Kathy Oxtoby returns to look at NHS Yorkshire and the Humber, a year on from when we last took a snapshot of its progress with PBC
PBC continues to flourish in large swathes of NHS Yorkshire and the Humber. But in some smaller areas clinicians say it has yet to make an impact. And across the region GPs report that budget cuts at PCTs are limiting the number of business cases getting off the ground.
In the December 2009 Department of Health survey, some 29% of practices in the region reported that none of their business cases or service redesign plans had been approved compared with a national average of 14%, though in the survey carried out last month these figures had improved to 14% and 12% respectively.
The latest survey also found that 64% of practices within NHS Yorkshire and the Humber rate their relationship with their PCT in terms of PBC as ‘good' – below the national average of 79%.
North Yorkshire – improved GP engagement
Financial problems are still hindering PBC progress in North Yorkshire, says Dr John Letham, chair of York Health Group PBC consortium. But Dr Letham stresses that NHS North Yorkshire and York's financial deficit ‘is not due to any mismanagement or lack of effort on behalf of both the PCT and PBC consortiums'.
As with the rest of the country, he says recent funding difficulties in the NHS ‘are starting to take effect'.
Although funds are limited, he says support for PBC is growing and the PCT is ‘doing its best' to back its development. Steps taken by the PCT to strengthen GP engagement include giving two permanent voting seats to PBC leads on its integrated commissioning executive. This allows PBC leads to play an integral part in making decisions about business cases, and to have an insight into difficulties hampering PBC that can be fed back to colleagues.
Last year, the PCT organised away-days for GP PBC leads and LMC members, which continue to offer an opportunity for the seven consortiums in the area to share best practice, Dr Letham believes. PBC leads also attend monthly link meetings with LMC and PCT representatives, which help to ensure the GP community is kept informed about PBC developments.
Recent PBC successes include a DVT/swollen leg assessment service, which has saved more than 50% of admissions and is fully integrated in the York Hospital A&E department.
A pilot to enhance end-of-life care in the Hambleton and Richmondshire areas is due to start shortly, and there are plans to set
up public-patient participation groups across the PCT to discuss how to modernise and rationalise a care pathway for all long-term conditions to reduce hospital admissions.
‘We want to introduce services that will keep patients well, that are safe but will hopefully cost less too,' says Dr Letham.
West Yorkshire – dealing with financial constraints
Dr Richard Vautrey, deputy chair of the GPC and a GP in Leeds, says his GP colleagues are concerned that PBC in West Yorkshire is not transforming services as fast as they had hoped. Dr Vautrey says: ‘GPs are used to seeing quick results in their working lives so are frustrated by slow progress when it comes to commissioning.'
He says there have been ‘big changes' at the PCT in Leeds with the appointment of a new chief executive and the replacement of the PEC with a commissioning executive that brings together PBC group leaders, clinical leaders and PCT members. Although these moves have ‘taken time to bed down', relationships between the PCT and PBC consortiums remain good, says Dr Vautrey.
However, for PBC to flourish more resources should be shifted from secondary to primary care, he believes. ‘PBC can't be done on a shoestring. It requires a clearly identified financial and management support structure to make it work,' he says.
The effectiveness of the PCT's new commissioning structure and whether it will speed up the launch of new schemes has yet to be tested, says Dr Andy Harris, a GP in Leeds and chair of the Leodis consortium. However, he feels the move is ‘a genuine attempt from the PCT to empower PBC groups and ensure they are involved in the decision-making process'.
Leodis, which includes 27 practices covering around 208,000 patients, has introduced several successful PBC schemes, including a systematic, proactive approach to the care of people living in residential and nursing homes. The service has increased patient satisfaction, reduced admissions and excess bed days, and discussions are under way to introduce a Leeds-wide approach to nursing home care. Other new projects at Leodis include a community dermatology service, and the launch of long- term condition pilots in two practices.
Dr Harris says PBC progress in Leeds is ‘better than in many areas'. However, he believes PBC in general is in limbo because of political uncertainty and financial constraints: ‘There is a lack of clarity over how commissioning will be funded.'
With funding tight in the Bradford and Airedale PCT district, GPs are finding it difficult to engage with PBC, says Dr Akram Khan, chair of the City Care Alliance.
He says the number of new care pathways being developed has fallen ‘dramatically' and there is a perception from GPs that they cannot make substantial savings from PBC. ‘If business cases don't get through the accreditation process and there are not sufficient financial rewards, then GPs aren't going to take that. Practices haven't left PBC groups yet, but there is a danger of that happening,' warns Dr Khan.
Real budgets – a prospect the PCT is considering – would help drive PBC, Dr Khan believes. ‘There are risks, because if we don't get the markers right we could be worse off. But if we spend wisely and achieve savings then we will get the financial rewards.'
South Yorkshire – PBC schemes go city-wide
The scale of PBC influence in Sheffield during the past year has been ‘taken to another level', says Steven Haigh, assistant director of strategy for NHS Sheffield. ‘A few years ago we were focused on local needs but now we are in a position where consortiums are looking at big-impact, citywide schemes'.
The four consortiums in Sheffield, which incorporate virtually all the practices in the area, are looking to collaborate on such health priorities as long-term conditions, COPD, diabetes and unscheduled care – particularly short-stay admissions.
Mr Haigh says consortiums recently signed up to a partnership agreement with the PCT. Clinical leads from each of the consortiums meet formally with the PCT's executive team on a monthly basis to agree commissioning priorities and support their delivery. The agreement has ‘levelled out the playing field' between consortiums and NHS Sheffield in terms of co-commissioning responsibilities, says Mr Haigh. ‘It's a genuine attempt to work together. We are looking to the consortiums to lead as much as we do on our health priority areas.'
A year ago, he says, the PCT was ‘quite risk-averse' to approving new schemes. Now the strategy is to speed up approval of those pilots that have worked well and have the potential to be rolled out citywide.
One pilot focusing on anticipatory care for the over-75s involves designated GPs managing the care of residents in 90 care homes in Sheffield. The scheme has improved continuity of care, reduced secondary care admissions and received positive feedback from residents. Practices across the city are also building ‘risk registers' for over-75s to minimise the risk of secondary care admissions.
Mr Haigh points out that Sheffield PCT is facing budget restrictions. ‘As the flow of cash begins to tighten up, tough decisions will have to be taken that could directly impact on primary care,' he says. But he adds that during these difficult times the PCT is ‘lucky to have a decent cohort of GPs with a passion for PBC'.
From a GP viewpoint, having a partnership agreement that allows clinicians to effectively co-commission services has enhanced relationships with the PCT, says Dr Eithne Cummins, a board member and clinical lead of Hallam and South Consortium (HASC): ‘There is now a mutual understanding of the issues that affect us. This is particularly helpful during a time of financial constraints.'
She believes the citywide approach to rolling out schemes ‘is the right focus in a time of financial crisis'. ‘It makes sense for GPs to work together so we can be as efficient as possible and get the best value from projects. There's a real feeling that we're pulling together to improve healthcare in the city,' she says.
Driving PBC forward will require more than the commitment of enthusiasts, she believes. ‘We need to enlist the support of a new generation to look at how we can manage systematic change in a way that's beneficial to patients and practices.'
East Yorkshire – PBC in limbo
PBC in East Yorkshire is making ‘very slow progress', according to Dr Russell Walshaw, chief executive of East Yorkshire LMC. The new chief executive of NHS East Riding of Yorkshire – appointed last year following a major restructuring of the PCT – is ‘enthusiastic about PBC', Dr Walshaw says. But practices are ‘less keen'.
With savings made on existing schemes being used to ‘tackle deficits within the PCT patch', there is little incentive for GPs to present new business cases to the trust, he suggests.
There is also a certain amount of ‘inertia' surrounding PBC because of the general election, he adds. ‘I'm certain PBC will still exist. It may be under a different arrangement – one that's more robust and positive – or it may even change direction. But at the moment it's hard to know what will happen as we're working in limbo.'
North Lincolnshire – patchy performance
PBC in Lincolnshire was slow to get off the ground, mainly because consortiums did not enjoy the ‘best of relationships' with the PCT, says Dr Walshaw, who is also chief executive of North Lincolnshire LMC.
Although that relationship has improved over the past year, PBC has yet to make a real impact on patient care in the area. Some practices have signed up to consortiums but others prefer to remain separate, says Dr Walshaw. ‘It's disjointed and patchy. And as yet, the PBC model hasn't delivered many projects,' he says.
One of the main difficulties preventing PBC from thriving is that practices are not given enough support to commission services. ‘Practices are expected to deliver so many targets. There just aren't enough people around to commission services.'
To boost PBC, he says practices need more support to deliver schemes and real budgets to target healthcare areas that GPs, not the PCT, believe should be prioritised. ‘If you don't have your hands on the money you can't direct it to where it needs to be used.'
Kathy Oxtoby is a freelance journalist
View from the boardroom
Over the past year, Yorkshire and Humber SHA has been working with PCTs to deliver the quality, innovation, productivity and prevention (QIPP) initiative. ‘We've done a lot of work around demand management and referral management, particularly in areas where there are bigger acute trusts,' says Erica Goodall, PBC lead for Yorkshire and Humber SHA.
Although recent months have seen ‘less activity' around new business cases, Ms Goodall has seen some ‘excellent' PBC schemes that fit with the QIPP agenda, including projects to enhance primary medical services for care home residents.
To progress PBC, Ms Goodall believes it is crucial to engage practices. A number of PCTs have been offering programmes designed to build clinical leadership and encourage GP engagement. And 12 out of the 14 PCTs in the region either have an agreement with their PBC consortiums or practices, or are developing one. Such measures have helped strengthen relationships between PCTs and PBC groups in many areas, says Ms Goodall.
Yorkshire and Humber SHA West Yorkshire North Yorkshire South Yorkshire East Yorkshire North Lincolnshire SHA graphs
The SHA is also developing sub-regional networks and plans to run a series of conference calls with clinical leaders in these areas. Ms Goodall hopes the process will allow GPs to share the challenges they face and how they can be overcome.