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Spotlight on... South London

In the second of our two-part special looking at how PBC is doing in the capital, Kathy Oxtoby reports on developments south of the Thames

In the second of our two-part special looking at how PBC is doing in the capital, Kathy Oxtoby reports on developments south of the Thames

London SHA rates well in the latest Department of Health PBC survey for many indicators of PBC progress. Some 91% are part of a PBC group, similar to a national average of 92%. And 53% of practices or PBC groups say they are now providing more services as a direct result of PBC – above the national average of 51%.

But experiences within individual PCTs differ greatly, and although many practices in south London are driving PBC forward, some are disillusioned with its ability to enhance care. Some are still demanding the very basic tool of accurate data to develop services, whereas others are thinking big and calling for real budgets.

Bexley – breaking new ground

When PBC began in Bexley the PCT was in financial deficit, says Dr Joanne Medhurst, lead for the Bexley PBC Federation of Consortiums. ‘PBC was thought to be a way of helping to control expenditure in the trust and to bring us back into financial balance. And for two years running it has achieved that.'

The federation is an umbrella organisation representing three consortiums, covering about 210,000 patients. Initially set up to drive PBC, it now operates on a strategic level, while 26 GPs across Bexley lead on clinical services.

Dr Medhurst says Bexley has been able to come up with some groundbreaking PBC initiatives because federation members sit on the PCT board, and GP clinical leads are consulted on any major service issue.

Major schemes include a cardiology service where virtually all aspects of the specialty, other than interventions, are carried out in the community.

The GPs receive real delegated budgets for prescribing, Dr Medhurst explains. If practices make savings they can use them, but they are also accountable for any losses.

To date, PBC activities have resulted in freed-up resources of £4m, which are being used for local incentive schemes and to pay staff for PBC work. The money also funds a ‘GP credit scheme', where five newly qualified, local GPs work four to six sessions a week in different practices. This frees up doctors to work at the PCT on PBC projects.

A PBC provider company is being set up, which all GPs are eligible to join. ‘The PCT asked clinicians if, as well as being part of a service redesign, they would like to provide services. We decided to create a large, local company to give us more credibility when tendering than if we were working in a fragmented way,' says Dr Medhurst.

Despite these successes, she says some GPs ‘still cannot get on board and find PBC threatening'. ‘We need to convince more GPs that PBC really works.'

Bromley – pump-priming ideas

There has been a ‘big sea change' in GPs' attitudes towards PBC since the PCT allocated resources a year ago to free up time for them to spend on progressing projects, says Dr Andrew Parson, clinical lead for Bromley Cluster.

Each of the clinical leads from the three PBC groups in Bromley is freed up to work a session a week on initiatives. This has resulted in groups becoming ‘very organised over the past 12 months, and has made a significant difference to the work we are doing', according to Dr Parson.

The clusters, which between them cover a population of about 300,000, jointly employ a senior manager to help lead on negotiations with the PCT and organise projects. New schemes include a pulmonary rehabilitation service launched last month and a diabetes service where a consultant, dieticians and other healthcare staff work together in the community to deliver care.

Discussions are under way to merge the provider arm of the PCT with a GP group or social enterprise scheme. The chosen group would be able to retain the delivery of all essential community services already commissioned by the PCT, but might also be able to tender for the provision of new services through PBC, Dr Parson explains.

A ‘bone of contention' among PBC groups has been ‘the poor-quality data about activity at our local acute trust', he says.

Not being able to understand or assess budgets is another difficulty, he believes. ‘The trouble is any savings we make are swallowed up by overspend in other areas.'

Dr Parson wants ‘regular, robust information on hospital activity, meaningful budget information and a process by which freed-up resources can be made available to commission further services in the community'.

Kingston – disillusioned with PBC

GPs were hopeful that PBC would offer opportunities to provide better care for patients closer to home, and for clinicians to develop new skills, says Dr Jeremy Harris, LMC chair for Kingston and Richmond.

All 28 practices in Kingston – which covers an area of about 270,000 patients – formed the Kingston Co-operative Initiative (KCI) to take PBC forward.

Dr Harris says the first two years of PBC seemed to work ‘relatively well'. The delivery of diabetes care into the community was thought to have reduced routine hospital referrals by 10%, and GPs anticipated that savings had been made. ‘But when the numbers were crunched, it appeared practices had overspent,' he says.

This has resulted in GPs becoming disillusioned with PBC. ‘There is a sense of lethargy and inactivity when it comes to PBC in the area,' he believes. This is shown by the fact 80% of practices in Kingston say they are not providing more services as a result of PBC, compared with a national average of 42%.

He says one of the difficulties is that the PCT wants practices – which need to run as effective businesses – to provide services in the community at a lower cost per patient than acute care. He cites the example of how last year, KCI proposed a community ophthalmology service, but the PCT wanted it to cost £40 less per patient than the outpatient service at Kingston Hospital. Faced with these expectations, he feels it is inevitable such schemes have failed to get off the ground.

Sutton and Merton – benefiting from PCT commitment

Pressure from GPs on the PCT has helped bring about indicative budgets and appropriate resources, says Dr Nav Chana, chair of Integrated Primary Care Commissioning in Sutton and vice-chair of the NAPC.

Since GPs voiced their frustrations with PBC, the PCT has made a ‘genuine attempt to support the process where it can', he says.

Such developments might explain why 69% of GPs describe their relationship with the PCT in terms of PBC as ‘good', slightly above the national average of 64%.

Project highlights include a deep vein thrombosis scheme and an ophthalmology service that is about to be rolled out across all PBC groups. There are also plans to create a virtual ward, integrating social, health and nursing care around discreet populations to provide integrated care.

Despite this progress, he says there are still ‘significant gaps' in the way PBC works in Sutton and Merton, which has six groups covering a population of 390,000. A deep understanding of the population's health needs is still lacking, he feels. The solution would be to focus in detail on the sorts of services required down to street level, rather than looking at the whole PCT area.

Dr Chana says clinicians are not sufficiently incentivised and ‘many feel nothing will change and they'll never be able to make a difference'.

Real rather than indicative budgets would encourage GPs to get more involved in PBC, but he cautions that ‘with real money comes accountability'.

Wandsworth – freed-up resources driving progress

PBC has made good progress in Wandsworth because groups are well organised, and GPs feel included in activities, says Dr Nicola Jones, PBC lead for Wandle Practices Commissioning Group. This explains why 67% of practices who are members of a PBC group in the area say they are involved in ‘a great deal' of activities, compared with a national average of 32%. Practices have benefited from ‘a lot of freed-up resources' and this too has been an incentive to drive PBC, Dr Jones reports.

Wandsworth has five groups covering a population of 260,000, the largest of which is Wandle Practices Commissioning Group, which serves 165,000 patients.

Small but well-established and valuable projects include a service that provides INR testing for patients on warfarin so patients no longer have to visit their local hospital for what is a simple blood test. Now PBC groups want to develop larger services to tackle areas of greater need, such as diabetes.

Although indicative budgets have been available, they ‘don't come as soon as we'd like', Dr Jones says. A lack of data to help set up services is also a frustration. ‘Data is either poor in quality, prone to error or not available,' she says. ‘So we make do with what we've got, and look at what we can improve.'

Maintaining effective relationships with the PCT when personnel are constantly changing has been a challenge she says. ‘We need understanding between practices and the PCT to achieve common goals. That's the key to achieving change with PBC.'

Lewisham – lack of funds slowing development

A shortage of PCT funds has hampered the progress of PBC, says Dr Helen Tattersfield, chair of Lewisham Primary Care Federation and chair of the Seven Fields PBC cluster.

‘The PCT is always trying to make ends meet, so there's no surplus for new services.'

Lewisham is divided into four PBC clusters, which cover a population of around 250,000, and come under the umbrella of the federation. ‘In terms of GP representation and engagement, PBC has worked well,' says Dr Tattersfield.

A community vasectomy service which has been running for a year and costs £300 per patient compared to £800 in secondary care, should have resulted in significant savings, ‘but we haven't seen any', says Dr Tattersfield. ‘The cost of secondary care is soaring and absorbing any savings made.'

Another concern is the mixed messages associated with PBC, she says. ‘It seems doctors should be leading PBC, and yet the Government appears to want control.'

Although she expects PBC groups in Lewisham to receive their indicative budgets, she says they are ‘meaningless'. ‘It's not real money, so it's not going to have an influence,' she says.

Dedicated staff and money would help PBC to work in the area, she says. ‘But we haven't had either. What else can we expect from a PCT that is understaffed and overstretched?'

View from the boardroom

Sam Higginson, assistant director of strategy at NHS London, says that even though London's performance according to the Department of Health's latest PBC GP survey is about average, ‘there is a long way to go'.
‘London seems to be doing well in terms of relationships between PCTs and practice-based commissioners. But in other areas, such as quality of information, we're not doing so well,' he says.

The biggest challenge is to ensure PBC groups can deliver on health inequalities. Lack of support and resources for GPs and the need to raise the profile of PBC in the PCT boardroom and more widely are areas of concern.

The SHA wants to ‘ramp up' the work going on in PBC to re-engage healthcare staff, he explains. ‘We want practice-based commissioners to be at the front and centre of redesigning services for patients, with GPs potentially providing them.'

The Government's World Class Commissioning initiative, which will involve PCTs demonstrating how they are supporting PBC in their localities, is ‘partly a signal, partly an incentive to encourage trusts to really engage in PBC', he says.

'One of the roles of the SHA will be to have a dialogue with PCTs and PBC groups to make sure they have the right financial support and information in place.'

Other priorities for the SHA will be to look at how PBC can help drive the rollout of polyclinics. There are also now six geographical groups to lead acute commissioning in the capital.

In the current economic climate, when there is a greater emphasis on value for money and on moving care out of the acute sector and into the community, PBC is becoming increasingly important, believes Mr Higginson.

NHS South London Bromley Wandsworth Sutton Kingston Lewisham Bexley

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