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The single practice pathfinder

In this series, we check in with pathfinders around the country to see what makes them special. This month, we meet Whitstable Practice pathfinder chair, Dr John Ribchester.

Someone very clever once said: ‘Whatever size you are – it's the wrong size for something.' Our pathfinder is a single practice – 18 GP partners plus one salaried doctor – based in three surgeries covering 92% of Whitstable in east Kent. Part of the practice is based in a new medical centre with outpatient clinics, diagnostics, a day-surgery suite and minor injuries unit with X-ray, so our set-up is quite unusual.

We believe our provider services, currently commissioned via a range of PCT contracts, will play a big part in our success as a pathfinder. But the pathfinder can only really work as part of the federated model we have here in east Kent, which currently includes nine consortia. Each group has its own shadow clinical accountable officer, funded for one day a week.

Our practice is working with C4 – the Canterbury and Coastal Commissioning Consortium – another second-wave pathfinder. The Health and Social Care Bill says each consortium needs to include a minimum of two practices and it is likely that we will merge with C4 at some point.

Outside help

The federation has already had some consultancy help in to develop the model. We will need to draw up a risk-sharing agreement for the federation and might need some help with that too. The federation is developing a commissioning support unit and its structure may involve integrating a number of different providers for different functions.

The reforms turn everything upside down because now it will be clinicians who get to prioritise and redesign, whereas previously we've had to go cap in hand to the PCT for approval of what we wanted to do.

Provider model

Our day surgery and minor injury services are provided from the Estuary View Medical Centre, which is innovative in both its design and what it accommodates – a range of outpatients clinics, diagnostics including X-ray, ultrasound and echocardiography, a day-surgery suite, a medical injuries unit, community pharmacy, ambulance response base, physio tenant, and out-of-hours telephone advice and IT centre.

The GP area is the only part notionally rented – the rest is on a conventional mortgage, so it is quite a commitment. Many practices in C4 provide care such as ENT and ophthalmic clinics and we would hope that there will be some cross-pollenisation and cross-referral. We've been getting mixed messages about our provider status ever since the white paper came out, suggesting consortia won't be allowed to provide care.

When Andrew Lansley visited us last year, he said there would be no problem and that Monitor would hold the ring for probity. But then other Department of Health sources suggested it wouldn't be allowed to happen. We're now waiting to hear from the DH as to whether we'll have to change anything to fit in as a provider in the new world. It would make things difficult for us if we had to form a separate provider organisation, particularly as the majority of staff work across both ‘sides'.


NHS Eastern and Coastal Kent is challenged to reach financial balance this year, so the task for the next 12 months is how to make extra savings. All the emerging consortia have written their QIPP plans – amounting to a plan for the whole of east Kent each with a financial figure attached.

The QIPP programme for our practice has a target of about £2m savings and will involve contract changes with the main provider. Some initiatives are PCT-wide. Our own schemes are within our Whitstable integrated health and social care integrated care pilot – it's not one of the DH ones. Four workstreams have been identified:

• Long-term condition management: COPD, cardiac, diabetes and mental healthcare

• Urgent care: our minor injury unit is open 12 hours a day, 365 days a year with X-ray for those hours and we're looking for savings of more than £300,000 on that. It's also an ambulance response base

• Elective care: We have a range of clinics using both visiting consultants and GPSIs – our practice has seven GPSIs doing day surgery, endoscopy and dermatology.

• Diagnostics: X-ray, ultrasound and echo-cardiography as well as visiting MRI/CT to be provided on our own or with partners.


Achieving financial balance and truly integrated community healthcare for the area are the main challenges ahead. In three years' time, success will be defined as better healthcare, a better patient experience, care closer to home and better job satisfaction, for both clinical and support staff.

Dr John Ribchester: 'Our provider services will play a big part in our success as a pathfinder' Dr John Ribchester: 'Our provider services will play a big part in our success as a pathfinder' Pathfinder: Whitstable practice

Wave: Second
Practices: One
Structure: Single practice but part of a federation of nine consortia. Provides services including outpatients and day surgery
Population: 32,000
PCT: NHS Eastern and Coastal Kent, now clustering with NHS West Kent and NHS Medway
Hospital: East Kent University Hospitals NHS Foundation Trust
Geography: East Kent is a peninsula. Whitstable is one of the larger urban communities on the coastal fringes
Disease rates: The main causes of illness are hypertension, asthma, diabetes and coronary heart disease. Prevalence is slightly higher in Eastern and Coastal than in West Kent. Hypertension is the most common of these treated within primary care. In Eastern and Coastal Kent, 13% of the population suffers from hypertension – about average for England and Wales. Mental illness is also a key issue and cause of admission in Kent