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Spotlight on Yorkshire and the Humber

Each month we delve behind the headline figures to find out how PBC is working in individual SHAs. This month, Miranda Hart looks at NHS Yorkshire and the Humber

Each month we delve behind the headline figures to find out how PBC is working in individual SHAs. This month, Miranda Hart looks at NHS Yorkshire and the Humber

NHS Yorkshire and the Humber comprises an area where large pockets of innovation and strong PBC activity flourish alongside smaller areas where management reorganisation, poor communication and lack of clinical engagement have hampered the progress of PBC.

NHS Yorkshire and the Humber's performance does not greatly deviate from the national averages reported in the Department of Health's quarterly survey, published in March 2009. The SHA was above average in PBC indicators for the receipt of indicative budgets (72%), financial incentive schemes (74%) and rating the quality of managerial support for PBC from the PCT as good (50%).

North Yorkshire – trust throws down the gauntlet

PBC progress in North Yorkshire has been hampered by financial problems over the past two years, according to Dr Douglas Moederle-Lumb, chief executive of YORLMC, a singlehanded GP in Scarborough and a member of the BMA's GPC.

He says there have been lots of frustrated GPs who have worked very hard with limited resources but with little gain, simply because the PCT's finances have meant that it has not been prepared to take any risks by allowing GPs to control a budget.

Dr Moederle-Lumb says: ‘North Yorkshire PCT has had one of the biggest financial deficits in the country, and it has taken the last three or four years to sort this out.' He hopes that from April, things will begin to improve: ‘At least, that is what I have been promised.'

North Yorkshire PCT, now called NHS North Yorkshire and York, has recently made it plain it is willing to let go of the budgetary reins. Dr Moederle-Lumb says the PCT has effectively ‘thrown down the gauntlet' and told GPs to show what they can do with PBC. However, with this freedom comes responsibility for GPs, including the onus to prove PBC can deliver the ‘must-dos' set out for the PCT.

NHS North Yorkshire and York has started by making more resources available, and by organising awaydays with GP PBC leads and LMC members.

These will provide consortiums with an opportunity to outline their vision for PBC and discuss development plans, and also to identify what PCT support is needed.

The future for PBC in North Yorkshire looks promising, but Dr Moederle-Lumb has one caveat. NHS North Yorkshire and York has now proved it can ‘talk the talk', but can it ‘walk the walk'? He says: ‘I am very hopeful.'

West Yorkshire – robust PBC environment

In the DH survey, the proportion of GP practices in West Yorkshire who rated their relationship with their PCT in terms of PBC as ‘good' was above the national average (62%) – at 76% in Kirklees, 73% in Wakefield and 69% in Bradford. But Leeds was below average at 59%.

The PCT has not imposed a structure on practices, so the consortiums that have formed reflect likeminded practices that want to work together. There are currently three large consortiums, covering more than 80% of the population between them.

Dr Richard Vautrey, deputy chair of the GPC and a GP in Leeds, describes a very healthy environment for PBC in West Yorkshire. He says: ‘There are a number of robust PBC consortiums that have developed over a wide range of practices – with business cases focusing on a variety of schemes, including prescribing, redesigning care pathways, and bringing clinics closer to patients.

The PCT is supportive because, he says, ‘it wants to see it work'. However, although the relationship between PBC consortiums and the PCT is good, consortiums have been a bit frustrated in the past with how slowly the PCT wheels turn.

Other GPs echo that frustration over the time taken for the PCT to agree market rules and the accreditation process for providers. Dr Chris Reid, a GP in Leeds and chief executive of the Leodis consortium, says it has been a learning process for both the consortium and the PCT – but, having gone through it together once, ‘we now expect these processes to be slicker and faster'.

He adds: ‘Our experience with PBC is generally positive. Leodis includes 30 practices covering 208,000 registered patients and its size is a key factor in allowing GPs to feel they are able to directly influence the healthcare system to improve services for patients.'

Leodis has a good relationship with the trust, which recognises mutual interest and dependency, Dr Reid explains. ‘Leodis provides clinical leadership and practice engagement to the various workstreams in our PBC plan, and the PCT reciprocates by providing public health, finance and information support and nominated staff for the different priority areas.'

Leodis has introduced several new schemes as a direct result of PBC. These include a systematic, proactive approach to the care of people living in residential and nursing homes and investment in a medicines management team to work with practices in the consortium. Based on first-wave achievements, the care home scheme has reduced acute admissions by 40% and reduced excess bed-days by 90%, as well as improving the quality of care experienced by residents.

South Yorkshire – a promising outlook

The enthusiasm among GPs for PBC continues across the border in South Yorkshire, according to Linda Tully, assistant director of strategy for NHS Sheffield. She says: ‘We have 97% coverage, with only two of our practices not part of a consortium.'

NHS Sheffield feels the relationship with consortiums is good and the feedback from GPs confirms that. ‘Over the past two years, NHS Sheffield has invested heavily in building the co-commissioning relationship, and our consortiums are covering the full spectrum of commissioning opportunities,' says Ms Tully. These include redesigning services (there are currently 35 schemes on the order book), prescribing and demand management.

Evaluation is built into all these schemes, but it is too early to accurately quantify success – although Ms Tully says: ‘Some schemes may prove to be more about the patient experience, improving quality and access in terms of value for money.' However, consortiums are demonstrating freed-up resources and investments are mainly being used to fund time-limited pilots to test new ideas.

The future for PBC in the area looks promising. In 2009/10 NHS Sheffield is offering a clinical leadership course and a PBC development programme, which will combine to identify future leaders, develop the commissioning capacity and nurture a mature co-commissioning relationship. The PCT has also offered to support consortiums to strengthen their capacity by employing staff on their behalf.

From a GP perspective, PBC was initially a very negative development in Sheffield as it was associated with the turnaround process, explains Dr Eithne Cummins, a board member and clinical lead of Hallam and South Consortium (HASC). ‘It has taken time to develop relationships with PCT teams, but we are now in a position to say we largely act as co-commissioners for the benefit of patients.'

HASC has been involved in many pathway and service specification redesigns, including ophthalmology, dermatology and continence. Considerable work has been done on prescribing, focusing on best practice and evidence. Work at a local level has also examined the pathway for patients with palpitations, foot and ankle problems and chronic pain.

According to Dr Cummins, ensuring clinical involvement is key for the future of PBC – and this must mean sorting out pension problems for many GPs. She says: ‘GPs, like me, have given up clinical sessions for PBC sessions and although I am paid, my PBC work is not pensionable. This means that longer-term PBC work may not be sustainable for me.'

East Yorkshire – new PBC hope

Locality commissioning is high on the agenda of NHS Hull (formerly Hull Teaching PCT), which means that PBC has the potential to flourish.

Carole Robinson, strategic business manager for the Hull Health Commissioning Collaborative (H2C2), says PBC is in its infancy, but the emphasis on locality commissioning within the PCT means business cases are being welcomed. H2C2 involves nine practices in Hull.

Ms Robinson says: ‘We have already had two successful business cases, which are aimed at improving local services and patient care. We are now ready to run with these and focus on implementation.' One of H2C2's first business case approvals has focused on patients with COPD, but a number of other proposals are in the pipeline, covering varying therapeutic areas including gastroenterology and urology.

According to Ms Robinson, the working relationship between H2C2 and NHS Hull is very good. She says: ‘We have been working closely with good locality development managers, and the PCT has been providing good budgetary information.'

In other areas of East Yorkshire, PBC progress has been hampered by PCT reorganisation. NHS East Riding of Yorkshire was only set up in October 2008, replacing the East Riding of Yorkshire PCT, which was itself only created in October 2006. The recent DH quarterly survey illustrates that there is support from GPs for PBC in East Yorkshire, with a score of 63%. However, out of these practices, only 37% had agreed a commissioning plan with the PCT.

According to Dr Russell Walshaw, chief executive of East Yorkshire and North Lincolnshire LMCs, PBC progress has been slow in many areas and GPs have not received much incentive to take the initiative. However, Dr Walshaw expects attitudes to improve with the change of executive in the NHS East Riding of Yorkshire: ‘The new chief executive is enthusiastic and keen to give PBC the momentum it needs.'

North Lincolnshire – flickering signs of life

GPs in North Lincolnshire are frustrated with PBC, particularly the PCTs' inability to engage people clinically. There is general agreement that it has got off to a slow start, and GPs have not seen the progress they had hoped for. However, over the last couple of months, some GPs have reported flickering signs of improvement, due to better working relationships between GPs and PCTs.

This improvement is perhaps reflected in the DH quarterly survey, which reported that 88% of practices in north-east Lincolnshire had received an indicative budget.

Dr Russell Walshaw, chief executive of North Lincolnshire LMC, says: ‘GPs are striving to ensure patients get a good deal. Ultimately, that is the aim of everyone in primary care, but it requires a good working relationship between GPs and the PCT.'

He adds: ‘For PBC to develop, GPs need to receive the right incentives from the PCT and the right encouragement.'

Miranda Hart is a freelance journalist

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