West Midlands revisited

Kathy Oxtoby takes a look at how PBC is faring in this part of the country

West Midlands SHA rates favourably in the latest Department of Health PBC survey. Some 83% of PBC leads say their relationship with the PCT is good, just above the national average of 82%. And 61% rate the quality of management support as good – above the national response of 57%. But experiences across the counties continue to vary widely, with some GPs saying PBC has stalled because of budget cuts and poor PCT support.

Staffordshire – moving towards one voice

Plans are under way to change the model of PBC to boost collaboration between GPs. Dr David Hughes, LMC chair for Staffordshire and chair of Leek and Warrington PBC, says that while the model of five clusters ‘worked well', the amount of useful collaboration between GPs was variable and there was ‘a feeling that potentially our model of five clusters was not ideal'.

Having looked at other PBC management structures, it was decided that the best model would be one large, well organised body with ‘a single board and a single focus,' says Dr Hughes.

Introducing ‘doctor champions' to develop care pathways for different clinical areas, such as stroke, diabetes and oncology, has worked well, but now commissioners are dealing with PCT financial constraints. Dr Hughes says: ‘These constraints have not allowed us to do the long-term conditions work we envisaged.'

Getting the necessary data from PCTs to set up services has improved now there is a dedicated person in to provide information to PBC clusters. ‘We are using those details to scrutinise what is happening to patients to enhance care and we are seeing some improvement in terms of having access to regular information about services,' says Dr Hughes.

Lack of involvement in public health procurement, such as smoking cessation services, remains a concern, but Dr Hughes says the PCT has been made aware of this issue and is ‘now listening'.

Dr Hughes believes it is vital to make PBC relevant to all GP surgeries. ‘We have to find ways of involving all practices, not just those where GPs are enthusiastic. Hopefully the new model will inspire all practices to get heavily involved in PBC.'

Herefordshire – working to formalise PBC projects

Keeping the momentum going for PBC in Herefordshire has been a ‘struggle', says Dr Andrew Watts, GP chair of the PBC group in Herefordshire.

‘The PCT has not been obstructive, but mainstreaming successful projects has been slow. Instead of giving a long-term commitment to schemes, the PCT has kept them running as pilots, explains Dr Watts.

He gives the example of a scheme where GPs have been working with nursing homes on a structured approach to end-of-life care. He says this has improved the quality of medical care considerably as well as reducing admissions.

‘It's a great project which should be formally adopted, but getting it commissioned in the PCT's framework has proved difficult and this is true for most of our schemes.'

One pilot the group hopes will be adopted across the PCT is a practice-based musculoskeletal clinic, which has led to an 83% reduction in hospital referrals.

To ensure more schemes are formalised, the group – which is made up of 24 practices covering 180,000 patients – has been establishing an accountability agreement with the PCT. This sets out an agreed set of criteria for what constitutes a successful pilot, and if the project is adopted by the PCT it should then become part of the mainstream commissioning process.

Another challenge has been that Herefordshire is trying to combine as a single provider. ‘The PCT, hospitals and social services are looking at how to come together as one unit and are carrying out major clinical redesign in such areas as diabetes. This means the PBC group needs to focus on what it can do to contribute to that process,' says Dr Watts.

To drive PBC forward, he says the group wants to work more closely with not only primary care clinicians, but also hospital consultants, nurses and therapy workers. ‘In this way we hope to develop a network that allows the clinical voice to be heard. We can achieve so much more if we work with other healthcare colleagues,' says Dr Watts.

Shropshire – PBC progress halted

Little progress has been made with PBC in Shropshire in the past year, and GP members of the area's five locality commissioning groups are disillusioned, says Dr Mary McCarthy, the county's LMC chair and a GP in Shrewsbury.

With the PCT ‘financially constrained' and budgets tight, PBC groups have been unable to get new projects off the ground, while freed-up resources (FURs) ‘seem to disappear into a black hole', she says. ‘We seem to be treading water with PBC,' says Dr McCarthy.

Dr McCarthy thinks it unlikely that a change of government would boost PBC.

She believes the NHS should be ‘taken out of government hands so that targets don't change every few years. They should be driven by the healthcare needs of the population rather than political need'.

West Midlands Metropolitan County – improved collaboration

PBC is making headway in South Birmingham now more practices are working together

to drive forward projects, says Dr Ajay Singal, vice-chair for Hall Green Health PBC cluster.

‘Smaller surgeries have realised they aren't going to make the service changes they want unless they join with others.'

Ophthalmology, dermatology and cellulitis are just some of the schemes bringing care closer to home in South Birmingham, and there are also plans to improve access to acute services. Dr Singal says all these projects will need to be reviewed ‘mainly to look at their value to patients, but also to see whether they're value for money'.

Recognising the need for greater clinical input from GPs, South Birmingham PCT has set up a commissioning board of directors, locality leads and PEC board members. This acts as a decision-making body for the trust.

However, a lack of clinical involvement in PBC remains a frustration, says Dr Singal. ‘We need buy-in from clinicians otherwise we won't get very far.'

Breaking down barriers between secondary and primary care and working with professional bodies will boost PBC, he believes. ‘This is happening but slowly. The different professional groups need to stop competing and to trust each other more.'

GPs in Coventry feel their PCT is now giving them more support with PBC, says Dr Manoj Pai, a member of the Gables PBC group and the city's LMC chair.

‘Things have definitely got better and the SHA has encouraged the trust to do more with PBC,' says Dr Pai. As part of this drive, the PCT has recruited staff to analyse the data required to help PBC groups set up services in the community.

Another sign of support for PBC is that during the past year more practices have joined the Gables PBC group, swelling its patient population from 36,000 to 52,000.

However, Dr Pai says that PBC has yet to make a difference to healthcare. The Godiva PBC group, which has 40 practices with 150,000 patients, has set up an orthopaedics service closer to home, and the Gables group is establishing a similar scheme. ‘But other than that we don't have much to show from PBC in Coventry,' says Dr Pai.

The problem, he believes, is that ‘instead of giving PBC real teeth the Government has given it administrative impediments'.

‘The PCT wants to see results before it will say yes to a project. But to make a difference we need to be able to get on with these schemes.'

Whatever the outcome of the general election, Wolverhampton's LMC chair Dr Satya Sharma says PBC is ‘here to stay and is crucial for the future of the NHS'.

Recently the PCT carried out a think-tank exercise with the area's PBC leads about ways to improve support for PBC and now group meetings are attended by a trust director. But Dr Sharma says their presence has had little impact on how PBC runs in Wolverhampton. ‘There's been a lot of talking but we haven't seen any positive outcomes. The PCT needs a year or so for practices to get more involved.'

Dr Sharma says there have been few new schemes over the past year, but the three locality groups have jointly enhanced existing services. They pressed the PCT to employ more physiotherapists. ‘Patients were waiting up to 24 weeks. Now it's four weeks, which is tremendous.'

Despite lobbying the PCT to give GPs access to FURs, the PCT still holds the purse strings, says Dr Sharma. ‘Last November we were told the money would be available, if projects would lead to recurrent savings over several years. But we would have only a few months to come up with schemes with demonstrable savings. This was impossible, as schemes need six months to a year to prove their value,' he explains.

For PBC to make a difference, such restrictions must be lifted, he believes. He would also like to see the PCT involved and giving real power to GPs.

Warwickshire – PBC stalled

Financial difficulties have stalled PBC, says Dr Andrew Kennedy, LMC secretary and a GP in Warwick. ‘The PCT has an overspend of around £26m,' he says, so ‘rather than looking at innovative ideas, it has had to look at what it can stop doing.'

Although the county's five main PBC groups have set up innovative schemes, such as musculoskeletal assessment and triage and community warfarin monitoring, Dr Kennedy says these are under review. ‘The PCT will look at how useful these schemes have been and whether there are more cost-effective ways of delivering such services.'

Internal restructuring at the PCT during the past 12 months, which included the appointment of a director of primary care, indicates that the focus could be on bringing services into the community, ‘but that change is not likely to be instant', he predicts.

Kathy Oxtoby is a freelance journalist

View from the SHA Boardroom

Patricia Barnett, programme consultant for primary care and PBC for NHS West Midlands, says PCTs and PBC groups are focused on reinvigorating PBC locally and strengthening the role of clinicians.

Ms Barnett believes there is an ‘encouraging trend' of PBC groups and individuals reporting that they are receiving the support they need, and that they are having a greater influence on commissioning and strategic planning.

Each PCT and PBC group has jointly developed a reinvigoration plan and many are developing compacts. ‘These explore the contribution PBC can make, as well as the culture, vision and behaviours needed to transform patient care and embrace the quality and productivity challenge facing the NHS as a whole,' says Ms Barnett.

However, in common with the rest of the country, there are some areas where PBC needs to improve, she says. To support PBC groups, the SHA is encouraging the sharing of good practice and networking at both PCT and PBC levels. It has developed a clinical champions programme, to enable PBC clinicians to ‘promote good practice locally, ensure PBC commissioning plans are aligned with Darzi clinical pathways, and to be more effective at influencing and leading change'.

More must be done for PBC groups to encourage innovation and ensure greater autonomy, Ms Barnett says. But she stresses: ‘With this goes stronger accountability for improvement outcomes and cost effectiveness, which need to be evident across the whole system.'