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Spotlight on...East Midlands

Kathy Oxtoby looks at how PBC is progressing in this part of the country

Kathy Oxtoby looks at how PBC is progressing in this part of the country

One area of the East Midlands is forging ahead while others are facing setbacks. But a few areas have recently noticed greater enthusiasm for PBC projects from their PCTs, which are recognising the potential to make savings at a time of substantial cutbacks.

In the latest Department of Health PBC survey, 63% of respondents rate their relationship with PCTs on PBC as good, compared with the national average of 61%. In the same survey, 57% described management support for PBC as good, above the national average of 50%. And 69% of surgeries have commissioning plans – above the typical national response of 64%.

Northamptonshire – a powerful PBC voice

PBC has been thriving in Northamptonshire because GPs feel empowered to make all the significant decisions about the redesign of services for patients, says Dr Darin Seiger, chairman of Nene Commissioning which has collected the Most Advanced PBC Group trophy from the NAPC for two years running.

From the start, GPs in the area wanted to ‘grab PBC by the horns', Dr Seiger says. Initially that meant setting up four separate groups. ‘But we soon realised we were duplicating work and reinventing each others' wheels. We decided it would be better to combine forces, and that's how Nene Commissioning came about two years ago,' Dr Seiger recalls.

Now the largest PBC consortium in the country, this not-for-profit community interest company has 75 practices, 351 GP members and covers about 660,000 patients.

As a large organisation, Nene Commissioning is able to employ a team of staff involved in PBC who are ‘directly accountable to GPs, rather than seconded by the PCT,' Dr Seiger explains. But because Nene Commissioning is divided into four localities, it is also able to ensure that the voices of grass-roots GPs are heard. Monthly meetings to discuss PBC are held by each locality and attended by practice representatives. GP representatives from each locality sit on the Nene Commissioning Board, ensuring that both countywide and local issues are influencing the healthcare improvement agenda.

Strong clinical engagement and a good working relationship with the PCT have helped to bring about numerous service redesigns, with 19 already under way. Headline projects include a peer review scheme that has reduced referrals by 20% and a system for looking after patients in the comfort of their own homes when they are at high risk of admission to hospital.

Nene Commissioning's success is measured not only in the awards it has won, but also by its ability to influence healthcare – the consortium is co-producing the PCT's primary care strategy for the next five years.

PBC in Northamptonshire is not immune from common concerns – such as the lack of reliable data to inform the service redesign process and late indicative budgets. But despite these difficulties Dr Seiger believes PBC can still become a ‘greater force' nationally. To achieve this he suggests the DH should create exemplar sites to share good practice and that the Government should ‘lead the way in highlighting the benefits of PBC'.

Bassetlaw – good PBC relations

Close working between GPs and the PCT is helping to drive PBC in Bassetlaw, says Dr Stephen Kell, clinical lead for the A1 Alliance cluster. This explains why 80% of respondents to the DH's PBC survey said their relationship with the PCT was ‘good' – the highest rating for the region.

‘GPs and the PCT have always worked well together and this has helped ensure clinical engagement with PBC,' says Dr Kell.

With support from the PCT, the three clusters in Bassetlaw, which together serve a population of around 106,000, are becoming clearer about how to develop PBC initiatives, he believes. Representatives from Bassetlaw practices meet annually with the PCT to decide what issues to address in the coming year. GPs then work with the PCT to develop local enhanced services. A monthly commissioning forum attended by cluster leads and PCT directors helps to encourage clinical engagement and develop projects.

Through PBC, GPs have reduced inappropriate arthroscopies in orthopaedics and increased access to MRI scanning. Vascular screening is up and running in the community and a pathway for managing deep vein thrombosis closer to home has just been developed.

Most projects are approved within the Government's eight-week limit, Dr Kell says, and the Government‘s target for practices to have their indicative budgets by May this year was also met.

While Bassetlaw does not have many of the common PBC frustrations experienced in other PCTs, ‘getting accurate and timely information from secondary care activity' is a problem, says Dr Kell.

‘More dedicated management time' for GPs to devote to PBC would also be welcome, he says. And while PBC in Bassetlaw is moving in the right direction, he believes that ‘as with everywhere, it's still a work in progress'.

Derby City – new PBC mindset

Initial enthusiasm for PBC waned when the ‘risk-averse' attitude of the PCT meant projects were stalled, says Dr Brian Bates, clinical lead for First Commissioning Group.

‘PBC has gone through a bad 12 months. It went a bit flat with no-one developing programmes,' says Dr Bates. ‘The PCT was slow to approve projects – in some cases ideas have taken a year to get approval.'

However, in the last few months he feels PBC has ‘turned a corner'. He suggests this is mainly because the PCT has recognised that PBC is a way of making significant savings. The PCT has employed a dedicated PBC manager and a team of staff working with Derby City's five PBC groups to develop projects.

‘PBC is beginning to take off and the PCT is less risk averse and more involved in supporting clinicians to make projects happen,' says Dr Bates.

PBC projects that had been on the back burner are now being approved. These include a community gynaecology scheme, under discussion for two years, and an integrated diabetes service based half in the community and half in hospital, with consultants and dieticians running clinics alongside GPSIs and community nurses.

Now, PBC in Derby City has ‘real potential', Dr Bates believes. ‘But we need to keep up the momentum and have managers who will work with us and keep their promises,' he says.

Leicester City – a few championing the cause

For Dr Durairaj Jawahar, PBC chair of Millennium Healthcare Consortium, ‘there are two types of GPs: those in the front line who want to be champions and try things out and others who watch and wait'.

Such was the case when PBC started in Leicester City, Dr Jawahar recalls – ‘a few GPs like myself were interested while the rest sat back and waited'.

The PCT has been ‘very supportive' of PBC, he says, encouraging all GPs to get involved. This approach has paid off as the most recent DH quarterly survey showed 73% of practices rated their relationship with the PCT in terms of PBC as good.

Dr Jawahar says the PCT is also aware of the value of backing PBC at a time when substantial cuts are needed. ‘The only way to keep providing services at a time of zero growth is to think outside the box and redesign them closer to patients,' he says.

Creative thinking at the four PBC clusters in the city has led to several service redesigns, including a community diabetes service and a scheme to take genitourinary medicine into primary care.

All four clusters made savings in the last financial year – £280,000 by the Millennium Healthcare Consortium alone – and clinicians are able to use the money for services to improve patient care.

But Dr Jawahar feels that having real budgets would give GPs the freedom to transform services more quickly, allowing them to ‘take hold of PBC and really make things happen'.

Nottinghamshire – PBC is working well

GPs' attitudes towards PBC here are ‘generally positive, and there is a willingness from the majority to be involved', says Dr Tony Marsh, clinical lead for Nottingham North and East PBC Consortium.

Four consortiums and two standalone practices are driving PBC. Dr Marsh's group, which covers 122,000 patients, has concentrated on preventing emergency admissions, setting up a community crisis intervention service with the British Red Cross. The service provides social care in the home for patients whose medical condition is not sufficient to require secondary care treatment but whose social circumstances mean the GP would normally have to send them to hospital.

Dr Marsh's cluster has employed a data analyst to work with practices to validate data, which comes mainly from Nottingham University Hospitals Trust. Within a few months the analyst's efforts saved around £100,000.

Despite these successes, Dr Marsh senses the PCT still lacks confidence in clusters' abilities to commission a good service. He gives the example of how 18 months ago his group identified a need to improve community services for COPD. But the trust decided it should be a PCT-wide process and commissioned management consultants to design it. As a consequence, the service has only just begun, and ‘we have lost at least two winters where patients have been vulnerable', Dr Marsh says.

Although on balance ‘things are going well', Dr Marsh points out GPs are well aware of the ‘stringent financial situation'. He believes that over the next four years this will mean ‘a greater concentration on trying to save money, rather than necessarily expanding services'.

Despite predicted financial constraints he concludes: ‘PBC is working well, the PCT still supports it and the "experiment" has far from failed.'

Lincolnshire – PBC ‘here to stay'

PBC is ‘working well' in Lincolnshire and the feeling among the 460 practices in the area is that the approach is ‘here to stay', says Dr Brynnen Massey, PEC chair of NHS Lincolnshire and chair of the East Lindsey Cluster.

There are eight PBC clusters of varying sizes in the area, the largest covering a population of over 200,000 and the smallest approximately 60,000.

Project highlights include near-patient testing for deep vein thrombosis, increased availability of urgent outpatient slots for the elderly to reduce emergency admissions and an acute back pain clinic. A co-ordinated GP education programme is also running, giving protected time for focused learning days on such areas as dementia.

A lack of information about year-end results from 2008-9 has been frustrating for clusters, Dr Massey says. He points out that implementing bigger projects, like the county-wide intermediate musculoskeletal service, ‘has taken longer than expected', acknowledging that projects of a certain size must go through rigorous procedures.

Recently PBC in the area has received a boost, with the appointment of a lead director for PBC. Additional PCT staff have also been allocated to help each cluster develop PBC, he says.

While these measures are welcome, he says: ‘The difficulty with PBC is that GPs never have enough time. We could do more, but we have other jobs to do, and that's the real issue.'

Kathy Oxtoby is a freelance journalist

View from the SHA boardroom View from the SHA boardroom

When Andy Gregory, assistant director of performance and delivery, NHS East Midlands came into post in November 2008, one of his first priorities was to establish a network of clinicians of ‘active PBCers across the area, to discuss progress, ideas and work through any challenges'.
Mr Gregory's rationale for setting up such a network was partly because he had worked for the PCT in a previous role and was aware that ‘often good work is going on with PBC that people don't necessarily share'.
Workshops were held across the region to discuss PBC, while a website was developed to talk about examples of good practice.
SHA staff have visited consortiums to find out how PBC is developing and what the authority can do to boost its quality and productivity. Armed with this feedback, the SHA's vision is to strengthen relationships with PCTs and clinicians to progress PBC across the East Midlands. ‘The SHA wants to work with clinicians and PCTs to say: "here's a model of three parties working together",' says Mr Gregory.
Given that ‘80% percent of NHS resources goes through GP practice', Mr Gregory believes that it is ‘vitally important' that primary care practitioners are involved in service redesign decisions around commissioning across the region.
He says NHS East Midlands and PCTs ‘want to empower clinicians as much as possible' and hopes that in a year's time, PBC will have progressed to the extent that there will be ‘further sharing and adoption of what works well, improved quality of patient care and increased clinical influence on PCT commissioning decisions'.
Key to this progress he believes is further development of doctors as commissioners, pointing out that a package of support and development have been put in place to help realise that aim. ‘We want clinicians equipped with the necessary skills to commission services on behalf of patients,' he says.

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