says. The council and PCT are involved in several joint working schemes, such as providing services for people with learning disabilities, and one member of the senior social service team always attends forum meetings.

Having one local council and one health authority ensures the lines of communication are more straightforward than for some areas. But the island is not immune to the DH rules of commissioning imposed, which, despite support from the PCT, can make getting schemes off the ground ‘a long-winded and frustrating process', Dr Gent feels.

Red tape aside, he says the island's practices not only accept PBC but also continue to put in the effort to make it work.

Hampshire – patchy progress

Although PBC got off to a good start in Hampshire by investing millions in locality managers and in pump-priming new services, it has a long way to go, says Dr Nigel Watson, chief executive of Wessex LMCs.

‘The provision of new services is coming along, but progress is patchy. Bringing services from conception to inception is still a tortuous process,' says Dr Watson. This could explain why nearly half (44%) of practices say they are not providing more services as a result of PBC.

The rules of tendering make getting new projects off the ground a ‘bureaucratic nightmare', he believes, with PBC commissioners still not closely enough aligned with PCT commissioners. ‘If we are to deliver anything like the potential need, things need to speed up. And given the financial situation, we can't afford to wait five years to get structures in place.'

Data is still ‘not good or timely'. ‘We either get nothing or masses of data, which we look at and don't know what it means. We need information to be analysed in bite- sized chunks,' Dr Watson says.

For PBC to work, PCTs also need to be less risk averse, he believes. ‘Even when money is tight we have to take some risks to move things forward. Clinicians become disengaged with PBC because there's a perception that nothing is happening.'

Despite these difficulties, discussions are under way to develop community gynaecology and cardiology services and an initiative to ensure that the vulnerable elderly have the care they need to stay at home and not be hospitalised.

An incentive scheme set up to examine whether referrals are appropriate is now focusing on what practices deliver. This involves getting back GPs' referral letters from acute care and looking at what action occurred – whether the patient has been referred for further investigations or discharge.

Whereas some GPs are inspired by PBC, others are increasingly cynical because they don't see any changes in services. To challenge this cynicism, PCTs should ‘champion changes that have been implemented' by, for example, promoting inspirational projects on their websites, Dr Watson believes.

Berkshire – coming into its own

PBC in West Berkshire is ‘coming into its own' now that the PCT has realised it's a means to deliver more effective community services during recessionary times, says Dr James Cave, a GP in Newbury who is on the board of the Newbury and Community PBC group.

‘Until recently, it seemed that PBC was yet another task for NHS Berkshire West. But working in this financial climate, the PCT realises it's got to step up to the mark and get as as effective at commissioning as the acute trusts. To do this will involve engaging GPs in PBC,' says Dr Cave.

PBC in West Berkshire is a mixture of well-developed organisations covering large populations – such as the Newbury and Community PBC group, which has 11 practices serving around 110,000 patients – and small PBC groups, including single practices.

An early PBC success was a project to reduce around 30 urgent or emergency admissions of the elderly to acute care per year. A community geriatrician is employed on a 50:50 basis by the acute trust and PCT to lead the scheme, and district nurses are trained to do assessment and medical management of older patients.

More recent developments include South Reading PBC group forming a partnership with health provider Assura to establish a joint provider arm to deliver PBC projects. Practices are also focusing on reducing health inequalities in mental health and cancer care, addressing alcohol misuse and boosting awareness about sexual health.

Lack of capacity to develop projects is slowing PBC development, Dr Cave believes. ‘General practice has never been more complicated or harder work. In addition to dealing with everything from QOF to LESs, we are expected to get involved in commissioning, but we need more capacity built into the system for GPs to do all these things,' he says. The latest PBC survey shows managerial support for PBC provided by the PCT could be improved, with 40% of practices rating it as ‘poor'.

Dr Cave believes the coming months will be a critical time for PBC groups to demonstrate they can deliver services in the community and reduce referrals. That ability has been boosted by the fact groups are finally receiving meaningful referral data every month. Now they have this information, practitioners will be able to compare practice referral rates and share good practice to reduce them. But to make this happen, Dr Cave says practitioners ‘will need to ask tough questions that get right to the root of general practice'.

Oxfordshire – stifled by financial worries

PBC progress in Oxfordshire is still being blocked by financial problems, with only a minority of practices having access to freed-up resources.

‘Purse strings are tight in Oxfordshire, as they are generally. PBC is being used not to free up resources for service redesign, but to reduce PCT spending,' says Dr Prit Buttar, a member of Oxfordshire LMC and GPC representative. Dr Buttar's practice is one of the few in the area not to be aligned to a consortium.

He says hospitals continue to become more adept at ensuring that money available goes back to them. The situation is not helped by the fact that so much of the primary care budget is being top-sliced for contingency funds or has disappeared into overspend, he believes. As a result, PBC seems to be having little impact. There have been some ‘modest' service redesigns, including a DVT community service, but overall ‘the priority appears to be saving rather than redeploying money', says Dr Buttar.

One of the problems with PBC, he feels, is that ‘the PCT is too risk averse and not prepared to let practices speculate'.

‘There's a lack of trust, and people are worrying about their jobs and about overspending,' he says. ‘Until practices are given freedom to manoeuvre, enthusiasm for PBC will remain greater than the reality.'

Kathy Oxtoby is a freelance journalist

south central SHA south central SHA Buckinghamshire Buckinghamshire Berkshire Berkshire Oxfordshire oxfordshire Hampshire Hampshire View from the SHA boardroom View from the SHA boardroom

PBC continues to develop in a variable way, but PCTs have now got to grips with what the approach is all about, says Hilary Todd, programme manager for PBC at South Central SHA.
‘PCTs have embraced change and are now starting to develop teams to gain traction on projects, new ways of working, business cases, and all the other elements that support PBC.'
Ms Todd says PBC progress has made ‘huge strides' in the past year. The biggest change has been the increase in clinical engagement with PBC across the region, with PCTs reporting that 50% more practices are having regular meetings. Now the SHA wants to see wider engagement with practice and specialist nurses.PCTs are also speeding up the approval process for projects, and it now takes an average of eight weeks for a scheme to be approved. Project proposals are becoming more innovative – such as a scheme in Berkshire East promoting healthy eating in the Asian community – as PCTs are gaining confidence in PBC, Ms Todd believes.Clinicians are also becoming more comfortable with the idea of peer review and several consortiums have set up schemes where GPs discuss each other's referral letters to see whether patients could benefit from different care pathways.Although staffing capacity remains a challenge for PCTs, quality of data is improving, which is helping to ensure GPs are better informed when looking at potential areas for service redesign.The next step will be for all SHAs to look at the big issues, such as how to devolve real budgets and to ensure PBC commissioners have ‘the confidence, capability and capacity to deal with bigger budgets', says Ms Todd. Maintaining clinical engagement, making PBC integral to PCT strategy and tackling bigger service redesigns such as urgent care will be the big challenges facing healthcare professionals in the coming year. They will face them in a tough financial climate. But Ms Dodd stresses: ‘This should not force GPs to restrict their PBC vision.'

Survey results: then and now Survey results: then and now

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