Dr Ethie Kong explains how 69 practices in her area set up a federation and are now driving forward a revamp of patient services
Brent is one of the few areas where practice-based commissioning has been able to engage local GPs in a real way. In recognition of this, in 2009 Brent became the first PCT to go live with Department of Health investment in the PBC Development Framework.
But for all this, at times, it has been difficult to engage with the PCT on PBC. GPs in our area recognise there is a limit to the influence PBC groups can have.
Each of our groups covers 54,000 to 83,000 patients, and serves local needs well, but it can be difficult to have a cohesive voice on commissioning issues that need a borough-wide approach.
It was this realisation that prompted us to consider setting up a federation, linking the five existing PCT hubs. We wanted to influence commissioning decisions from the bottom up and to shift them to a place where they can be driven and delivered by clinicians from all specialties within primary care, not exclusively GPs.
How we persuaded the PCT
Discussions ensued between the PBC groups and NHS managers. The PCT saw how our PBC groups operate, with some more advanced than others, but we had to persuade them that the federation would be more than the sum of its parts.
We explained that the federation would enable us to work together and would support clinician-led commissioning (a key goal of the DH) and ultimately have a beneficial effect on the health of patients.
It was a hard sell, but we persuaded the PCT to give us support. The Brent GP Federation came together in early 2008.
How it works
There are 69 practices signed up to five PBC groups. Each group has its own board, which meets monthly and functions separately, with its own governance structure. The federation board is supported by a PCT administrator, employed by the PCT, and board members are generally paid from funds raised through achievements under the PBC incentive scheme.
Each PBC group sends two representatives to form the federation council. They are funded by the PCT under a similar arrangement to the PEC. With representation from the PCT, the council forms the federation executive, a decision-making committee chaired by the director of primary care commissioning.
We have a rotating chair so all five groups are equally represented and the federation leads each have their area of expertise. Their responsibilities extend across all acute and mental health trusts and community services, as well as systems, budgets and governance.
The federation council and executive both meet monthly to discuss cluster or group progress on their commissioning plans and update members on their activities. These meetings cover progress on pathways, referrals based on peer reviews, prescribing and identifying potential areas for partnership working.
The LMC chair is an observer member of the federation. This way, the LMC can make comments and be consulted directly if there is any GP contractual business.
We are looking at giving the federation a legal constitution in the future – possibly along the lines of a social enterprise.
What has changed
Five groups coming together to form a federation council can be intimidating. We have had to overcome long-established ways of working and recognise our strengths and weaknesses as well as those of others.
Prior to the formation of the federation, PBC groups in each locality worked in isolation and were not fully exposed to other groups’ progress. As a full-time GP with extra commissioning responsibilities, my workload was enormous.
The federation structure allows us the flexibility to be locality-specific and autonomous when appropriate, but also to come together as a federation of clinical commissioners, sharing expertise, skills and resources. This frees up our time and reduces the cost of commissioning. We can also negotiate with the PCT more effectively and with the providers in unison – preventing differential treatment, which can be destabilising and inequitable.
For example, federation leads have formed a subgroup that will oversee the implementation of the Transforming Care programme, which is charged with helping to identify and deliver the planned transfer of service provision from secondary to primary care. This change is crucial if NHS Brent is to achieve financial stability in the future, but its implementation will only be possible if appropriate training and investment is transferred to primary care and there is the willingness to change current practice. This is a key focus of the federation subgroup.
The federation has developed ENT and gastroenterology pathways to be used across the borough and shifted some diagnostics nearer to patients’ homes.
When commissioning objectives are shared, PBC groups join forces. For example, two groups have been approved to run two pathway redesign pilots for gynaecology and ophthalmology.
One group is using training and education on musculoskeletal conditions to upskill primary care clinicians and has demonstrated a reduction in referrals to trauma and orthopaedic outpatients. Its experience has been rolled out to the other four groups.
With close working of the federation and the PCT’s prescribing advisory team, we have so far been successful year on year at containing the costs of prescribing without compromising patient care.
We are all aware of minimal growth in the NHS budget, with PCTs instructed to maintain financial balance and make savings or cuts. This means we have a tough time ahead of us and the future of the federation is uncertain.
We recognise we need to work smarter within the limited resources and workforce, to be more effective clinical leaders, but even with some good clinical engagement and involvement through PBC and the PEC, realistically, there has been minimal transformational change.
In London there is a move towards polysystem structures, but for this to be clinically led we need GPs in partnership with all primary care services to drive and deliver the agenda, taking PBC to a higher level and managing hard budgets.
We are currently working with the PEC, to define the number and size of polysystems we need and to establish a new clinical cabinet, which will be the guiding umbrella across the polysystems. This will be another major change, merging PEC and PBC leaders, but we are optimistic we can continue to lead from the front in delivering better care for our population.
Dr Etheldreda Kong is PBC clinical lead for the Harness GP Co-Operative, one of the five PBC groups in Brent Federation, NHS Brent
Dr Etheldreda Kong is PBC clinical lead for the Harness GP Co-Operative, one of the five PBC groups in Brent Federation, NHS Brent Resources
• Brent Federation, www.brentfed.nhs.uk
• Primary Care Federations. Putting patients first, August 2008. www.rcgp.org.uk and search for ‘federations’