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Spotlight on... North London

We look beyond the headline figures to examine the progress of PBC in individual SHAs. In the first of two articles focusing on the capital, Kathy Oxtoby reports on developments north of the Thames.

We look beyond the headline figures to examine the progress of PBC in individual SHAs. In the first of two articles focusing on the capital, Kathy Oxtoby reports on developments north of the Thames.

London SHA rates favourably in the latest Department of Health PBC survey for many indicators of PBC progress. Support for PBC is 62%, similar to a national average of 64%, while 64% of practices considered their relationship with the PCT in terms of PBC to be good – again just above the national average of 62%.

However, experiences within individual PCTs vary greatly, and while many practices in north London have embraced PBC, some remain sceptical about its value, and others want more realistic indicative budgets and greater freedom to develop services.

Hackney – social enterprise scheme encouraging PBC

GPs in Hackney have the support of a social enterprise scheme to help them develop PBC services. City and Hackney East London Integrated Care (ELIC) Society Ltd is an umbrella organisation representing six consortiums and covering around 230,000 patients.

The driver behind setting up ELIC was to ensure services ‘remained in GPs' hands rather than being delivered by private organisations', explains Dr Deborah Colvin, an ELIC executive and City and Hackney LMC chair.

This umbrella approach means GPs have access to an organisation that can negotiate with the PCT and deal with the business aspects of PBC, including budgets. The scheme is funded by GP members on a pounds-per-patient basis, and by a PBC LES.

GPs also feel supported to develop both large-scale projects and smaller schemes, Dr Colvin says. This explains why 67% of practices who are members of a PBC consortium in the area say they are involved in a ‘great deal' of activities compared with a national average of 32%.

Recent initiatives include an ENT community service, which has reduced waiting times, and training for GPs from a consultant neurologist to help reduce referrals for headache patients.

Dr Colvin says primary care clinicians have a good relationship with Homerton Hospital NHS Trust, but she adds: ‘GPs are doing all the extra work to save on budgets to buy patients more services, but have no control over what the hospital decides to charge us. This needs to be addressed – there has to be a balance of power.'

Brent – development support framework to boost PBC

Despite being praised for its ‘extraordinary turnaround', Brent PCT is the first in England to use the DH's PBC development support framework. This is not so surprising, says Dr Ethie Kong, chair of the Harness PBC consortium. ‘We've been so busy turning things around, that for two years PBC has been slow to progress.'

While Dr Kong says there has not been a great deal of innovation, she adds that GPs have welcomed PBC and worked hard to develop an infrastructure for it ‘while waiting for the turnaround'.

Virtually all of Brent's 72 practices, which serve a population of around 320,000, belong to one of four locality clusters and some belong to the Harness consortium, which has members from across Brent.

Care pathways in diabetes, ophthalmology and gynaecology are being redesigned to meet the needs of patients in the community, and with their input.

Realistic indicative budgets have been holding PBC back, says Dr Kong. ‘When we are eventually given a budget, we know it's not going to be enough. But we are working with the PCT to get a reasonably realistic indicative budget by this May.'

Now Brent has the opportunity to have extra support for PBC development, she believes this will create a closer relationship with PBC and PCT personnel to drive PBC.

Islington – a mix of scepticism and enthusiasm

Islington's GPs greeted PBC with a mixture of scepticism and enthusiasm, says Dr Renu Hans, clinical lead of the North Federation PBC group.

‘Sceptics thought PBC was just fundholding dressed up and that the PCT was trying to run the show. Some felt they had too much work to do already,' she says.

Dr Hans feels PBC tends to make better progress in the leafier areas of London – where there are many GPs working in large practices – than in inner-city areas where there are a lot of singlehanded GPs dealing with ‘enormous workloads'.

While 10% of practices strongly oppose PBC, 20% are strongly in favour. ‘Enthusiastic GPs see PBC as a way they can have a say in shaping the future of primary care,' Dr Hans says.

Three PBC groups cover the north, centre and south of the area, and serve around 100,000 patients. Dr Hans explains the North Federation is the only PBC group to strike out on its own as an independent commissioning organisation, while the central and south local commissioning groups are led by the PCT.

All groups have been involved in setting up a musculoskeletal service in the community, which has cut waiting times and reduced costs for seeing patients in secondary care. A community service that all Islington GPs can refer into has just been established to treat patients with a wide range of ENT conditions.

Some GPs feel they have not had true independence from Islington PCT to carry out PBC projects. For PBC to be a success, Dr Hans says the PCT will need to ‘relinquish some of its power'.

Tower Hamlets – work pressures holding back PBC

GPs in Tower Hamlets would love to do more PBC projects but ‘the pressure of ordinary work in the most deprived area in the country with massive poverty and unemployment is enormous', says Dr Sam Everington, a GP in Bromley by Bow and PBC lead for his practice.

Despite these pressures, GPs in the area, (which has a patient population of about 300,000) are looking at how PBC can improve care by making systems more effective. For example, at a monthly meeting of Tower Hamlet's four PBC localities, GPs highlighted the problems patients were having with Choose and Book at the Royal London Hospital. This led to a meeting with the hospital chief executive and the PCT, which has resulted in improvements to the system.

One of 16 areas in the country to take part in an integrated pilot scheme, Tower Hamlets' project will involve helping patients with long-term conditions to manage their own care.

Dr Everington says a constant problem is that indicative budgets do not reflect the average turnover of patients in Tower Hamlets (around 30% a year), the level of deprivation or the rapid expansion of practices.

For PBC to progress, Dr Everington says GPs need to be ‘freed up so that they can spend more time on it. The good news is the PCT has done a detailed analysis of what extra resources are needed in primary care, and is clearly committed to PBC.'

Harrow – slow but steady progress

One of the strengths of PBC in Harrow is that ‘its structure has been developed by GPs organically, rather than being imposed on them', says Dr Chaand Nagpaul, LMC vice chair for Harrow. The four clusters in Harrow, serving a population of around 240,000, are the result of GPs getting together with others with similar interests, Dr Nagpaul says.

He believes that PBC in Harrow has developed slowly but steadily. The PCT has honoured its responsibility to allow practices to use 70% of savings made from PBC services. It ensures that GPs know their indicative budgets and their monthly expenditure against that budget.

Clinical assessment services provided by GPSIs in a range of areas – including dermatology, cardiology and minor surgery – have resulted in a significant reduction in the number of referrals to North West London Hospitals Trust, Dr Nagpaul reports. However, he believes that GPs should always have the choice and ability to make a direct referral to a specialist, based on clinical judgement.

Trusts' motivation to generate income through payment by results has undermined the potential for PBC to have a significant influence, Dr Nagpaul believes. This has resulted in requests for repeated fresh referrals when patients have missed appointments, or when they need to receive a related treatment. He says this situation has ‘diminished what could have been a more collaborative approach between GPs and hospitals'.

Redbridge – committed to making PBC work

From an initial mood of ‘no more change', practices in Redbridge have signed up to PBC, says Dr Richard Price, a member of the west PBC cluster.

PCT roadshows and protected learning events helped to convince GPs of the benefits of PBC. Now three PBC clusters serve around 260,000 patients in the area, and aim to bring as many services out of hospital as possible, says Dr Price.

One of Redbridge's main PBC successes is the introduction of a statin prescribing initiative involving all practices. This development has resulted in sufficient savings to fund a consultant and a GPSI to deliver a heart failure service, which has cut admissions to hospital by about 30%.

Other achievements include a dermatology service, which is led by a consultant but run by GPSIs and specialist nurse practitioners; this has reduced referrals by around 60%.

One frustration, says Dr Price, is that GPs have not received ‘anywhere near' the savings they should have from PBC services to reinvest in business plans. Practice-based commissioners would also like detailed patient and hospital data to help inform the decisions they make about services.

PBC progress seemed to plateau last year following the restructuring of the PCT to meet the demands of World Class Commissioning, says Dr Price. However, the restructuring has given the PCT a solid platform for progress and PBC in Redbridge is ‘moving forward again'.

Barking and Dagenham – GPs feel supported by PCT

When GPs in Barking and Dagenham heard about PBC, their first priority was to see how it could help to avoid admissions for long-term conditions.

‘In this part of east London there is a high prevalence rate of conditions like CHD and diabetes,' explains Dr Gurkirit Kalkat, PBC cluster lead for Barking and Dagenham Quality Health Care consortium.

‘The PCT provided us with managers to help design services to bring care of chronic diseases into the community. We felt well supported,' he says. This is reflected in the fact that 100% of practices in the area report having a good relationship with the PCT in terms of PBC.

The two PBC groups in the area, which cover around 125,000 patients, have established projects that have reduced admissions to hospital for long-term conditions. In particular, a PCT-funded COPD service has saved £15,000 from reduced admissions, and is forecast to do even better this year.

Now that PBC groups have made ‘the bigger savings' with services dealing with long-term conditions, Dr Kalkat says GPs are looking at smaller projects. However, turning around such business cases ‘is not as speedy as we would like', he says.

Kathy Oxtoby is a freelance journalist

Brent PCT Hackney PCT Islington PCT North London Survey results Tower Hamlets PCT Barking PCT Harrow PCT Redbridge PCT

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