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Ten tips to kick PBC into action

Many GPs are still stuck on the PBC starting line, unsure of how to get going – but experts say now is the perfect time to get moving. Emma Wilkinson offers 10 top tips

Many GPs are still stuck on the PBC starting line, unsure of how to get going – but experts say now is the perfect time to get moving. Emma Wilkinson offers 10 top tips

1 Read the instruction book: ‘You need to know the rules'

Most people would not attempt to build a piece of flatpack furniture without looking at the instructions. You need to understand the pieces you have in front of you, how they fit together and the order you need to work in. Dr James Kingsland, NAPC president, says getting involved in PBC is no different. He is amazed at how many people attempt to do PBC without a basic understanding. It may be boring to read the detail but, he says, it is absolutely the first step.

‘Most people have heard about PBC on the hoof and in snippets and as a result have information that's wrong. There is no point doing anything unless you understand the rules – it is a rule-based system.'

Dr Kingsland recommends starting with Practice Based Commissioning: practical implementation, which is available on the Department of Health website.

‘This is guidance that's really comprehensive and done in conjunction with the NAPC, the NHS Alliance and Improvement Foundation. If you don't read it, you won't have a clue where to start.'

2 Talk to clinicians in your area: ‘You'll find you have the same problems'

Working out your most pressing clinical problem should not be too hard, says Dr Nav Chana, chair of Integrated Primary Care Commissioning and vice-chair of the NAPC. Simply sharing stories with other GPs in the area will quickly highlight the issues that cause clinicians the most grief, and it could be something as simple as access to a reliable and quick phlebotomy service.

‘If you stick a load of clinicians together in a room and ask them what's bothering them, you will find for most it is the same thing,' he says. ‘You will also be able to identify the resources that exist among practices in your area that you might not have been aware of.

‘For example, the practice down the road might have a fantastic diabetes nurse and that could be something worth looking into – it gives you a starting point to think about areas you could redesign.'

3 Start small: ‘What would make one patient's journey a bit easier?'

The inevitable management speak that accompanies any discussion or policy paper on PBC can be a turn-off to those who are new to the idea.

But instead of getting bogged down in a language you do not understand or grand plans for overhauling whole areas of clinical care, start small and just think about what would make the patient's and the referrer's life that little bit easier. What is it that on a day-to-day basis really causes frustration – that one thing that just does not seem to make sense for anyone involved?

‘You don't have to start with a plan to redesign diabetes services,' says Dr Kingsland. ‘Just think about how to make one patient's journey better.'

He adds: ‘You do need to be ambitious but start with simple everyday challenges and barriers. Once you get to that stage, then you can start to think on a bigger scale.'

When thinking about PBC, many people focus immediately on PCT-wide reform but actually there are ‘adjustments' that individual practices can make, he says.

4 Get organised: ‘Align yourself with like-minded practices'

Dr Shane Gordon, co-lead of the NHS Alliance PBC Federation, says GPs will have a much better chance of making an impact if they are strategic in their approach. ‘PBC messages are heard better by PCTs if you all say the same thing at the same time.'

He adds: ‘Your PBC cluster needs a plan if it is going to attract support and resources. Make sure this is couched in language your PCT will empathise with; refer to your PCT's strategic plan and how you will support it.

‘And use Department of Health policy papers to support your arguments; the PBC "entitlements" in the recent Primary Care Strategy are there to give a clear message about the minimum support PBC clusters should expect.'

Dr Kingsland agrees – and adds that practices should choose to align themselves with like-minded colleagues. ‘Don't be herded into areas that suit some PCT agenda,' he advises.

‘Once you have got your group together, consider formalising it into a limited company or some similar entity. I probably wouldn't have said that three or four years ago but it gives some sense of ownership of the agenda. It doesn't prevent doing some projects as individual practices and it certainly doesn't amalgamate your primary care contracts.'

Having some sort of corporate structure mandates responsibility for a budget and employees but also gives independence, he says. ‘You also have responsibility for peer review to make sure everyone is working to the standards set by the group as a company.'

Dr Mike Dixon, chair of the NHS Alliance, adds it is important to decide on your identity. ‘Decide if you're going to be a group of practices or a social enterprise or a limited company. Unless you have an identity you will always be one man and his dog doing it in your spare time.'

5 Make friends with the PCT: ‘It has to work both ways'

Dr Stewart Findlay, PBC chair of Durham Dales Cluster, says it has to be a joint approach. ‘We have got to really work together and for a long time I think there has been a stand-off: PCTs haven't trusted GPs and GPs haven't trusted PCTs.

‘PCTs have to find a way of allaying their fears that we are all rogues and renegades and we need to be given the freedom to develop services quickly and efficiently – it works both ways.'

It could be as simple as taking your PCT chief executive out to lunch, but remember there are lots of other people at the PCT who are responsible for, and know a lot about, commissioning. They are a resource to tap into.

‘A lot of it is about PCT colleagues – viewing those people as friends and collaborators rather than the other side,' says Dr Chana. ‘If you have got good people in the PCT who are interested in making a difference you should be able to iron out a lot of things that could go wrong.'

6 Follow the leader: ‘Find someone to stir excitement'

Having an energetic individual to sort you all into some sort of coherent voice is a must, says Dr Kingsland.

‘You need strong local leadership to make it work. It's those leaders who are prepared to put time and thought and effort in, chair or administrate the group – and you need someone who can stir the excitement in colleagues.'

Dr Dixon says this may even be the most important factor. ‘You need to choose a strong leader who can give you a lot of time but also credibility and determination. They will make sure services are improved but also make sure once you have got those services, member practices and GPs are signed up to using them.'

Dr Gordon adds: ‘Make sure someone takes time to understand the NHS policy and local issues – helping the PCT meet its obligations will earn quid pro quo.'

7 Get the tools to do the job: ‘Without data you can't do anything'

You need a budget and you need timely accurate data as a minimum first step. ‘Without that you can't do anything,' says Dr Kingsland. ‘It may seem obvious but the number of people I've seen who don't have that – I don't know what they're doing but it's not PBC.'

Data is a must, agrees Dr Gordon, and the tools are there if you know where to look.

‘There are lots of free NHS data tools on N3. And GSK do some very useful PCT level analysis if you ask nicely.'

The NHS Information Centre also acts as a gateway to data sources, such as hospital episode statistics, and tools including NHS comparators and the demographic and social information, which can be used to identify needs and plan services. Also don't forget the PCT will have datasets and analysts who can help put it into some sort of easily accessible format.

8 Don't be disheartened: ‘The levers are there'

Dr Chana admits there has been frustration among some of the clinicians who have tried to get PBC off the ground.

‘The people who have taken up the challenge did so on the understanding they would have some control and that they would be able to make a difference. But changing things can be very hard and a lot of the time everything continues as normal.

‘People have been disheartened by that in the short term, but the landscape does now seem to be changing. Department of Health policy seems stronger and budgets have moved on. These are the levers people need and now is the time to get involved.'

He adds: ‘Most GPs have 200,000-300,000 patient contacts in their careers so they are very well placed to know what can be improved.'

Dr Findlay agrees that PBC hasn't really got moving up until now.

‘With World Class Commissioning and the need to develop Integrated Care Organisations and involve clinicians in that, it really should push us together with PCTs and hopefully this time we might actually see commissioning start to work.'

9 Get political: ‘There are allies to be found'

Think community – if there is a problem with services then GPs will not be the only ones keen to make them more efficient. ‘There are many allies to be found if you want to improve services,' says Dr Gordon.

The first port of call would probably be patient groups – if they don't exist you could always start one, he says. ‘It also includes voluntary organisations, local authorities, and parish and district councils.'

Dr Dixon agrees the patient voice is particularly useful. ‘It gives you credibility – that you are speaking for the people.'

10 Pick off the low-hanging fruit: ‘It gives you an early win'

Dr Dixon advises building confidence by picking an easy first project.

‘Go for the low-hanging fruit for your first few initiatives and make sure you make them happen. You need to go for an early win to show you can hack it and you can make a difference for patients.

‘It shows sources outside that you are capable and shows sources inside who don't think PBC is worth it's salt what you can do.'

Emma Wilkinson is a freelance journalist

GPs will have a much better change of making an impact if they are strategic in their approach

Go for the low-hanging fruit first - few initiatives and make sure they happen.

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