Covering a staggering 670,000 patients across 83 practices, the Oxfordshire pathfinder is the biggest yet. Dr Stephen Richards explains the background.
Oxfordshire is the largest of the pathfinder commissioning consortia – something that brings both advantages and challenges. Our approach can best be summed up as: where there are economies of scale we want to use them – for example, negotiating major contracts with providers – but we will also be responsive to the needs of the localities and the communities they represent.
We have 670,000 patients covered by 83 practices. The relatively healthy community has significant areas of deprivation in the city of Oxford and in Banbury.
The county is currently covered by NHS Oxfordshire (PCT), and until last year seven PBC groups covered the county. Late last year the GP localities agreed unanimously that, because of the scope of GP commissioning, it would be logical to work together as a single Oxfordshire consortium – provided that the different needs of the six localities were addressed. Each of the localities elected their own locality leads, with another 11 elected GPs across the county working anything from half a day up to two days a week on the commissioning agenda. I was elected by GP colleagues to lead the consortium.
The six locality leads and I constitute the core of the GP consortium board. The work of the Oxfordshire GP consortium (OGPC) is informed both by grassroots GPs in their localities and the needs of the whole health economy across Oxfordshire. We have meetings every two weeks involving PCT colleagues with whom we are still working extremely closely.
The extent of the localities' autonomy will be more clear once we have a greater understanding of the accountability and governance of the GP commissioning agenda.
We anticipate that the consortium board will be a subcommittee of the cluster board comprising NHS Oxfordshire and NHS Buckinghamshire and we are working closely with PCT and cluster colleagues to shape the transition towards GP commissioning.
Reasons for amalgamation
We examined various options, such as having two or three smaller consortia across the county, but in open meetings a consensus emerged that it would be better to have one large consortium.
There are a number of reasons for this. It is helpful that our boundaries are the same as the county's – historically, commissioners have worked closely with our county council. We have one major acute provider for the county, The Oxford Radcliffe Hospitals NHS Trust, and a single county-wide provider, Oxford Health NHS Foundation Trust, for community and mental health services. In order to negotiate with these large trusts, GP colleagues felt it was better to be formed into a single consortium rather than trying to address issues and negotiate contracts in a piecemeal way.
In terms of our relationships with the local Health and Wellbeing partnership board and with the public, it is also more straightforward if we are seen clearly as a single Oxfordshire consortium.
The key challenge is to give the right degree of autonomy and authority to the localities to ensure we are responsive to the needs of different parts of the county. For example, there are projects in place to redevelop community hospitals in two of the localities. They need to progress, but are not common to the other localities – so handling this could be a challenge.
Ensuring engagement across the breadth of all 83 practices of the GP community as well as such a large public is essential, but also a major challenge.
We joined the first wave of pathfinder consortia because we recognised the need for greater clinical leadership and engagement in commissioning. Sadly, over the past few years there has been a widening chasm between primary care clinicians and acute sector colleagues. The chance to bridge that chasm and work in a more integrated way to deliver a seamless healthcare system is what the clinical community is looking for from GP commissioning.
We are holding public events in each of the six localities to clarify what the changes are about, listen to concerns and hear what the public want us to do to shape the future of GP commissioning in Oxfordshire.
Our size gives us some advantages when it comes to managing the risks, but I don't underestimate them. NHS Oxfordshire has a £20m cost-improvement plan around the QIPP agenda and the Oxford Radcliffe Hospitals NHS Trust has a cost-improvement plan of £52.8m this year. With QIPP, we are very aware that the need for these ongoing cost savings will continue for another three years.
Locally, we are in a strong financial position – all the local trusts met their agreed budgets at the end of the last financial year, so we start from a position of balance. However, we are aware of the effects of the efficiency and productivity savings to be made by the NHS by 2014.
The NHS in Oxfordshire estimates the need to find efficiencies of £194m over the next four years if it is going to continue to meet the demand for its services within tightening budgets.
We also have an elderly population – the highest users of the health system.
One specific issue that needs to be addressed is rates of emergency admissions to hospital. We have managed to stabilise increases in admission rates, but recognise that to reduce them we need to improve care of those with long-term conditions in their homes and communities.
We have a number of projects to deal with this, including a case-management project linking GP and hospital services to improve care. We are also working with people with long-term conditions to improve their self-care and prevent deterioration, as well as focusing on the growing number of patients with dementia and looking at integration of community teams to give support closer to or in the home.
We are a pioneer site for the roll-out of the urgent care dashboard and will be using it with our current systems to deliver anticipatory care to the most at risk.
The community service provider arm of the PCT is now completely separate from commissioning. The recently formed Oxford Health NHS Foundation Trust is the combination of Community Health Oxfordshire and the Oxfordshire and Buckinghamshire Mental Health Foundation Trust and is the main provider for all community and mental health services.
The pause in the health bill seems sensible, and we were able to put our views to David Nicholson and his team when they came to the region as part of the Government's listening process. But we are pressing ahead to build the clinical leadership community so that however the bill changes, we will still be well placed to move forward. I believe the fundamental core of clinical GP commissioning is sound, although there are important areas – such as accountability and competition – that require further discussion.
David Cameron's constituency of Witney falls within Oxfordshire and this could open us up to particular scrutiny, so we are taking the processes around our development very seriously.
GPs in Oxfordshire are becoming increasingly engaged as they understand what we are trying to do. Between the 17 elected GPs on the consortium board, we have over 350 years worth of clinical experience and over 100 years of NHS management experience.
We also have 70 GPs, practice managers and other clinicians across the county asking to work with the consortium. Understandably there are still doubters, but there is increasing momentum that we are very keen to build on.
Pathfinder: Oxfordshire GP consortium
Structure: Single large consortium, six locality leads and 11 elected GPs
PCT: NHS Oxfordshire
Geography: Core population is within city boundaries of Oxford, with rural and semi-rural communities around. Pathfinder covers PM David Cameron's Witney constituency
Disease rates: Patients' health generally better than England average. Prevalence of hypertension (11%), CHD (2.6%) and diabetes (4%) all below England average.
Efficiency challenge: £194m of savings to be found over the next four year
Dr Stephen Richards: leading the way in Oxfordshire Dr Stephen Richards: leading the way in Oxfordshire