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Using PBC savings to offer equal access to healthcare

PBC savings are being used to fund an initiative that aims to offer equal access to healthcare in Knowsley. Dr Matt Kearney explains how

PBC savings are being used to fund an initiative that aims to offer equal access to healthcare in Knowsley. Dr Matt Kearney explains how

This month, a long-term conditions LES will be launched in Knowsley, Lancashire. Knowsley is one of the 70 council and 88 corresponding PCT areas named by the Department of Health in 2004 as ‘spearhead' areas, in which urgent action is needed to tackle poor mortality, disease and deprivation rates.
The LES will use PBC savings to increase case-finding and improve systematic management of cardiovascular disease, CVD risk, COPD and diabetes.

How PBC can help

Commissioning is a powerful tool for tackling health inequalities.

Guidance from NICE on reducing death rates in disadvantaged populations is due to be published this month. Evidence shows that we are less likely to identify individuals with disease if they belong to disadvantaged populations and that, once diagnosed, such people are less likely to be successful in accessing and using services.

Taking cardiovascular and smoking-related diseases as examples, the new NICE guidance will recommend three key strategies for reducing health inequalities, which are:

• improving case-finding
• improving access to services
• supporting retention in services.

Variation in care is bad for health and increases health inequalities. There is clear evidence of substantial variation between general practices in the management of LTCs.

Looking at coronary heart disease, stroke, hypertension, COPD and diabetes, it is not unusual to see huge variations, of fivefold or greater, in diagnosis (prevalence recording), management (use of drugs) and patient outcomes and experience (hospital admissions).

For example, locally we have identified a tenfold variation in non-elective angina admissions. For the patient with CHD, this means they are 10 times more likely to be admitted with angina if they are registered with practice A than if they are registered with practice B.

Such variation is common in primary care and is likely to have a disproportionate effect on disadvantaged individuals, thereby worsening health inequalities.

In Knowsley, the three PBC consortiums, which collectively cover nearly 30 practices and 154,000 patients, have recognised that the most effective way of addressing such variation in patient care and use of resources is to promote a systematic approach to disease management. To achieve this, they have agreed to join forces and use PBC savings to fund the LES.

The savings were generated from GP efforts in reducing hospital referrals and emergency admissions, introducing primary care-based services in areas such as ENT and minor surgery, and making prescribing savings. The funding will support practices to put systems in place to improve management of CVD, COPD and diabetes, in line with the new NICE recommendations.

The LES focuses on what can be done in a clinical setting. But quality of healthcare is only one of a number of factors that influence health and contribute to health inequalities.

Wider determinants such as poverty, education, access to transport and leisure, the built environment and social support have a much greater impact on health and will disproportionately affect people who are already disadvantaged.

As world-class commissioning evolves, it will bring opportunities for PBC groups to collaborate with other sectors (such as education, local authority and the third sector) to commission services that address these wider issues.

The LES strategy

CVD is responsible for a third of all deaths in Knowsley. Large numbers of people (21% of men and 8% of women aged 40-74) have a 10-year CVD risk that exceeds 20%.

Most people at high risk are unaware of their risk and are therefore unsupported in reducing it. The LES will offer incentives to practices to detect those at high risk and to conduct annual reviews offering lifestyle interventions and medical treatment (such as aspirin and statins) to reduce the risk.

Hypertension is a significant reversible risk factor for CVD, but up to half of all people with high blood pressure remain undiagnosed and therefore untreated.

The LES will encourage practices to detect more people with hypertension and offer the most appropriate treatment.

Targets for BP control will be set above QOF levels (see box overleaf) – so, for example, it must be 150/90 for more than 80% of patients for the past nine months to qualify for CVD payments. No exception reporting is allowed as this disproportionately excludes disadvantaged individuals.

Conservative modelling suggests that nationally, at least half of all people with COPD remain undiagnosed. At the same time, practice COPD registers often include patients who do not have COPD.

Patients who are undetected will not receive appropriate care, and variation in diagnosis and treatment will have a significant impact on patient experience and outcomes.

Prompt diagnosis and systematic management is the most effective way of preventing disability, exacerbations and admission to hospital. In year one, the LES will focus on cleaning up COPD registers and case-finding.

Practices will be funded to refer all patients on the COPD register and those at high risk of the condition to the local community COPD service for verification of diagnosis.

The community COPD service was set up a year ago. The tender was won by the local hospital respiratory unit, but the bulk of the service is run in the community.

Its aim is to dramatically reduce emergency admissions through better, proactive management and prevention, and prompt treatment of exacerbations.

In year two, the LES will focus on improved clinical management with targets for review, therapy optimisation and appropriate referral for specialist care.

There will be incentives for annual clinical review and management to NICE standards, so practices are likely to be rewarded for systematic management and appropriate referrals (such as low FEV1).

The prevalence of diabetes is rising in parallel with the increase in obesity. It is estimated that up to one-third of people with diabetes are undiagnosed and are therefore not receiving appropriate medical treatment.

Diabetes is a major cause of CVD, kidney disease, sight loss and nerve damage. There is very strong evidence that early diagnosis and effective management of blood pressure and blood sugar reduce these complications and the premature mortality associated with the condition.

Practices will be funded to increase case-finding and to achieve targets for lowering blood pressure, HbA1c and cholesterol. Again, these targets (see box right) will be set above QOF levels, and no exception reporting will be allowed.

Reaching the hard to reach

In parallel with the LES, Knowsley PCT has commissioned an external provider (called Optimal) to conduct vascular checks in the community, starting this month.

To reach the maximum number of people, the service will have a strong community development approach and will be supported by social marketing and engagement strategies. It is expected that in addition to assessing cardiovascular risk these checks will detect undiagnosed hypertension and diabetes among those who do not routinely access GP services, and so increase case-finding in disadvantaged populations.
The checks will be carried out by registered nurses following clear protocols in a variety of locations – such as community centres, local shops, pharmacies and supermarkets – and at times to suit local people, such as the evenings. Drop-in sessions will also be run where no appointment is required.

Assessment will include:
• questions (medical history, smoking status, family history, medication etc)
• measurement (BMI, BP)
• blood tests (total cholesterol, HDL, blood sugar).

CVD risk will be calculated using the Framingham equation. Patients with CVD risk greater than 20% or with raised

BP or blood glucose will be referred to their GP for further management. Through the LTC LES, practices will be funded to review these patients and optimise their management.

Patients with risks greater than 20% will also be referred to weight management, physical activity and smoking cessation services as appropriate and will be supported by PCT-employed health trainers. The trainers' role will be to improve access to and retention in services, such as by helping individuals make and keep practice appointments.

Professional development

To foster clinical leadership and continuing professional development in the key clinical areas, GPs and practice nurses in Knowsley will also be required to attend 10 lunchtime masterclasses each year.

These will be designed and organised by primary care clinicians so that they are topical and relevant to primary care.

Topics will include:
• strategies for case-finding
• guidelines for diagnosis (such as NICE/NHS for hypertension)
• guidelines for treatment (such as NICE for hypertension, COPD and diabetes).


PBC savings of £450,000 have been earmarked for investment in the LTC LES, for three years. For each practice, this will generate an annual income of about £3 per registered patient.

It is envisaged that PBC groups may pool some resources to fund nursing time for patient assessment and review.

The funding will also pay for a software package that practices can use to interrogate their clinical systems. This will identify patients on the basis of previous records (such as blood pressure, weight, family history, glucose and lipid results) who have a higher likelihood of CVD risk, hypertension or diabetes. This will help substantially with case-finding.

Clinical engagement

A key lesson we have learned has been the importance of gaining clinical engagement in the process of developing the LES. This has been achieved largely through the establishment of new clinical forums for CVD, COPD and diabetes.

After initial discussions about the extent and impact of variation, each PBC group nominated GPs and nurses to join a ‘community of practice' in one of the three clinical areas.

Each community looked at the evidence of variation and the evidence related to systematic clinical practice. The clinicians then drafted proposals for clinical and prevention targets and circulated them by email to a wider GP audience. This was followed by vigorous electronic debate and the targets were adjusted and fine-tuned.

The process has been slow, taking about nine months, mainly because so many people had a view to share. Many GPs found it difficult to believe that we were diagnosing only about half of all hypertensive patients.

Although we are measuring BP in most patients, those who present with a first raised BP often don't come back for follow-up and systems to ensure we recalled them did not exist.

The process was very productive in that we now have a LES that has been developed by local GPs and nurses and has widespread clinical support.

The communities of practice have also demonstrated their value as clinical forums. They will now continue to support GPs in delivering the LES by assisting with peer review and audit, developing treatment and prevention pathways, publishing local guidance documents on case-finding, preventive interventions and clinical management, and sharing best practice.


There is significant variation in clinical practice within primary care. This has a substantial impact on health outcomes, health inequalities and healthcare resources. The key to reducing variation is to focus not on individual practitioners but on systems that can deliver improvement.

The Knowsley LTC LES will build on the NICE guidance, which recommends a focus on case-finding, access to and retention

in services in order to reduce health inequalities. The LES provides a framework for using PBC savings to fund system change that will reduce variation, reduce costs and improve outcomes.

Dr Matt Kearney is a GP in Runcorn, Cheshire, a public health practitioner at Knowsley PCT and a member of NICE's public health interventions advisory committee

The LES will offer incentives to practices to detect those at high risk and conduct annual reviews

Key to reducing variation is to focus not on individual GPs but on systems that can deliver improvement

Dr Matt Kearney: commissioning is a powerful weapon against inequality Dr Matt Kearney: commissioning is a powerful weapon against inequality 60-second summary Targets and incentives set for practices

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