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South London revisited

In the second of our two-part special looking at how PBC is progressing in London, Kathy Oxtoby reports on developments south of the river

London SHA continues to match the national average when it comes to many indicators of PBC progress, according to the latest Department of Health PBC survey. Some 61% of practice-based commissioners say they have a ‘great deal' or a ‘fair amount' of influence over their PCT, above the national average of 54%. But other areas fall short of the typical response from PBC groups and independent practice leads, with only 53% rating the quality of management support they receive as good, compared to the national average of 65%.

Many GPs in south London say their PCTs have become more enthusiastic about PBC, although some believe this is fuelled more by a drive to save money than to improve care. There are also concerns that a lack of accurate data and funding is restricting PBC.

Bexley – supporting GPs to get the most out of PBC

Last year, despite achievements being made, some clinicians had still not got on board with PBC. Now, says Dr Joanne Medhurst, clinical director for Bexley Care Trust, ‘the work we are doing is being acknowledged both locally and nationally and we have good GP engagement'.

As proof of that engagement, she says GPs are signed up to a polysystem approach. The borough's three localities are being replaced by three polysystem clusters and there are plans for each one to have its own polyclinic hub.

During the past 12 months there have been major structural changes to PBC. A clinical cabinet and a clinical executive group represent the commissioning element. The cabinet is responsible for agreeing service priorities and developing pathways across Bexley. It is chaired by a GP who is also a member of the PCT's executive team and includes practitioners leading PBC and the chief executive of the trust. The executive group is accountable to the cabinet and is made up of GPs who do the day-to-day operational work, such as redesigns.

Bexley's three consortiums have become three locality provider companies and there are plans to set up a pan-Bexley company to bid for borough-wide initiatives.

Major projects include a rapid-access chest pain service, which is being rolled out across Bexley, and the piloting of a scheme to move 80% of all diabetes care into the community.

Giving GPs real delegated budgets for prescribing has proved ‘enormously successful', says Dr Medhurst, and there are plans to give clinicians real delegated budgets for 2011.

The borough has rolled out several initiatives to help clinicians get the most out of PBC, which include setting up a patient management centre to monitor GP referrals and recruiting a business manager for practices to show GPs how to maximise their budgets.

A practice kite-mark has been introduced to help practices measure their PBC performance and to raise standards. At the end of each year, practices will be assessed and rewarded according to their ability to meet a set of criteria, such as staying within PBC budgets.

Practitioners also have access to ‘Map of Medicine' – an internet-based tool that gives details of the latest care pathways – ‘allowing GPs to keep up with the pace of change', says Dr Medhurst.

Southwark – PCT revives GP support

PBC got off to a slow start in the borough, but the need to make savings has brought about a ‘sea change' in the PCT's attitude towards developing services in the community, says Dr Stewart Kay, chair of Southwark LMC.

‘There was an initial enthusiasm from GPs towards PBC, but nothing happened during the first two years because the PCT wouldn't let go of the commissioning reins.

‘But nine months ago, the PCT had to make huge savings, particularly in terms of costs associated with secondary care provision. That's when the trust started to realise the only way to deliver this was through PBC,' he suggests.

Now GPs ‘not only have a voice, but are actually listened to,' says Dr Catherine Otty, PBC lead for the Bermondsey and Rotherhithe locality. She says the PCT's appointment of a director for primary care with a specific remit for PBC last July has ‘professionalised' the roles of GPs involved in PBC. ‘We now have proper job descriptions and are remunerated appropriately.'

This sense of renewed support is evident in the latest DH PBC survey, with 100% of practices saying they have a good relationship with the PCT in terms of PBC.

To address frustrations about the lack of information about referrals, the PCT has commissioned a new data handling program that allows GPs to identify what has been happening during a patient journey. ‘The program allows us to compare referral data with other practices, which gives us an idea about what we are doing right,' says Dr Otty.

While Dr Otty would still like to see more managerial support for GPs involved with PBC, she believes that during the past year the PCT has ‘really stepped up' to the mark – 18 months ago I felt that PBC was a waste of time, but now I feel we're really making progress'.

Bromley – PBC gets boost

With the drive to bring care closer to home and the need to tackle the healthcare budget deficit, the past year has seen the PCT become ‘even keener' on PBC, says Dr Andrew Parson, clinical lead for Bromley cluster.

‘We've moved from being a group of GPs thinking up clever ideas for the PCT, to looking at how we're going to sort out the huge movement of clinical work into the community,' says Dr Parson.

He says the PCT recognises clinical engagement is essential to moving services from secondary care into the community. Steps taken by the PCT to strengthen GP engagement include appointing Dr Parson as a senior clinical manager to help lead on negotiations with the trust and organise projects. ‘The PCT has learned that when clinicians have an input in discussions about PBC, their comments seem to have more relevance and resonance,' says Dr Parson.

PBC schemes launched during the past year include a musculoskeletal physiotherapy pilot, which is improving waiting times to access services and has reduced the number of outpatient appointments.

The three PBC clusters in Bromley are looking to develop new care pathways in gynaecology, dermatology and atrial fibrillation. There are plans to set up a clinical executive board to act as a bridge between the clusters and to help roll out care pathways across the PCT.

To boost the number of services being launched in the borough, the PCT has shortened the process by which business plans are approved. GPs are told at an early stage whether in principle their schemes will be approved or not, after which they are required to produce a full business plan. Dr Parson hopes this will lead to a quicker roll-out of services but he would like ‘more resources to help implement and monitor schemes'.

GPs continue to be frustrated with the lack of data about activity at the local acute trust. It is hoped that plans to launch a referral management centre will give clinicians more accurate information. However, Dr Parson stresses clinicians will need some incentive to reduce referrals, as ‘faced with an increasing workload there are already so many competing demands on their time'.

Lewisham – positive despite cuts

With Lewisham PCT constantly looking to cut costs there is not much scope for establishing new PBC services, says Dr Helen Tattersfield, chair of Lewisham Primary Care Federation and chair of the Seven Fields PBC cluster.

‘We are having to make savings and then more savings, so money is really tight,' says Dr Tattersfield.

PBC is in danger of becoming more about ‘saving money than influencing care', Dr Tattersfield feels, and she is concerned these savings are being swallowed up by secondary care.

‘Hospitals seem to be taking more money and it seems to be impossible to control this,' she says.

GPs are concerned about how the development of polysystems will pan out in Lewisham, she says. The borough already has one polyclinic and Dr Tattersfield understands more are planned, along with four polysystems. But practitioners are unclear as to how they will be structured and organised and how PBC will work alongside these systems.

Despite cost savings and uncertainties surrounding primary care development, clinicians are still ‘engaged with PBC', says Dr Tattersfield.

‘GPs are involved in meetings about primary care so they have a voice that they didn't have before. We've now got support workers employed by the PCT to help make things happen, and this year we're expecting to have our own prescribing budget, so we can try to make savings – all of which is very positive,' she says. This positive mood is reflected in the DH PBC survey, where 67% of respondents say they have a ‘great deal or a fair amount' of influence with their PCT.

But Dr Tattersfield believes ‘more autonomy, particularly in terms of how we spend money and more practical support when it comes to, say, setting up provider organisations', would help drive PBC in the borough'.

Sutton and Merton – enthusiasm despite financial difficulties

Financial constraints are hampering PBC development, says Dr Ian Harper, LMC chair of Merton, Sutton and Wandsworth. The six PBC groups in the borough want to set up integrated care organisations (ICOs). But plans are ‘moving forward slowly', Dr Harper says.

‘This is partly because of the financially challenging position we're in, which makes it more difficult for GPs to agree how the risk involved with becoming part of an ICO should be allocated,' he says.

With practitioners already having to make 3.5% savings on community nursing across the borough, Dr Harper is concerned budget restrictions will prevent schemes from being launched and may cause ‘a loss of engagement from GPs'.

Dr Nav Chana, chair of Integrated Primary Care Commissioning in Sutton and Merton and vice-chair of the NAPC, says that with the PCT in financial deficit, clinicians lack the incentive to ‘really get stuck in to redesigning services'.

He says: ‘Compared to last year we're in a position of stalling and stasis.'

But he still feels both the PCT and clinicians are ‘genuinely interested in moving services out of hospital into primary care'.

That enthusiasm is evident in a new pathway for COPD patients, which has led to collaborative working with acute care respiratory physicians across two trusts. Since its launch in January, the service has helped manage complex patients more effectively and resulted in savings on reduced admissions of around £140,000.

A more detailed insight into the population's health needs is still required, he feels. ‘We are still receiving information that is several months out of date so it's hard to get a clear picture of where there are gaps in care. We need to merge the data that exists across local authority partners and health and make sure that information is accurate,' he says.

Greenwich – a slow start, but still keen

Disagreements between GPs about how PBC should work in Greenwich meant it got off to a slow start, says Dr Samir Arora, PBC lead for the Eltham forum. ‘Some thought PBC groups should be made up of a federation of like-minded GPs, while others felt the best way to progress would be to set up groups based on geographical areas,' explains Dr Arora.

A federation PBC model made up of self-appointed clusters was adopted but dissolved last year, partly because of the ‘fundamental split' between how GPs wanted PBC to work in the borough. Now there are five area forums with an appointed PBC lead.

‘GPs and the PCT felt an area-based PBC model made more sense, particularly in terms of service redesign,' says Dr Arora.

As yet, a PBC scheme has not been launched in the borough. ‘The federation collapsed before any plans were made,' says Dr Arora. Since then the PCT has been busy with contract renegotiations and the general election also ‘slowed things down', he says. ‘There's been a feeling of "let's wait and see who comes into power", because policies may change.'

Dr Arora is hopeful that now Greenwich has a PBC structure that suits GPs, it will catch up with other areas and schemes will be launched.

However, he says a ‘lot of work needs to be done' to make this happen because PBC is such an involved and complicated process'.

Work will also need to be done to engage GPs. Dr Arora suggests those involved with PBC should go out to practices to explain its agenda, and that meetings should be held at times convenient for GPs rather than expecting them to take time out from their busy workload.

Despite these challenges, Dr Arora says practitioners are looking forward to being part of ‘the biggest cultural change in healthcare – the notion that healthcare can be done in the community makes sense in the current economic climate. Patients appreciate it and we're looking forward to getting more involved.'

Kathy Oxtoby is a freelance journalist

South London