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North London revisited

In the first of two articles focusing on London, Kathy Oxtoby looks at how PBC projects have been progressing north of the river

The latest Department of Health PBC survey shows support for PBC in London is 51%, the same as the national average, while 84% of practices considered their relationship with the PCT in terms of PBC to be good. Again this reflects the view of the typical GP practice.

Polysystems have yet to make an impact in most parts of north London, while PBC progress continues to vary widely within individual PCTs. Many boroughs are setting up new services and redesigning care pathways to cut secondary care costs, but in some areas GPs say efforts to establish schemes have come to nothing, leaving them disillusioned with PBC.

Redbridge – pioneering polysystems

Last summer, five GP-led polysystems replaced Redbridge's three PBC clusters. ‘PBC had been working okay but we thought it could work even better,' says Conor Burke, interim chief executive of NHS Redbridge.

Each polysystem covers a distinct area. Currently one polyclinic – the first in the capital – sits at the heart of these polysystems and is connected to other health professionals such as GPs, pharmacists and opticians. There are plans to establish four more polyclinics.

The polysystems work together through a clinical commissioning board, which is accountable for borough-wide commissioning and the redesign of health services. Eventually the polysystems will manage their own budgets with the aim of providing each of their 50,000 strong communities with services closer to home.

Since polysystems were introduced, GP referrals have decreased by 15%, says Mr Burke. And cardiac care – a priority condition and high area of spend in the borough – has a new pathway, which means that within two weeks the patient's care plan is agreed. There are plans to apply this approach to other long-term conditions such as COPD, depression and diabetes, he says.

Dr Narinder Sharma is clinical director for the Loxford polysystem, which has five practice members. He says that while it is ‘still a challenge' to get practitioners on board with the new approach, ‘we try to get the message across that patients can continue to access services from their GP, but have the added benefit of a polyclinic for tests or advice'.

Dr Sharma, a former member of a large PBC cluster, is pragmatic about polysystems. ‘It is better for those at the front line of primary care to be in the driving seat,' he says. Post election he hopes GPs will be given ‘genuine autonomy to influence commissioning decisions'.

Islington – greater PCT engagement with PBC

Islington GPs now have a social enterprise scheme to take PBC projects forward. The Independent Commissioners for Islington Society (ICIS) was established last August to help its 10 member practices deal with the business aspects of PBC, to make savings and develop care pathways.

Dr Renu Hans, clinical lead of the North Islington Federation, says ICIS has ‘done well' with regards to identifying ‘where costs can be cut and how the hospital has been charging the practices. ‘Unfortunately we are unable to hold hospitals accountable for a lot of the current overspend,' she says.

During the past year Dr Hans feels NHS Islington has been engaging more with practice-based commissioners. ‘The PCT appears to be listening to us, seems keen to take PBC forward and has been more supportive of commissioners,' she says.

While the PCT might be showing greater support for PBC, no new projects have got off the ground in the past 12 months. In the coming year, Dr Hans hopes the North Islington Federation will be able to develop several services designed to bring care closer to home, including minor surgery, cardiology and a community diagnostics scheme.

Giving GPs more independence from the PCT to deliver PBC schemes would benefit patients, she believes. ‘Ideally we want to be the ones commissioning. Great savings can be made in healthcare when local GPs are given the chance to get involved.'

Harrow – focus on referrals boosts expansion

Financial pressures have meant that commissioning has focused on reducing referrals and admissions to secondary care, says Dr Chaand Nagpaul, LMC vice-chair for Harrow.

In the past year that focus has meant the four clusters in Harrow have worked together to set up a range of community- based services, which GPs are being encouraged to use instead of referring to hospitals. Clinical assessment services provided by GPSIs with support from hospital specialists now cover most specialties including cardiology, ophthalmology, orthopaedics and rheumatology.

Efforts to cut secondary care admissions have also resulted in the setting up of a clinical assessment unit by the PCT. This direct GP referral service is for patients who need acute medical attention, but whose condition could be stabilised in hospital and subsequently managed at home.

To help ensure that local practitioners, rather than large commercial providers deliver services to the community, a GP-owned limited company – Harrow Health – has been set up, in which all local GPs are members and shareholders. Harrow Health provides community services such as anticoagulation, ophthalmology and musculoskeletal medicine.

Hospital referrals are expected to be reduced still further with the launch this month of a referral management centre commissioned by the PCT and run by Harrow Health. Referrals will be triaged by local GPs at the centre, to be sent on to a community service, or to hospital or returned to the GP if deemed inappropriate. Dr Nagpaul hopes the new system will result in more accurate referral information about practices and individual GPs than the hospital-generated data which has been ‘fraught with inaccuracies', he says.

Dr Nagpaul says the biggest commissioning challenge facing Harrow GPs will be agreeing on how polysystems will be implemented. ‘We need to make sure any plans are developed from the ground rather than imposed on us.'

Brent – better working relations with the PCT

PBC in Brent has progressed ‘fairly well' in the last 12 months, says Dr Ethie Kong, chair of the Harness PBC consortium. Last year, Brent PCT became the first in England to use the DH's PBC development support framework, and since then GPs have been benefiting from the training it has provided. ‘The programme has also encouraged better relationships between the PCT and PBC,' says Dr Kong. The latest DH survey supports this view, with 100% of practices saying their PBC relationship with the PCT is good.

A musculoskeletal scheme is being rolled out across all five clusters and pilot projects in gynaecology and ophthalmology have been given the go-ahead, which if successful will also go borough wide. Dr Kong also says the clusters have negotiated reasonable and equitable PBC budgets based on ‘fair shares methodology' with the PCT.

How polysystems will work in Brent has yet to be decided, but Dr Kong says the PCT has made sure PBC leads are involved in discussions and it is likely there will be three or five, which will evolve from the clusters.

Dr Kong would like PCT managers to be more sensitive to GPs' ‘enormous workload'. ‘As well as concentrating on PBC we still have our main job to do. And while we get reimbursed for one session a week on PBC work, in reality we spend much more time doing it because we have a passion for it.'

Brent LMC chair Dr Helen Clark agrees that practice workload makes it difficult to drive PBC forward. ‘It's frustrating that you're too busy running your practice to do, say, a pathway redesign,' she says.

Despite workload pressures, she believes it is important for grass-roots GPs to get involved with PBC because it gives them the chance to enhance patient care. ‘It is better for us to be part of the changes taking place in healthcare than to be sidelined.'

Westminster – hoping for more commissioning muscle

GPs in Westminster were keen to embrace PBC but have been frustrated with progress, says Dr Matthew Johnson, a member of Central London Health and former chair of West End Commissioning Cluster.

‘Although GPs are supposedly commissioning services, in reality we're allowed to provide input while procurement is carried out by the PCT,' says Dr Johnson.

In the early days of PBC, he says West End Commissioning Cluster was able to develop small-scale community projects that responded to local requirements, such as an allergy testing service that bypassed the need for outpatient referrals.

‘In a small way we were successful,' says Dr Johnson. But practice members were concerned that they didn't have enough commissioning muscle and weren't big enough to cope with the move to polysystems. So this April, West End Commissioning Cluster merged with the larger Central London Health, giving a combined population of around 100, 000. There are now four clusters in Westminster, which are expected to evolve into polysystems.

While Dr Johnson believes PBC still has value, he would like ‘a radical overhaul'. ‘If the Government really wants a primary care-led NHS it needs to give us adequate resources, which hasn't happened.'

Hackney – saving on referrals – but not seeing the benefits

GPs in Hackney have been working with hospital consultants to develop clinical care pathways with the support of a social enterprise scheme. City and Hackney East London Integrated Care (ELIC) Society, which represents six consortiums, has helped practitioners to create pathways in several specialties including gynaecology and cardiology.

Information about the pathways is available on the ELIC website as are details of the consultant advice service, which has been set up to support GPs to manage patients without outpatient referral. ‘I can get answers to clinical questions quickly, which leaves me to manage my patient's care,' says Dr Deborah Colvin, an ELIC executive and City and Hackney LMC chair.

While referral rates have dropped 13% in the past year, Dr Colvin says PBC costs have increased because of rising hospital charges. ‘The new costing codes for hospital activity have meant we're now being charged for all sorts of minor procedures. So in spite of all the work we've been doing to save on referrals we're not really seeing the benefits,' says Dr Colvin.

The Inner North East London sector – an alliance of Tower Hamlets, Newham, and City and Hackney Teaching PCTs – has formed a unit to manage the performance of acute trusts, which Dr Colvin hopes will help to address the problem of rising secondary care costs. ‘Now that all three PCTs have got together to negotiate with the hospitals, primary care should have greater bargaining power,' she says.

Ealing – from a positive start to disillusionment

GPs in Ealing were initially ‘very positive' about PBC, says Dr Adam Jenkins, LMC chair of Ealing, Hammersmith and Fulham, and Hounslow. ‘We were enthusiastic, PCTs engaged with the practices and we moved forward with schemes fairly quickly,' says Dr Jenkins.

Several community schemes were set up by the five PBC groups in the borough, including urology, ENT and ophthalmology services. The ophthalmology scheme continues to thrive and has made ‘enormous savings' but ‘bit by bit' the majority of PBC schemes have been closed down, says Dr Jenkins.

‘Even though they were convenient for patients, the PCT's argument was that our overall commissioning budget had been overspent, therefore we hadn't made any savings,' he says. This explains why only 50% of practices in the area described their relationship with the PCT in terms of PBC as ‘good'.

Last year, PBC leads, Ealing PCT and other professional groups associated with healthcare discussed ways to reinvigorate PBC. They decided groups connected to healthcare, such as voluntary organisations, should be involved in taking PBC services forward.

To give PBC groups more commissioning power, there are plans to increase their size through amalgamation, ‘but nothing concrete has happened yet', says Dr Jenkins.

Dr Ric Naish, former lead of North PBC group and a GP at Hanwell Health Centre, says PBC in Ealing has become a ‘talking shop'. ‘We worked hard to get freed up resources but they didn't materialise. We were flooded with extra work, which made it impossible to be a GP and do PBC work and so we lost heart,' Dr Naish says.

He urges the PCT to ‘let GPs manage what we are able to manage, to give us a fair budget and let us build on projects'.

Kathy Oxtoby is a freelance journalist

View from the King's Fund

A ‘mixed picture' is how Dr Nick Goodwin, senior fellow for the King's Fund, describes PBC progress in London in the past year. ‘In some places PBC seems to be working quite well, while in others the picture hasn't changed a great deal,' Dr Goodwin says.

One of the ongoing problems with PBC is that a clear definition of the policy has yet to be pinned down, he says. ‘PCTs and GPs have different expectations. It works best when there is a joining of those views.'

He says the polysystem suffers from a lack of definition and ‘a lack of vision'. ‘The polysystem doesn't have a particular organisational solution. It's a concept that requires a degree of local interpretation and implementation. And it pre-supposes that everyone is signed up to a common objective, which is not the case,' he says.

Giving GPs the opportunity to wield real budgets and make autonomous commissioning decisions could help move PBC forward, Dr Goodwin believes. But he says GPs would need more detailed data to manage hard budgets.

Improving care pathways and boosting health promotion in the capital will require PBC to become less GP centric and should encompass more viewpoints, he believes. ‘The next stage of PBC should be less about making changes to individual practices and more about the contribution that all those in healthcare can make to address local needs.'

Harrow North London Hackney Redbridge Islington Brent Ealing Survey results