Working in a polysystem

Are 'polysystems' just the latest PCT wheeze or can they revolutionise care? Dr Sarah Heyes, a GP in east London who works in one of the UK's first polysystems, describes how the scheme works for her

What is a polysystem?

More ambitious than the RCGP's idea of practices working closer together in federations, polysystems are designed to allow GPs and other care professionals to take control of a commissioning budget for their local population.

GPs have the power to design and deliver services that improve health outcomes as well as patient experience, including everything from completely redesigning care pathways to simpler and more practical measures, such as introducing a local blood-testing service.

Our systems in Redbridge, east London, are not physical structures – like polyclinics – but networks of healthcare professionals. We aim to create a seamless level of care where patients are treated for the majority of their needs closer to home by working closely with our colleagues in community services, pharmacies and hospitals.

How did you set the polysystems up?

We set up the polysystems in 2009 after a year of intense negotiation between the PCT and other health professionals.

The borough's three practice-based commissioning clusters consisting of 51 surgeries were then replaced by five neighbourhood-based polysystems.

The five polysystems include 50 GP practices, 40 pharmacists, 300 primary care professionals, two hospitals, a mental health trust and range of community and voluntary sector providers.

Each polysystem has a local GP acting as clinical director. The clinical directors chair a board of healthcare practitioners responsible for the health and wellbeing of their 50,000-strong communities.

The clinical directors, in turn, sit on a clinical commissioning board with PCT representatives who monitor performance and help deliver the local commissioning plan. This ensures there is an integrated approach to commissioning.

NHS Redbridge provides each polysystem with management support on business aspects such as commissioning and governance.

We have five senior officers who work full-time alongside clinical directors providing business support and advice on a range of issues including commissioning, performance and evaluation.

What is your role?

I am clinical director of the Wanstead polysystem, which includes 14 GP practices.

We meet once a month to discuss what needs to be done and see how each practice is performing against pre-agreed targets.

It is still developing and is lot of hard work, but I see my job as the link between GPs and the PCT. Both sides have skills to bring to the table and it is important we have a good working relationship.

Previous interaction with the PCT could be one-sided, which left many GPs initially sceptical about commissioning and how much influence we'd have. But polysystems have been a big step forward here and have huge potential to really improve outcomes.

What targets have you been set?

We have been charged with improving clinical outcomes and, at the same time, saving £3m by reducing first-time outpatient appointments and redesigning care pathways, starting with heart disease.

We also have responsibility for improving data gathering, GP referrals to the local independent sector treatment centre and the use of low-cost generic drugs.

The trust has already begun a phased handover of its commissioning function worth more than £400m a year and the polysystems are expected to be actively involved in 80% of the decision-making process by April 2010.

What differences have you seen since the polysystem was set up?

One of our first challenges is to reduce the number of first-time outpatient referrals and inappropriate use of A&E.

There has been a 36% rise in referrals across Redbridge in the past three years with huge variations in rates between practices, and an estimated 60% of A&E admissions could be handled elsewhere.

The polysystems collectively aim to reduce unnecessary first-time referrals and make a £3m saving across the borough.

This is a great opportunity to put our heads together and share what does and doesn't work. For example, the surgery I work at already has a low first-time referral rate because we club together to find an in-house solution or ring a consultant for advice before even considering a referral.

Fortunately, we have a manageable number of patients that attend A&E. We have attempted to reduce this by reviewing the information sent from the hospital and where appropriate making contact with the patient asking why they chose to go to A&E.

It's about educating patients on the alternatives and highlighting the fact that primary care can often offer, through GP access, a faster, more appropriate service.

Does everyone support the polysystem?

This approach has been surprisingly well received because it is non-confrontational. In fact, patients often welcome the extra attention and care they feel they receive.

Small but practical steps can make a big difference. Working smarter can save a lot of waste and the more we save, the more money comes back into the polysystem.

The recession has also had a positive effect in that it has given people a sense of urgency and focus to get things done.

How will the polysystem develop in the future?

We will eventually be responsible for commissioning local services and meeting statutory health targets set by NHS Redbridge and the Department of Health.

Each polysystem will have its own polyclinic that will offer a broad range of services under one roof. This will be linked using a ‘hub and spoke' model to local surgeries, pharmacies and hospitals, which can make use of its facilities, ensuring patients can be treated for the majority of their conditions in the community.

Loxford is the first polysystem to have its own polyclinic. This opens seven days a week and offers more than 20 services in one location including GPs, a pharmacy and hospital outpatient appointments.

We are also rolling out software to help us analyse our health outcomes and to design specific clinical interventions that will improve care. The program – called ‘Health Analytics' – allows us to integrate data from acute, GP and community providers and monitor the cost-effectiveness of care pathways across various providers for the first time.

We also are looking at giving patients a strong voice about how healthcare needs are addressed in their area, with the development of community panels. Our group of local residents meet on a monthly basis to make suggestions and provide feedback about the polyclinic and similar panels are being set up in the remaining four polysystems.

This is the first time GPs have been given the financial clout to make things happen and I'm optimistic about the future.

Dr Sarah Heyes is clinical director of the Wanstead polysystem in east London.