South East Coast revisited

Kathy Oxtoby goes back to the key players on the South East Coast to find out how PBC projects are progressing

Support for PBC in some areas of the South East Coast region seems to be wavering. Some 78% of respondents in the latest DH survey rate their relationship with PCTs on PBC as fairly or very good compared to 60% last year – still slightly below the national average of 82%. But this year, only 44% described management support for PBC as ‘good' compared with 50% in 2008 – also below the national average of 57%.

Although some GPs in the region report progress with PBC, others say it has stalled, and most are concerned that the current financial climate and cuts to PCT budgets will stop schemes getting off the ground.

Eastern and Coastal Kent – lack of funds preventing progress

Last year, one of the largest practices in the country planned to open a third surgery building linked to a centre run by private provider Circle. But in June 2009, the Whitstable Medical Practice – which has 18 partners and 33,000 patients – experienced a ‘huge disappointment', says Dr John Ribchester, one of two NHS Alliance PBC leads in the region. ‘Circle was due to take on the lease of the building and was going to fit out a third of it – but then decided not to proceed.'

The practice was left with two choices: either to use that part of the building for non-medical purposes or to take on the lease. ‘After much agonising we decided to take the risk, get a mortgage and take on the lease ourselves,' says Dr Ribchester.

The practice is about to exchange contracts with the developer and hopes to provide more diagnostic outpatients services in the vacant space left by Circle.

Despite the setback, two-thirds of the building has been open since September 2009, providing general practice services, a minor injury unit and a fully functioning day surgery suite manned by two GPSIs.

The practice is also in discussions with the senior commissioners at the PCT about specialties that are missing – or close to missing – the 18-week waiting target, which could be delivered from the surgery.

The process of getting commissioning plans agreed has become more difficult in the past year, because of tight financial constraints at the PCT, Dr Ribchester explains. ‘Even if new services are cheaper, faster and better, they are still seen as an additional expense so you need to demonstrate an extremely robust business case to move patient care forward,' he says.

To improve PBC in the area, Dr Ribchester would like to see an end to block contracts and to see secondary care become ‘more accepting' of consultants working for more than one provider.

Elsewhere, in east Kent, financial constraints remain a barrier to taking PBC forward, says Dr John Neden, PBC lead for East Cliff Practice in Ramsgate. ‘It's been a frustrating year and, of late, we're no longer working in an environment where there is money to do innovative schemes, but are being restricted by lack of funding. This means looking at projects that offer added value to the PCT and this has become the name of the game,' he says.

A ‘big success', he says, has been work done to integrate nursing teams to keep older people and multiple attenders cared for in the community, and to ensure that nurse support is there for palliative care patients to have the choice to die at home rather than in hospital.

Dr Neden stresses there is a ‘real desire' to see PBC working in East Kent. ‘But to make it work we need to be given some incentives that will allow us to take risks because that is the only way you can really redesign services – otherwise you are tinkering around the edges, which won't make any difference to the patient experience.'

Brighton and Hove – keen to work collaboratively

In Brighton and Hove, practitioners have been ‘frustrated with the slowness of the PCT's procurement processes', according to Dr Peter Devlin, a local GP and clinical director of Brighton Integrated Care Service (BICS), a not-for-profit organisation owned and managed by local GPs and primary care staff. Another difficulty has been ‘the very long drawn-out process to secure agreement on freed-up resources', he says.

Despite these difficulties, BICS has launched several schemes during the past year that are bringing care closer to home.

A community ENT clinic and a minor eye clinic are up and running and BICS has delivered service designs in neurology and gynaecology. The organisation has agreement from the PCT to set up an integrated dermatology outpatient service and is developing a redesigned musculoskeletal service.

Dr Devlin says GPs would like to have real budgets to drive PBC forward. ‘It's only through holding a budget that we can really secure the engagement and accountability of practitioners to make PBC as effective as possible,' he says.

He would also like to see practices being supported to work collaboratively in areas where there is mutual interest. ‘This will help us to secure the best clinical models for care so that PBC becomes an unstoppable train.'

West Kent – cutback concerns

During the past year the PCT has shown more commitment to PBC, appointing some locality managers to support PBC groups, says Dr Sanjay Singh, chair of the Invicta PBC group.

The group is in the process of establishing community-based dermatology and orthopaedic services. An integrated care project is also under way, with GPs and social services working together to regularly discuss the needs of high-risk and elderly patients.

But the economic downturn is a worry for GPs in the area.

‘The financial climate has put a cloud over PBC, and we are worried about how cutbacks will affect our commissioning work,' says Dr Singh.

‘There is a danger that projects might not progress and there will be sacrifices to maintain the financial balance.'

Currently, the power to progress PBC ‘is still very much in the grip of the PCT', he believes. ‘Localities have well defined responsibilities without any statutory power attached. This is a false business model because you can't give GPs responsibilities without the ability to make decisions.'

However, he is confident that ‘both GPs and the PCT want to make PBC in this area work'.

East Sussex, Downs and Weald – drive to empower GPs

Since the formation of the new East Sussex, Downs & Weald PCT, chair John Barnes says the eight PBC clusters have now grouped into three ‘super-clusters' and that PBC is ‘functioning pretty well'.

One of the difficulties in the region, he suggests, is that the management and analysis of data that is required to make PBC work has not been sufficiently outsourced.

‘What GPs are brilliant at is coming up with the ideas. Then it becomes a process of wading through treacle to turn those ideas into business cases,' says Mr Barnes.

‘In the past, we have not been very good at dealing with small projects for GPs or at energising clinicians. However, in the past year we have been successful at getting business cases approved.'

A triage of physiotherapy schemes is reducing referrals by about 30%, and there are plans to introduce musculoskeletal and audiometry services to reduce secondary care waiting lists.

Although PBC is ‘moving in the right direction', Mr Barnes believes it's still a case of one step back for every two steps forward.

‘We are still too slow when it comes to translating GP aspirations into schemes. And we need to give the super-clusters more management support.'

Hastings & Rother – a positive PBC experience

Developing pathways to bring care to the community continues to be the main thrust of the one PBC consortium in Hastings & Rother, which covers almost all the practices in the area.

Recent schemes include an orthopaedic care pathway, anticoagulation in primary care and a COPD service that allows patients to be identified, monitored, treated and followed up in the community.

Embedding these schemes into everyday practice takes time, says PEC chair Dr Greg Wilcox.

‘People should not underestimate how much work is required to develop pathways. It's not about having an idea, it's about getting people on side.'

Having ‘good support' from the PCT's primary care team has helped the consortium to make progress with PBC, Dr Wilcox believes.

As part of that support, the PCT holds regular educational events for GPs, practice managers and nurses to spread the word about how to use new pathways.

Making sure practices get budget information and involving practice managers and GPs in the PCT's budget setting group has also boosted attitudes towards PBC, Dr Wilcox says.

A source of concern is that the current financial climate could impede PBC progress.

‘We have an increasingly cash-strapped NHS and this will have an impact on us in the coming year.

‘There is no doubt in my mind that PBC is a success but it has to be recognised and supported to make sure it's not one of the victims of the recession.'

Surrey – PBC stalled

Last year, Dr Ralph Burton, clinical locality lead for south-east Surrey, was hopeful that the letting of two contracts for integrated care organisations would be a blueprint for the way PBC might deliver in the future.

Since then, the PCT has cancelled both contracts, and the past year has been ‘disastrous' for PBC he says.

‘The PCT has more or less abandoned the concept of PBC and seem to be centralising healthcare as fast as it can,' he says.

‘It might be that the PCT sees the only way out of its financial difficulties is to revert to the old ways. But this won't lead to fundamental change,' he says.

This attitude is in sharp contrast to when PBC began.

‘GPs were supportive of PBC and saw it as a positive way to move healthcare forward. They signed up for incentive schemes and lots of plans were made, which are now unlikely to come to fruition. Some schemes are still running but unless they are rescued pretty rapidly, PBC will have been an abortive exercise,' says Dr Burton.

Kathy Oxtoby is a freelance journalist

To see more PBC case studies from across the country, search our new interactive PBC map practicalcommissioning.net

Oliver Phillips, head of commissioning and planning at NHS South East Coast, says there has been ‘a gradual increase' in GP engagement with PBC over the past year.
However, Mr Phillips adds PBC has yet to reach its full potential: ‘We've seen a lot of small changes in different pathways, which have undoubtedly had benefits for patients, but we are still seeing the same proportion of work going into the acute sector as four years ago, so PBC has not yet had the transformative effect we had hoped for.'
Since last year, the SHA has been through the World-Class Commissioning programme to ensure that all PCTs in NHS South East Coast see clinical engagement in the commissioning process as a high priority. Development plans have been agreed with each PCT to ensure GPs are supported to take a key role in the commissioning process. Mr Phillips has visited PCTs to review those plans and it has also been made clear that for year two of the WCC process they will be expected to meet the Department of Health's minimum requirements. As well as supporting PBC at practice level, a number of PCTs in the region have changed the way clinicians are involved in the strategic planning process. ‘Several have moved from the traditional professional executive committee to something more like a clinical strategic board, which has PBC membership,' says Mr Phillips. ‘This is really driving clinical strategy and is ensuring that PBC locality leads are at the centre of the decision making process,' he adds. This approach, he hopes, will help ensure more ‘substantial changes' are realised through PBC.