Polysystems launched in NE London

Posted on January 4, 2010. Filed under: News stories, Polyclinics | Tags: , |

Nursing in Practice | Press Association | 4 January 2010

North-east London GPs are to get the power to decide how and where healthcare budgets will be spent, as a primary care trust becomes the first in the country to hand over its commissioning function.

NHS Redbridge has disbanded its three practice-based commissioning clusters and replaced them with five polysystems to represent the interests of the borough’s 51 general practices.

In a move that could eventually give family doctors control of a £400m budget, the new polysystems are designed around a “hub and spoke” model, with each covering a distinct geographical area.

At the “hub” is a multipurpose polyclinic, which will offer a range of services, including outpatients and diagnostics, surrounded by local hospitals, pharmacies and surgeries to make up the “spokes”.

Each polysystem is run by a board of local GPs, who may be given responsibilities to commission services and meet targets from the Department of Health and NHS Redbridge.

Local GP Narinder Sharma, Clinical Director for Loxford Polysystem, said: “Health needs vary from area to area and being able to focus the appropriate resources on specific areas as well as anticipate future health trends is a great step forward.”

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Pay GPs and hospital specialists to work together on PBC, says NHS Alliance

Posted on November 25, 2009. Filed under: News stories | Tags: |

Pulse | Tom Ireland | 25 November 2009

Incentivised partnerships between GPs and hospital specialists could kick-start practice-based commissioning, according to the NHS Alliance.

 

A report suggests that PBC has become unfit for purpose in its present form

A joint report by the NHS Alliance and think-tank The Nuffield Trust says radical solutions are needed to ‘nudge clinically-led commissioning into life.’ 

Beyond PBC proposes multi-specialty groups of clinicians take responsibility for designing health services.

These ‘local clinical partnerships’ (LCPs) should be given population-based budgets covering at least 100,000 people, the reports says. It also suggests adding incentives into to GMS and PMS contracts to get GPs to join an LCP.

PBC has become ‘unfit for purpose in its present form,’ the report suggests.

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GP spending role debated

Posted on November 25, 2009. Filed under: Journals | Tags: |

Health Service Journal | By Steve Ford | 25 November 2009

Practice based commissioning should be replaced by consortia with “real” budgets but comprising clinicians from both primary and secondary care, according to a think tank report.

The Nuffield Trust and the NHS Alliance this week called on the government to consider “radical alternatives” to GP commissioning to engage frontline clinicians in service design.

While the Conservatives have said they will give GPs“real budgets” to incentivise commissioning, the Nuffield Trust and NHS Alliance have suggested a more major shake-up is needed.

Their joint report Beyond Practice-Based Commissioning: the local clinical partnership calls for new organisations made up of groups of clinicians based in hospitals and in the community. These would be known as local clinical partnerships and would typically be led by a GP but with the active involvement of specialists, nurses and pharmacists.

The two organisations based their conclusions on workshops with clinicians, managers, academics and other stakeholders.

The report said: “With PBC apparently unfit for purpose in its present form, and [primary care trust] commissioning frequently cautious and tentative, further thought is urgently needed as to how to boost commissioning, and specifically how to nudge or evolve clinically led commissioning into life.”

Nuffield Trust head of policy and report lead author Judith Smith said: “If clinicians are going to play a key role in designing and changing services during this uncertain period radical action will be necessary.

“PBC has shown patches of promise but we need a more far reaching alternative that re-engages GPs and other clinicians in this agenda. We believe groups of clinicians working together in local clinical partnerships could not only revitalise local commissioning but also improve the quality of care patients receive and potentially save the NHS money at this critical time.”

PCT Network director David Stout said: “We welcome the emphasis in this report on local clinical leadership and better integration across historical primary and secondary divides.”

But he added that “further discussion and testing” was needed on the significant practical and policy changes needed to implement the local clinical partnership model.

The Commons health committee is carrying out an inquiry into commissioning, including practice based commissioning, which held its first oral evidence session last month.

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DoH urges GPs to rebel against PCTs over PBC

Posted on November 20, 2009. Filed under: News stories | Tags: |

Healthcare Republic | Neil Durham | 20 November 2009

Practices should ‘rebel’ against unhelpful PCTs on practice-based commissioning (PBC), according to the DoH.

Dr Chris Grant, a Cambridgeshire GP and former professional executive committee chairman, told the National Association of Primary Careannual conference in Birmingham on Tuesday that PBC was ‘almost impossible’ for his practice.

‘We’re right on the edges of a big PCT and know that it’s only interested in really pushing us into using its secondary care provider services. Our patients want to go to a more convenient secondary care provider,’ added Dr Grant.

Gary Belfield, the DoH’s acting director general of commissioning, said: ‘Where PCTs are trying to corral PBC, forcing you to work together in an alliance which doesn’t work, I think you should rebel.

‘Patient choice is key. I would rebel against your PCT. There needs to be some disruption in the system to get some change coming through. I would rebel against what’s happening in your area.’

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GPs hope for share of £1.4bn as managers under threat

Posted on November 19, 2009. Filed under: News stories | Tags: , |

Healthcare Republic | Neil Durham | 19 November 2009

GPs are hoping for a share of the £1.4bn running costs of strategic health authorities (SHAs) and PCTs if they are slimmed down.

NHS chief executive David Nicholson signalled that the future of SHAs and PCTs was under review when he questioned their value at the annual meeting of the National Association of Primary Care (NAPC) in Birmingham on Wednesday.

GPs looking for incentives to make real their plans for community health collaboratives of ‘foundation practices‘ holding real budgets were heartened by Mr Nicholson’s speech.

Mr Nicholson said: ‘We spend £1.4bn on SHAs and the running costs of PCTs. Can we genuinely say that money is spent to the best effect?

‘Can some of it be spent much better? Can we organise ourselves much better? The answer is undoubtedly yes. These are the issues we need to tackle.’

He described the £20bn savings that would need to be found 2011 to 2014 as a ‘massive challenge’. He welcomed the emphasis of the Darzi review on quality.

He said: ‘It’s perfectly possible to improve quality and reduce costs simultaneously.’

Mr Nicholson described primary care as ‘critical’ to this goal because it was at the ‘heart of solutions’.

He said a transformation of community services was key and that plans ‘to give it a real sense of direction and pace’ would become public at the end of this year

Mr Nicholson added: ‘The potential of commissioning is enormous but now it needs ambition and drive to make it a reality. I welcome the NAPC manifesto. We need to make sure that we have a real system that can bring people from dependence on their PCTs to one where they have some independence from PCTs and more power to invest money in the way you want. That has to be earned.’

Key was enabling PCTs to give away power to clinicians on the frontline who were the only ones who could truly make a difference to patient care.

Afterwards Dr James Kingsland, NAPC president, said: ‘£1.4bn? We could do something with that.’

Dr Kingsland expects a greater emphasis on practice-based commissioning (PBC) in the NHS operating framework to be published early next month

Dr Peter Smith, NAPC vice president, said: ‘I would like to see more management devolved down to practice level to start doing PBC effectively, so our managers are working for primary care rather than seeking to control it.’

He described it as more than incentivising community health collaboratives. ‘We need a lot of good information at primary care-level it just isn’t there. We need to start putting resources into accurate activity information.’

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Labour backs real budgets to revitalise PBC

Posted on November 18, 2009. Filed under: News stories | Tags: , , |

Healthcare Republic | By Neil Durham | 18 November 2009

An idea to revitalise practice-based commissioning (PBC) by allowing groups of practices to hold real budgets has been welcomed by England’s health minister Mike O’Brien.

Speaking at the annual National Association of Primary Care (NAPC) conference in Birmingham on Tuesday Mr O’Brien broadly welcomed the group’s manifesto.

It says that PBC success has been limited and that urgent action is needed.

The 14-page document suggests local practices should form community health collaboratives (CHCs), which would be given real budgets.

The patient voice would be heard in the design of services and also how the health dividend, or freed-up resources, is spent.

PCTs would set headline commissioning outcomes for a population and agree contracts with CHCs.

Once practices have delivered the appropriate quality of primary care services they would qualify to become ‘foundation practices’.

Management resources would transfer from PCTs to develop CHCs.

Mr O’Brien said: ‘Foundation practices would have much greater independence to run budgets. I welcome these ideas. I think the NAPC is bringing forward interesting proposals. The government wants to look at this with great care.’

In a speech that was far more party political than his address to the RCGP conference in Glasgow earlier this month, Mr O’Brien sought to outline the differences between Labour and Conservative party policy on the NHS.

Mr O’Brien explained that smaller practices would not be forced into CHCs or to become foundation practices.

He said: ‘Some smaller practices could be broken if forced to manage budgets. Practices would have the choice rather than forcing them as some would do.’

Once again the theme of Mr O’Brien’s speech was that improved quality would result in savings, so important as the NHS has identified that £20 billion must be found to maintain services between 2011 and 2014.

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PBC innovation through creating a new company

Posted on November 17, 2009. Filed under: Commissioner, News stories | Tags: , , , , |

Pulse | Focus on…..Social Enterprise | 17 November 2009

Dr David Morris and Dee Kyne explain how they remortgaged their practice to kick-start the process of PBC innovation in their area

When I came into general practice in 2000, I found it immensely frustrating that patients would come back time and time again with the same problems. Faced with a 20-month wait before they can do anything for them, their GP can feel powerless. And so we began to look for a way to have more control and to find a better, more efficient and more rewarding way of working.

Accessing the right person in the health service is difficult at the moment and often requires several steps. We wanted to create a service that would ensure efficient and streamlined access to the right person at the right time in the right place, and would take the surgery to the patients – rather than the patient having to come to us.

All change needs a driving force and models of successful innovation, but few are willing to take the necessary risks. PCTs tend to be risk averse as their priority is to make the finances balance. GPs often feel they should be insulated from risk and PBC clusters are often defined by geography rather than attitude to risk and willingness to innovate. The other 22 practices in our PBC cluster weren’t ready to take the next step. So we took it alone.

Setting up the social enterprise

We decided the best model to adopt would be a social enterprise so we could take the risks necessary for successful innovation, which others could then follow.

In 2006 we decided to establish a community interest company, which we called Pathfinder Healthcare Developments (PHD). We decided on this approach so that we could access funds and prove we had a strong governance framework. We reinvest our profits and assets for the public good. The idea was initiated by Dr Niti Pall, a partner in our practice and PEC chair at the time, and took about a year to develop. The company started in 2007, then took around nine months to really take off. The company is now owned by the practice along with business development director Dee Kyne, who was brought in to set up the social enterprise. The company was initially run separately from the practice. It now covers three practices.

The 11 partners invested £34,000 of their own money (about £3,000 each) to start the company and support initial staff salaries. As the company has grown, it has been able to pay the current 12 staff salaries out of its turnover.

A further investment to fund redesign of our primary care services came in a £200,000 loan from the Big Issue Invest – a fund that invests in groundbreaking social enterprise. We were its first health investment. The partners took the risk of underwriting the loan by remortgaging the practice premises.

PCT involvement

At this stage, our PCT, Sandwell, had not invested in the company. We started on a programme of redesigning our services using the £200,000, focusing on preventive care and early intervention, which is where we will eventually make the most significant savings.

Once the PCT could see what we were doing, it came on board and in various ways has invested around £400,000 of its own money. It has paid for us to run the community aspect of its CVD programme and contributed to the risk stratification analysis (see right) and workforce development for both clinical and non-clinical health professionals across the cluster. (We had already funded this with some £25,000.) The PCT invested a further £35,000 to develop a supervision and medical mentoring programme for the cluster.

Some of the money has also come from the PCT’s innovation fund. It is very supportive of what we are doing and has given us almost total freedom. The social enterprise has put us in a strong position to bid for contracts such as PMS Plus, APMS, LESs and DESs.

We work with the PCT collaboratively – we don’t have to ask for permission. It’s a healthy relationship – the innovators push the agenda and hold the power because we are the providers and we are very close to the patients. A PCT is more restricted in this area because it is trying to be a good banker.

PBC involvement

Although PHD has no immediate direct link with PBC, we’re using the practice development as a pathfinder-incubator company for areas in PBC. What we’re trying to do is linked very clearly with the set aims of PBC: improving primary care access, moving more services to primary care and minimising unnecessary use of secondary care.

Having an incubator company in the cluster enables us to test innovation. We have taken huge gambles to see if we can restructure the way we offer primary care services. That then becomes available to the PBC cluster and sets the tone for what may be achieved as a collective. Others in the cluster have access to everything we’re achieving, such as IT innovation and risk stratification of the managed population.

Data

We have worked with Aetna, which is one of the Government’s Framework for External Support for Commissioners (FESC), to develop a robust risk stratification tool.

This uses primary and secondary care data to establish how our patient population is at relative risk of becoming unwell and allows us to become a very effective health population manager. This is being used though the cluster and is supported by the NHS Evidence Centre.

The data has dispelled some myths about how our patients access healthcare and has shown us the areas we need to change.

For example, when we started out we believed diabetes and mental health were our ‘low-hanging fruit’. But when we risk-stratified the population, the high spenders turned out to be asthma in young people and people who had two or more long-term conditions. Interestingly, the latter group was any combination of any two conditions. So we realised that no single condition drives urgent admissions and therefore that care management that focused on specific disease areas would not meet patients’ needs.

This information showed us the way forward and led to the development of a model of work that will ultimately reshape services to the benefit of everyone.

Our aims became:

• to redesign services to improve access in primary care

• to keep people well who are currently well and reach out to those we don’t normally see

• to maximise the health of those who do have illness in a targeted way, focussing on those with more than one illness through a care management programme

• to develop staff and personnel in a very positive way

• to provide value for money – not just providing cheaper services but making sure costs aren’t multiplied by ensuring patients are seen by the right person at the right time.

The service redesign model

The service redesign model we have developed comprises various elements, as follows.

Self-care

We are developing personal care packages, working with people in their homes and looking at how technology can help them.

This service promotes confidence in self-management and provides an opportunity for community members to develop skills that improve the health of others in the community. We are also exploring using telemedicine.

Outreach/inreach

Working within communities that have not until now been contacted proactively, for example church communities, Gurdwaras, mosques, pubs and shopping centres.

We have carried out mid-life health check sessions in supermarkets, connecting with more than 500 people. By actively looking for patients at risk of ill-health this service will reduce inequalities in health.

On behalf of the PCT we carried out the community aspect for the CVD programme. We were so successful in engaging members of the community that we now have a 45-strong volunteer force who have become health champions. This has rolled out into the cluster and is now operating across the whole of Sandwell.

This group now forms the bones of a patient reference group, which will be an important part of everything we do in the future.

Fast-track referral and treatment

We have triage and clinical assessment teams working closely together to ensure people are no longer slowed down by the system. Clinicians and support staff are streamlined into effective multidisciplinary teams.

Signposting

This aims to identify all the resources locally that can help to improve people’s health – whether this is simply identifying a local ramblers’ club, or putting someone in touch with the Citizens’ Advice Bureau to discuss housing needs.

We set out to bring together the information on a single website to make it as up to date and easily accessible as possible. We anticipate it will go live at the beginning of 2010.

Group consultations

This is a new style of consultation, for practice staff and patients with long-term conditions or recurrent acute conditions, delivered at the practice. It means a reduction in the use of primary care resources as well as better use of the most appropriate clinical expertise.

Diabetes and asthma group consultations are now a part of daily life at the practice. We will be launching other groups shortly, including back pain and hypertension.

Outcomes

Our model uses primary care as an agent of regeneration and raises expectations in a community that traditionally has low aspirations.

At this stage we are creating our own freed-up resources through redesigning primary care so we can then focus on innovation in secondary care redesign with our secondary care colleagues.

We have seen a slight reduction in non-elective procedures but can’t at this stage say it’s because of what we’re doing. We are now 13 months into our new way of working and all the financial modelling we have done suggests that by year five we will have made a saving of £40 a patient – £400,000 for a population of 10,000 through keeping them out of secondary care. The big win is that this money will be reinvested into NHS services.

We have taken this risk to get us where we need to be for contract reviews. We now have the power to negotiate and develop services. If we’d taken no risk we wouldn’t be in that position.

What we get from this is autonomy – developing the level of services we believe we should be developing.

The future

We talk in terms of becoming a health management organisation that would manage the whole of the patient’s capitated budget – the natural evolution for PBC.

We would like to call ourselves a social

HMO and bring together a lot of the social public health services that impact on our patients’ lives.

We are working towards holding our own budgets to provide outstanding excellence in primary care, with full control over the health economy spend of the patients we have responsibility for and delivering that as effectively and efficiently as possibly. We will take on the real budget risk with the PCT.

Once we move into a more sophisticated system of earned autonomy we intend to set up an effective discharge-planning programme and support service.

Dr David Morris is a GP partner at Smethwick medical centre, West Midlands, and partner in Pathfinder Healthcare Developments

Dee Kyne is business development director of Pathfinder Healthcare Developments

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How our social enterprise model moved PBC up a gear

Posted on November 17, 2009. Filed under: Commissioner, News stories, Social enterprise | Tags: , |

Pulse | Focus on…..Social Enterprise | 17 November 2009

Dr Bill Tamkin explains how becoming a social enterprise helped his PBC cluster get ahead in the game

Turning our PBC group into a social enterprise company has given us more clout with providers and the PCT. Manchester Practice-Based Commissioning (South) Ltd grew out of our consortium of 26 practices known as the South Manchester PBC Hub, which was launched four-and-a-half years ago.

There was a long history of like minded working between practices. When PBC came in, the PCT encouraged us to start working as a consortium but reorganisation in 2004/5 meant a dramatic slowdown.

Most of the people we knew in the trust disappeared and we were left in limbo as the three trusts merged into one – NHS Manchester. There was a lot of frustration from GPs and we felt we would be more effective if we had a formal set-up.

The decision to opt for a social enterprise format was both practical and philosophical. We had seen it working in Stockport and we wanted charitable status – to be a company for the community rather than being about profit for shareholders.

Having now created the social enterprise, we have the potential to hold a real budget for our 160,000 patients and an agreement to provide commissioning support to the PCT with a devolved budget of £1m.

Relationships

We wanted to focus on three key relationships:

• with the PCT

• between our practices

• with the main providers.

Members felt we needed some clarity about what the new PCT expected from us and what our role was.

There was also a need to firm up relationships between practices. We are all independent and most of the time work in isolation – a more formal relationship where we all agreed to move in the same direction would be very powerful in terms of improving the quality of primary care as well as helping us negotiate with the acute sector and the PCT.

GPs had very little ability to negotiate with providers on behalf of patients. There were daily frustrations about the struggle to get good care. Tales of inefficiency, long waits, duplication of tests and futile outpatient appointments spurred us on.

Sometimes trusts would refuse to see patients because they were in the wrong patch – Manchester is one of the largest metropolitan areas in the UK with a population of more than 2.5 million and there are a number of large, powerful providers, from the University Hospital South Manchester to the Manchester Royal Infirmary, Pennine Acute, Central Manchester and others. We had no influence over these trusts as individual GPs but as a corporate entity we would be able to negotiate on behalf of 160,000 patients.

There was also a need to make sure the new organisation had longevity rather than simply relying on a few enthusiasts. We wanted to set up something that would be sustainable in its goal of improving the health of the population we care for.

And we wanted to look to the future – whichever political party comes into power, it’s clear healthcare spending can’t keep going up and up. PBC is currently the only game in town to tackle this. And as a legal entity we have the potential to hold a real budget for our 160,000 patients.

What kind of model?

We looked at various structures and took advice from people who had been there and done that, such as our neighbours in Stockport PBC who had set up a social enterprise – a business or service with social objectives where surpluses are reinvested, rather than being driven by the need to maximise profit for shareholders.

We wanted commissioning to be credible with our patients and the PCT. The idea of joint ownership, all being in this together, seemed to fit our approach.

But setting up the organisation was a cumbersome process. From the initial idea four years ago, it has only been in the past 18 months that things have started to happen.

We took the idea to one of the PBC group’s quarterly meetings where all the 26 practices came together and supported the plan. But it took a year to win hearts and minds at the PCT, which was frustrating.

We had to keep plugging away, building relationships and showing we had a robust vision. It was about understanding the issues and the pressures on both sides.

The current financial difficulties in the NHS tipped the balance in our favour.

To set up the organisation and register with Companies House we needed legal advice. It cost about £35,000, including employing the legal firm as company secretary. In future years we plan to have this role in house. We funded this through freed-up resources gained over the first couple of years of our consortium’s work.

We went for a particular type of social enterprise structure, the Industrial Provident Society. It’s a community-based organisation where all practices are members, which suits our egalitarian, inclusive commissioning ethos.

We had to hold our first AGM where we needed a quorum to vote for board members. Trying to get GPs to leave their surgeries was a challenge – the old line about herding cats comes to mind – so we made it clear the project couldn’t go forward without that commitment. Then it was hard work to get people to fill in the membership forms the right way. It’s something that inevitably goes to the bottom of the ‘to do’ list in a busy surgery – even my own practice managed to fill in the forms wrong! But we got there in the end, with a lot of chasing and support from PCT staff.

Nowadays there’s a lot more help available for people who want to go down the same route, from the Department of Health social enterprise support unit to the legal firms who specialise in this area.

How it works

We are a membership organisation where the number of members each practice has is proportionate to list size. The member could be a GP, nurse or practice manager.

I’m the chair and one of five GPs on the board. We also have five practice managers and one lay member on the board. All our GP leads have specific roles such as long-term conditions, finance and contracting, and we bring in expertise in specific clinical areas as needed. Each practice manager board member is linked to a GP lead.

There are quarterly meetings to which any staff member can come, which focus on clinical issues and service redesign. We usually have representatives from each practice and the relevant clinical leads.

As chair, I visit all the practices regularly to monitor performance and talk about PBC. It’s very much bottom-up, not top-down – peer pressure is important. Comparative data helps GPs know how they are doing and helps everyone feel they are all in this together.

We don’t provide services – we are about commissioning. Once we’ve identified a need and developed a patient pathway, we create a service specification. Procurement is handled separately by the PCT’s business case approval process. The aim is to get business cases approved within eight weeks.

Cultural change

At first the new PCT was largely paying lip-service to PBC – we had to win hearts and minds. It’s always tricky for people to give up power but there has been a big cultural change and we are now working much more closely together.

Relationships between the PBC group and PCT have developed as we’ve spent time together. We both now understand the two worlds we work in – so when we refer, we have an idea what the options are and what they cost, and the PCT understands how GPs work. There is better connectivity between the contracting and financial world of the PCT and the ‘coalface ‘ of general practice.

There’s a real sense of joint ownership. The financial pressures have really concentrated minds and the PCT realises PBC is part of the solution, not the problem.

Day to day

We have a service-level agreement with the PCT covering processes and responsibilities. Some 16 PCT staff are seconded to us to provide data, contracts and finance support. We have a management budget of £150,000 for cover for board members and clinical leads – I spend four sessions a week working for the company, and the other board members are covered for one session each.

The amount of work continues to grow – it often feels as if every piece of paper the PCT conjures crosses my desk. Board members and clinical leads complete timesheets so we can demonstrate the scale of work involved.

Our clinical leads for areas such as diabetes and COPD go into the PCT regularly and look at activity and other data, as well as providing feedback to the PCT, practices and the regular business meeting. Practice managers meet PCT teams and PCT staff go into practices to support them with prescribing and with using data.

The three chairs of each local PBC consortium attend PCT board meetings – we are guests rather than board members but it is clear the PCT takes us very seriously.

We have an overall devolved budget of £1m, which includes money for the local incentive schemes. These include peer review of referrals, prescribing targets and attending quarterly meetings.

New services
We’ve commissioned the ScriptSwitch prescribing management system. It sits on the practice computer and flags up expensive drugs, hospital-prescribed drugs and provides alternatives. For example some generics are now more expensive than non-generic preparations and this is flagged and can be changed with one click.

When we started out, there was a lot of frustration about growing demand from nursing homes and patients being discharged from hospital with little information. Now we’ve commissioned a team of a consultant geriatrician plus two GPs with nursing support, who go into nursing homes and actively manage patients. We are seeing a considerable reduction in home visits and admissions– in some cases visits have reduced by 50%. It was a hard slog, taking two years from idea to launch because of PCT reorganisation, but is now making a real difference.

We’ve also commissioned a minor surgery service. We found there were 1,700 procedures a year where patients were going into hospital for simple things such as removal of sebaceous cysts. Now there are three GP surgeons who carry out minor surgery in the community. Patients are very pleased that they don’t have to wait for ages and pay to park.

The future
We are currently working on ideas about commissioning better anticoagulation, ENT and phlebotomy services. The first is still based in outpatients, where people wait for hours (at an expensive tariff) for something that should be done more economically in the community.

One of the big performance issues is in orthopaedics, where the 18-week waiting time target is being breached and work is being sent out to the private sector at above tariff rates. We have drawn up a specification for a new service and are currently waiting for business cases to come in. Forming our company has been hard work but rewarding and has given ‘shop-floor’ general practice the chance to work in the macro world of the NHS.

Dr Bill Tamkin is chair of Manchester Practice-Based Commissioning (South) Ltd

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Tories back GPs and patients to control NHS funding

Posted on November 17, 2009. Filed under: News stories | Tags: , |

Healthcare Republic | Joe Lepper | 17 November 2009

A National Association of Primary Care (NAPC) ‘manifesto’ calling for GPs and patients to control NHS funding could become a blueprint for primary care reform in the next parliament, after it was endorsed by the Conservative Party.

The manifesto says practice-based commissioning (PBC) has failed in many areas and calls for practices and patients to control local health funding.

It calls for ‘full accountability for the use of NHS resources transferring from PCTs to GPs, giving practices significant independence from PCTs’.

Local people should be more involved with practices on commissioning decisions, ‘through use of a health dividend, the efficiency gain to be achieved through better use of NHS resources’, it adds.

The NAPC has met all three main political parties and aims to speak with MPs in the coming weeks to refine the plans.

Conservative shadow health minister Mark Simmonds said he had met the NAPC earlier this month. He said he was not involved in developing the manifesto, but backed its focus on local accountability.

‘I welcome many of the NAPC’s proposals, as they are in line with Conservative Party thinking on primary care.  We welcome their call for GPs to have accountability for resources, as we have proposed a system of GP commissioning, in which GPs hold real, not notional budgets.’

NAPC chairman Dr Johnny Marshall conceded that many of the manifesto’s aims are broadly in line with Tory plans.

‘But we are hoping to get support from politicians from all sides,’ he said. ‘PBC has failed to deliver universal improvements. In some areas it has worked, in others it has not. We need to take it to the next level and I hope there will be support for that in all parties.’

GP contracts would have to be renegotiated to incorporate practices’ new powers, he said.

NAPC vice-president Dr Peter Smith said details to be refined in the coming weeks include clarity on how local people will be involved in decisions about healthcare funding. ‘We want to see how local people and practices can work far more closely together so that practices can be more responsive to local needs.’

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David Colin-Thomé on practice based commissioning

Posted on November 12, 2009. Filed under: Journals | Tags: |

Health Service Journal | BY DAVID COLIN-THOMÉ | 12 November 2009

I feel I need to contribute further to the debate generated by my recent choice of words – used while attempting to raise the profile of practice based commissioning implementation.

Practice based commissioning is very much here to stay and remains a key plank of the Department of Health’s primary and community care policy. Indeed, health minister Mike O’Brien said in a recent speech: “As the national director for primary care, Dr David Colin-Thomé has said of GPs and GP practices – ‘We spend most of the money, commit most of the resources, who best to challenge where clinical quality is poor and to always improve on the best.’

“Now some of you may have read David’s reported description of practice based commissioning in last week’s HSJ as being like a ‘corpse’.

“Well, reports of its death have been greatly exaggerated!

“It is certainly true that it has not taken off everywhere, and we need to change that, but, and as indeed David Colin-Thomé actually said in his speech, where it has, the results have been truly impressive.”

Back to my thoughts – I am, as always, deeply committed to practice based commissioning. Aligning budgetary responsibility to the clinicians who commit the resources should be an important design principle for the whole NHS but only if those very same clinicians have the skills, aptitudes and capabilities to take on that responsibility. We need to find ways of involving clinicians who do not possess those attributes if we are to systematise practice based commissioning. When, as in primary care, that budget can be deployed to aid population health, the potential of practice based commissioning is even more enhanced.

I did use the words reported but went on to say – as was also reported – that there are many examples of excellent practice based commissioning implementation – so it is very much alive, well and kicking. If my words have confused or de-motivated the excellent, please accept my apologies.

But it is interesting to note that some GP leaders have welcomed my raising the profile by citing many examples where practice based commissioning has not ‘taken off’. Many PCTs and clinicians report an ever increasing involvement of clinicians in commissioning – which is excellent news, but many of the innovative and capable have not been offered devolved hard budgets. And that is the extra dimension that practice based commissioning offers and which is necessary if we are to deliver on the imperative of better quality, innovation, productivity and prevention. QIPP is our protection against a temptation to make arbitrary cuts when budgets appear to tighten.

To quote Mike O’Brien again: “Our challenge is how to achieve the vision of High Quality Care For All set out by Ara Darzi while finding new ways of releasing funds for frontline care from within existing budgets.

“Let me be clear, what I do not want to see are PCTs or trusts making their own, unprompted slash and burn hacks at budgets, second guessing the chancellor or the outcome of the general election and making drastic cuts.

“This simplistic, knee-jerk reaction will only undermine the incredible progress that a decade of investment has made and will only take us further from realising our collective vision for the health service.”

It is my belief that practice based commissioning is the vehicle most suited to achieving this vision. And I would add that implementation must be faster, more comprehensive and devolving if we are to succeed.

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PBC savings frozen in bid to plug PCT overspend

Posted on November 11, 2009. Filed under: News stories | Tags: , |

Pulse | By Nigel Praities | NHS South Birmingham | 11 November 2009

NHS managers have enraged GPs by shifting thousands of pounds of efficiency savings from primary care to plug a financial overspend by hospitals.

In a move GPs claim contravenes national guidance, NHS South Birmingham has frozen reinvestment of savings from practice-based commissioning, citing ‘significant pressures’ on its budget.

The trust has further angered GPs by announcing a partnership agreement with a consultancy firm that will cost the trust millions. The PCT will pay US company Aetna £3.5m over two years to improve PBC performance and help ‘introduce best practices’ from the private sector to the NHS.

A letter sent to all practices involved in PBC warns the allocation of freed-up resources was being ‘delayed’ indefinitely.

‘The organisation is experiencing some significant pressures primarily due to swine flu, and until we are clearer of the full extent, we will need to temporarily stop the release of freed-up-resources investment,’ says the letter.

‘Once the picture is clearer, we will review this,’ it adds.

A PCT financial report reveals it is also facing ‘significant risks’ from increasing outpatient appointments and a ‘failure to cut activity levels in A&E and emergency admissions’.

Dr Robert Morley, executive secretary of Birmingham LMC and a GP in the city, said: ‘They spend a fortune on sexy initiatives with private-sector partners, but won’t invest in general practice – the one thing that will solve their problems.

‘It is a clear contravention of DH guidelines to use freed-up resources to prop up PCT deficits, but the PCT have done exactly that,’ he added.

The trust said freed-up resources would be available from the new financial year.


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Has practice-based commissioning been turned against GPs?

Posted on November 3, 2009. Filed under: News stories | Tags: |

Pulse | By Gareth Iacobucci | 3 November 2009

It is five years since the Government launched practice-based commissioning with the grand ideal of allowing GPs to use their expert knowledge to reshape services and save money for their practices. Yet today not only are an increasing number of leading NHS leaders writing the policy off as a busted flush, but GPs are reporting a more disturbing twist – that it has become a crude weapon to drive down referrals and manage practice performance. Gareth Iacobucci reports on what the future holds for the flagship policy.

How has practice-based commissioning fared over the last five years?

Introduced in a time of unprecedented investment in the NHS, practice-based commissioning is now struggling to survive against the brutal backdrop of the recession. It was originally viewed as a way of transferring commissioning power back to GPs – following the abolition of GP fundholding in 1998 – in order to reconfigure services and drive improvements in their quality and efficiency. But Pulse revealed last year that PCTs hit financially by the surge in GP referrals were using PBC to impose strict limits in clinical areas that had ‘over-performed’ on waiting times, in a desperate attempt to claw back cash. PBC come to be seen as a valuable tool by PCTs as they case targets to cut their outpatient referrals by 10% or more. Since the onset of World Class Commissioning (WCC) two years ago, which placed greater focus on holding PCTs to account for their capabilities as commissioners of services, the Government’s commitment to commissioning at practice level has been in doubt.

For its part, the Government claims most GPs still support PBC – 64%, according to its latest survey. A similar proportion now provide new services commissioned as a direct result of PBC – eight points above the result for December last year – but that is a cumulative figure covering the entire five-year period PBC has been around.

What evidence is there of PBC being used against GPs?

In this time of economic crisis, PCTs increasingly appear willing to resort to desperate measures to save money, and this is spelling trouble for some practice-based commissioners. One of the most alarming examples to date has come in Hillingdon, West London, as revealed by Pulse last week. The cash-strapped PCT was forced to draft in private accountancy firm KPMG to devise a series of cost-cutting measures, including tough sanctions to punish high referrers and a clear instruction that the chair of the LMC could no longer remain at the head of the PBC group. All GPs in the area are threatening to quit PBC in protest at the plans to use GP commissioning primarily as a tool to drive efficiencies.

There is also emerging evidence that some trusts are reneging on promises made to commissioning groups on how savings are used. The National Association of Primary Care held an emergency summit for commissioning GPs last month, to examine claims that some trusts were going cold on PBC as the financial crisis kicks in. PBC consultant Gerry McLean, who attended the summit, said two commissioning groups he was working with had been refused access to savings of £700,000 and £600,000 respectively because of their PCTs’ financial deficits. Fellow PBC consultant Scott McKenzie, who also works with a number of PBC groups, said one PBC group had contacted him to say their PCT had withdrawn ‘all money from PBC’.

Dr Johnny Marshall, chair of the National Association of Primary Care, says there is ‘alarming evidence’ that PCTs are increasingly using PBC as a blunt instrument to crack down on the rise in GP referrals and are pulling the plug on forward-thinking service re-design because of the financial climate. ‘In an era of economic crisis, this transactional approach is doomed to failure,’ he said.

Where do the latest developments leave PBC?

On the ground, there is increasing evidence that GPs have become disengaged from the policy. Grassroots GPs tend to roll their eyes in meetings when PBC is brought up, and there are particular blackspots of disillusionment, where GPs feel they have not been supported by local trusts. In NHS East Midlands, even the Government’s own survey finds only 39% of GPs approve of their local trusts’ efforts at supporting the policy.

But this contrasts with a reasonably healthy 61% for NHS North West, widely considered to be one of the SHAs that has bought in most to the policy. It is areas such as this, and the handful of areas that have gone further by experimenting with real budgets for GPs, that offer a glimmer of hope for PBC. The Department of Heath recently flagged up a scheme In Bexley, south East London, where GPs made £4m worth of savings after being given real budgets for prescribing, as a blueprint for successful PBC. Dr Joanne Medhurst, GP in Sidcup and lead for the Bexley PBC federation consortiums, says giving GPs responsibility allowed them to free up resources effectively in partnership with the PCT: ‘We looked at how to take on a budget with a real risk, but with a risk pool arrangement, so no one practice does it in isolation. We also passed it through clinical Governance and made sure the LMC knew about it, and we made it go through the PEC. We enabled the doctors to do it.’

There are also positive moves afoot to hold managers to task if they are shown not to be taking PBC seriously, with the possibility of the chop if they fail to demonstrate efforts to engage with GPs. The Government has just announced it will split its quarterly PBC survey into two, with one going to lead individuals within PBC groups, and the other assessing opinions among grassroots GPs. The results of the PBC leads survey will feed into assessments for WCC, with trusts being held to account for failure. ‘Those PCTs that are simply using PBC to manage demand will get their fingers burnt by WCC,’ predicts Dr Michael Dixon, chair of the NHS Alliance. ‘Frankly, it’s been very easy to hide to date, but someone who is manifestly abusing PBC will be caught in the next round.’

What does the future hold for GP commissioning?

The question is whether the will to make PBC work is strong enough to overcome the current financial pressures. A common complaint from GP commissioners at the NAPC summit was that they felt their voice was not being heard, and that even the relatively few success stories for PBC were ‘framed’ in terms that appealed to managers – mostly in terms of cutting costs.

Dr James Kingsland, NAPC president and the Government’s national clinical lead for PBC, says that unless the principles behind the policy are adopted by all, the NHS will have to make ‘slash and burn’ cuts or severe reductions in workforce and pay – ‘neither of which are palatable’. ‘Clinical commissioning is the only show in town. If clinicians are not doing it, and PCTs don’t do it, it could be a career breaker,’ he warns.

This move towards real budgets looks certain to accelerate, particularly if the Conservatives win the next election. Shadow health secretary Andrew Lansley has declared the current PBC set-up as ‘bust’, but his plans for GPs to commission go far further than anything Labour has done. While the current Government will continue to leave commissioning as a voluntary option for GPs – albeit with greater budget-holding responsibility for high flyers – GPs will be contractually obliged to take on real budgets under a Tory Government, with commissioning responsibility transferring from PCT to practice. This will leave GPs free to use any savings they make, but also partly financially accountable for losses, although the Tories insist they will keep practice and patient budgets separate.

There is no doubt that the move would create a bigger incentive to get PBC working more effectively, and on a much wider scale. But some GPs fear it would be ‘financial suicide’ to take on budgetary risks without appropriate safeguards, which have yet to be fully set out by the Tories. And GP leaders have questioned the wisdom of forcing all GPs to take commissioning – even those not interested in it – with the RCGP pointing out that GPs currently receive little if any training on how to commission effectively.

The Conservatives plans remain short of detail, but one fact is plain. However tired PBC has become, and however disliked by many GPs, it is not yet dead. With the Tories likely to form the next Government, there’s plenty of life in GP commissioning yet.

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PBC is alive and real budgets a ‘maybe’, says tsar

Posted on October 26, 2009. Filed under: Journals | Tags: |

Pulse | 26 October 2009

Primary care tsar, Dr David Colin-Thome has set the record straight about reports he called PBC a ‘corpse’.

He told Practical Commissioning: ‘I asked a rhetorical question – I can’t remember the exact words, but it was essentially, are we reinvigorating a corpse? I then went on to say that actually there is plenty of good practice which is hardly saying there’s a corpse. And actually all the press reported that I was saying that there’s good in parts. What I’m saying is we need to get those energetic (PBC groups) to have more influence and power and maybe (real) budgets and need to be even more ambitious about what we can do in re-shaping care.’

He added real budgets were ‘always part of our policy if people were confident enough. And that’s a local decision.’

Primary care tsar, Dr David Colin-Thome has set the record straight about reports he called PBC a ‘corpse’.
In his speech to the NHS Alliance conference this week, health minister, Mike O’Brien, said: ‘Some of you may have read David’s reported description of practice- based commissioning as being like a ‘corpse’..

Well, reports of its death have been greatly exaggerated.’

‘It is certainly true that it has not taken off everywhere, and we need to change that, but, and as indeed David Colin-Thomé actually said in his speech, where it has the results have been truly impressive.’

Click here to find out more!Primary care tsar backs PBC

Pulse | 23 October 2009

National primary care tsar Dr David Colin-Thomé has insisted that he continues to support Practice Based Commissioning – just days after describing the troubled initiative as a ‘corpse not for resuscitation’.

Speaking at the NHS Alliance conference in Manchester, Dr Colin-Thomé said: ‘Of course I don’t think the darn thing’s dead.’

His remarks at a conference in London earlier this month had been misinterpreted, he claimed but he added: ‘I’m certainly disappointed with the impact PBC is having.’

Health minister Mike O’Brien also moved to defend the under-fire initiative in his keynote address to delegates, insisting ‘reports of its death have been greatly exaggerated.’

He said: ‘It’s certainly true that it’s not taken off everywhere and we need to change that. But as David also said in his speech, where it has taken off results have been truly impressive.’

Primary care czar jokes about PBC ‘corpse’ blunder

Healthcare Republic | 22 October 2009

Primary care czar Dr David Colin-Thome has said his description of practice-based commissioning (PBC) as a ‘corpse not for resuscitation’ was misunderstood and even joked about the blunder.

Addressing the NHS Alliance annual conference in Manchester on Wednesday, Dr Colin-Thomé said: ‘Perhaps the C in (my initials) DCT should stand for corpse, not Colin.’

Dr Colin-Thomé, England’s clinical director of primary care, made the controversial comment last week and it has been the talk of the NHS Alliance conference this week.

Health minister Mike O’Brien also took advantage of his appearance at the conference to defend PBC.

Mr O’Brien maintained that Labour’s drive to improve quality could deliver enough efficiency savings to reign in NHS finances.  ‘The only way forward in these times is to continue on the reform path we are on,’ he told delegates.

Earlier, shadow health secretary Andrew Lansley set out his vision of a drastically different NHS, where GPs commission all local health services for their population, including urgent and emergency care.

Mr Lansley said patients wanted GPs to make difficult rationing decisions about the care available to them. 

‘There will always be rationing in the NHS because we have finite resources. But ask people who they trust to make these difficult judgements – it’s not the secretary of state, it’s not PCT managers. The public are looking for someone they can look to, to manage their care.’

GP commissioning shows little sign of life – David Colin-Thomé

Health Service Journal | By Steve Ford | 14 October 2009

The government’s primary care tsar has admitted that efforts to “resuscitate” the “corpse” of practice based commissioning have had little effect.

National clinical director for primary care David Colin-Thomé said last week that the Department of Health is “hard at work trying to reinvigorate” practice based commissioningbut said it “isn’t really taking off, in any systematic way”.

He told delegates at the Wellards annual conference in London that it was hard to say why this was. “But it’s certainly not seen as a major vehicle for change,” he said.

The DH published extra guidance in March intended to mark the start of a new push to get practice based commissioning “working to its full potential” – five years after the policy was first launched. 

The document, Clinical Commissioning: our vision for practice based commissioning, included various ideas intended to try to “reinvigorate” the stalled policy.

It set out entitlements that commissioners could expect, including that primary care trusts should make decisions on practice plans and business cases within a maximum of eight weeks, and that PCTs would be held to account for the quality of their support.

Dr Colin-Thomé said: “We thought we’d try and reinvigorate it, and we had all sorts of ways of doing it – entitlements and things like that.

“But I think the corpse is not for resuscitation. There doesn’t seem to be much traction,” he said.

“We’re struggling to make it systematic,” he added. “There’s a lot of support around it but it’s not really taking off out there.”

However, Dr Colin-Thomé insisted that clinicians do need to have some form of budgetary responsibility in order to “reshape how clinical care is provided and challenge inappropriate and ineffective interventions”. “Clinicians, doctors especially, we spend the money,” he said.

The apparent failure of practice based commissioning has not deterred the Conservative Party from sticking to its policy of giving GPs “real” budgets if they win the election.

Writing in HSJ earlier this month, shadow health secretaryAndrew Lansley said: “We will hand them real budgets to manage the costs of their patients’ care. They will have a direct incentive to buy the most efficient services on behalf of their patients, because they will be able to keep any savings and use them to reinvest in care.”

Speaking at the Wellards conference last week, NHS Confederation director of policy Nigel Edwards said the Conservatives were “basically betting the ranch on hard budgets for GPs as a mechanism for change”.

“I’m torn on this,” he told delegates. “There are some big questions.”

Mr Edwards said he would have no concerns about GPs he had met who already do practice based commissioning and “do this well”. But he said: “There are some really interesting questions about what to do with the people who don’t want to do it or don’t have the skills or the capacity.”

He added: “The other issue of course is that GPs are also providers. If you want to bring new providers in, which is also part of Conservative policy, then it’s quite hard to do that if the commissioner is one of your potential competitors.”

Birmingham East and North PCT chief operating officer Andrew Donald said: “I tend to agree with the principle of giving GPs hard budgets because actually they are the ones who create most of the cost. They write referrals, they write prescriptions, their patients got to A&E, their patients have emergency admissions.”

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BMA chairman rejects GP commissioning plans

Posted on October 23, 2009. Filed under: News stories | Tags: |

Healthcare Republic | By Nick Bostock | 23 October 2009

GPs should not be handed full responsibility for commissioning, the head of the BMA has told MPs.

At a health select committee evidence session on commissioning on Thursday, BMA chairman Dr Hamish Meldrum appeared to reject Conservative plans to make GPs responsible for commissioning 24-hour care for their patients.

His comments come less than a week after RCGP chairman Dr Steve Field said GPs should take on 24-hour commissioning responsibility.

‘I don’t think putting all the power in the hands of GPs is the right thing,’ he told MPs.

Commissioning should operate as a collaborative process between NHS organisations, including GPs, he argued.

Giving commissioners full control of budgets seemed a ‘crude’ method of bringing people to the table where relationships between NHS organisations were poor, Dr Meldrum said.

Dr Meldrum said that commissioning was most effective in parts of the country where NHS organisations had ignored the ‘purchaser-provider split’ currently operating in the English health service.

He pointed out that in Scotland, Wales and New Zealand, this separation had been abandoned in favour of a more collaborative system.

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Tory plan could give GPs interest bonanza

Posted on October 22, 2009. Filed under: Journals | Tags: |

Health Service Journal | BY SALLY GAINSBURYSTEVE FORD | 22 October 2009

GP practices could earn thousands of pounds a year in interest payments under Conservative plans to turn practice based commissioning budgets into “hard cash”.

At present, primary care trusts spend on average £1,600 per head of population. Under Conservative plans to extend the scope of practice based commissioning, the average GP practice with 6,000 patients could be handed a cash budget of around £7m if practices were given responsibility for 70 per cent of the budget.

HSJ has calculated that if just half of that budget was stored for six months of the year in a deposit bank account paying 3 per cent interest, a typical practice could earn an extra £105,000 a year – a sum equivalent to an entire year’s pay for an average GP.

Most practices are expected to group together into consortia, covering populations of around 100,000, or 17 average size practices. That could translate into annual interest earnings of around £840,000.

A Conservative spokesman confirmed the party planned to transfer hard cash budgets into consortia bank accounts, but said interest earned could not be taken as profit. He said: “Any interest earned would have to be used to invest in patient care, not for their own profit.”

He said the party had yet to decide precisely how and when in the financial year cash budgets would be transferred toGPs.

Public finance experts have questioned how workable the plans are. For example they could involve the Treasury laying out up to 70 per cent of the NHS budget on “day one” of the financial year, as opposed to the current system where PCTs “draw down” funds when they are needed.

That would have implications for Treasury borrowing needs and, after the collapse of the Icelandic banks, there will be concerns about GPs’ ability to make wise choices about where to store money.

Jeff Finney, chair of the Institute of Chartered Accountants in England and Wales and director of a GP accountancy service, told HSJ practice consortia would need to set themselves up as not-for-profit entities in order to ensure interest earnings were not taken as profit.

The questions over GPs holding their own budgets follow national primary care director David Colin-Thomé’s admission last week, revealed by HSJ, that efforts to reinvigorate practice based commissioning have so far failed. He described the policy as a “corpse not for resuscitation”.

Social Market Foundation head of strategic development David Furness said it was time to stop ploughing money into expanding GP commissioning.

Mr Furness said at least £100m had been spent on trying to reinvigorate practice based commissioning through entitlements, and it was time to “turn off this tap”.

“Let it work where it is working,” he said. “But let’s stop trying to drive it from the centre.”

He said it was wrong in the current financial climate to place the “onus” for commissioning on those whose primary role was clinical practice, and the role of PCT commissioners should be strengthened instead.

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GPs could hand commissioning to private firms under Tories

Posted on July 17, 2009. Filed under: Journals | Tags: , |

Health Service Journal | By Helen Crump | 16 July 2009

GPs could be given the opportunity to bypass primary care trusts and hand commissioning to private sector organisations under Conservative plans. 1204591_blood_pressure_GP

Shadow health minister Mark Simmonds told HSJ that using companies such as Humana would be an option where GPs did not want to become commissioners.

The Conservatives have pledged to give GPs real commissioning budgets – the practice based commissioning system does not allow this.

Mr Simmonds acknowledged some GPs would not want to take on commissioning work.

Primary care trusts’ expertise might be called on in these situations. “There may also be circumstances where if there’s a continuing reluctance [from GPs] we may have to bring in others to commission on their behalf.”

“Federated” groups of GPs would be allowed to select whether another GP consortium, the PCT or a private firm did the commissioning, he said.

“We need to emancipate and empower GPs, and practice based commissioning doesn’t deliver.”

Mr Simmonds said commissioners would be paid to hit targets under an expanded quality and outcomes framework encompassing preventive measures.

But he would not say whether PCTs would be downsized as a result of moving some commissioning work into primary care. “That’s part of the discussion and decisions we need to make about where resources are allocated.”

Mr Simmonds called for a “greater aligning of incentives” between GPs, pharmacists, nurses and primary care trusts – including using the quality and outcomes framework.

He said: “We need much more effective commissioning and that means we have to have commissioning that is ultimately focused around driving improved patient outcomes.”

In order to avoid conflicts of interest he said GPs would be expected to use a “tendering process” to appoint providers.

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Concerns over GP surgery hospital buy-out

Posted on July 14, 2009. Filed under: Integrated care, News stories | Tags: |

OnMedica | 14 July 2009

The NHS Alliance has today criticised a pilot scheme which will see a GP surgery merge with and be directly employed by an NHS Foundation Trust. Darzi report.jpg

The Alliance says the integrated care scheme proposed by the City Hospitals Sunderland FT “is against the interests of both patients and taxpayers”.

At a time when there is greater competition between hospitals actively seeking the “business” provided by primary care commissioners, the Alliance says the merger is financially motivated.

“In fact, the perception could be that the interests of the Foundation Trust lie more in ‘capturing the supply chain’ than in achieving integration”, it added.

Integrated care is one of the key planks of health minister Lord Ara Darzi’s NHS reforms and is designed so that patients get more seamless health, community and social care.

The Alliance says it supports the concept and championed the idea of closer links with hospitals, community and local authority services, but feels that such collaborations should be about integrated care delivery rather than integrated organisations.

Under the scheme the Church View Medical Practice in Sunderland will merge and be directly employed by the Foundation Trust.

NHS Alliance chief executive Michael Sobanja, said: “An integrated organisation will not necessarily achieve the delivery of integrated care. There is some anecdotal evidence to support this in Northern Ireland where health and social care services have been the responsibility of a single organisation for over 10 years.”

Mr Sobanja said there are also concerns around independence, adding that this merge would compromise the practice’s ability to meaningfully engage in practice-based commissioning. By merging into one entity, the Trust would become, in effect, employer of the medical practice staff, including all practice-based clinical staff.

The Alliance says this could potentially impact on the GP’s role at least three levels: as an independent advocate for patients; as a gatekeeper for other NHS services, particularly hospital services; and as a key player in practice-based commissioning.

Mr Sobanja added: “How can an employee of a large organisation be guaranteed to offer independent advice when the vested interest of the hospital may be at stake? This may affect the best interests of patients and restrict choice.”

Mr Sobanja’s comments come in a response to the Co-operation and Competition Panel for NHS Funded Services consultation on the merger. The Panel should make its decision by next month. The trust said that there was nobody available to comment on the Alliance’s concerns.

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The ‘patchwork privatisation’ of our health service: a users’ guide

Posted on June 10, 2009. Filed under: GP-led health centres, ISTC, LIFT, Reports/papers, Social enterprise | Tags: , , |

NHS Support Federation

Executive summary

• The government is carrying out the ‘patchwork privatisation’ of the NHS. For the first time, this report presents a comprehensive picture of the many kinds of privatisation occurring in the health service. It provides indisputable evidence that a process of privatisation is in train.

• This is happening on such a scale and in so coordinated a way as to make it a unique phenomenon – the ‘patchwork privatisation’ of a major public concern.

• Unlike the Thatcher privatisations of the 1980s, the entire NHS is not being put up for auction – but historically this is only one manifestation of privatisation. The deregulation of state monopolies, the outsourcing of state responsibilities and the cessation of services are the forms of privatisation we see in the NHS today.

• The government is transforming the NHS from a comprehensive, equitable provider of healthcare into a tax-funded insurer, paying for care provided by others. What emerges will still be called the NHS, but it will take the form of a kite-mark attached to selected services.

• The government argues that while the health service remains free at the point of need, funded from taxation, it is still public. However, access does not determine whether a service is public. ITV is free for all to watch, but is clearly different from the BBC. Neither does public funding automatically translate into public service status. There are examples of private ventures that are publicly funded.

• The ‘patchwork privatisation’ of the NHS is deeply worrying because privatised healthcare tends to cost more; accountability suffers; the fog of ‘commercial confidentiality’ makes scrutinising public spending impossible; the profit motive encourages ‘cherry-picking’ of the lucrative work, ultimately leading to NHS services being cut.

• The report presents an anatomy of NHS privatisation:

Creating a market
o ‘Patchwork privatisation’ is only possible because of the creation of a market. This process began with the purchaser/provider split introduced by the Conservatives, but has been greatly accelerated under Labour with the introduction of ‘choose and book’ and a new financial system – ‘payment by results’. The latter has been rolled out faster and further than in any comparable country, creating powerful incentives that will have unpredictable consequences.

Privatisation in primary care
o Privatising GP services – Huge multinational corporations are taking over GP surgeries. This process will have profound implications. There are already examples of continuity of care suffering where companies are unable to retain doctors.

o Privatising the commissioning function of Primary Care Trusts – Takes privatisation into the heart of the NHS by giving the private sector a role in the decisions on what care patients can receive, determining to some extent how the NHS budget should be spent.

o Practice-based commissioning – Transfers the buying power for purchasing many treatments from a public body with responsibility for the whole local population to practices accountable only for their registered patients. Increasingly these will be run by corporations that could dominate the market in any region and gain huge power over what kind of care patients receive and who provides it.

o Outsourcing PCT care – The government wishes to see PCTs stop providing health care directly, instead contracting the private sector and social enterprises to provide services. This will increase administration costs and reduce flexibility.

o Unbundling of primary care services – Primary care services are being broken up into saleable commodities in a process known as unbundling. The most high profile instance is out-of-hours GP care, where the private sector has performed poorly.

Privatisation in secondary care
o Independent Sector Treatment Centres (ISTCs) – ISTCs (private sector clinics usually specialising in straightforward procedures like cataract surgery) have not provided value for money, have made only a very modest contribution to cutting waiting lists and in many areas have seriously destabilised NHS hospitals causing service closures.

o Privately run NHS hospitals – The fullest extension of the ISTC policy is the handing over of an entire hospital to the private sector as has happened at the Lymington New Forest Hospital. This is the first time a whole NHS hospital, including urgent care, is to be run by a private company, meaning local patients will have little choice but to use the private facility.

o Off-shoring medical secretaries – NHS trusts are cutting trained medical secretaries in favour of cheaper services abroad, raising fears for safety.

o Private ambulance services – Non-emergency ambulance services are being put out to tender. There are examples of serious problems where contracts have been awarded to the private sector.

Privatisation in diagnostics
o ICATS and CATS – Diagnostic and treatment centres that raise the prospect of conflicts of interest because of their ability to refer patients on for further care. One company, Netcare UK, has contracts for an ICATS and an ISTC in Manchester meaning it could refer patients to its own facilities.

o Privatisation of pathology services – The government has signed large contracts with private sector companies for pathology and diagnostic tests, despite warnings of the dangers involved in fragmenting pathology services through privatisation

Privatisation of NHS facilities
o PFI – A vastly expensive way of building hospitals that is taking money away from frontline care. PFI has a direct effect on patient services, as the fixed costs are borne by the local NHS trust and have first call on the available money.

o LIFT – Often referred to as the primary care version of PFI, LIFT projects are costing up to eight times more than traditional ways of building.

o Subsidising private sector infrastructure – Department of Health guidance advises that the NHS could pay a “supplement… to cover the set-up or development costs faced by a new provider,” to “reduce the capital investment required” – i.e., supply the buildings.

Privatisation in NHS supplies
o Privatisation of NHS Logistics – The government outsourced NHS supplies to delivery firm DHL and its sub-contractor Novation, which will control over £4 billion of NHS money. Novation is being investigated in the US over bribery and defrauding American public health schemes.

o Privatisation of oxygen supplies – The service supplying oxygen to patients with breathing difficulties was privatised in February 2006, resulting in chaos. One woman, Alice Broderick, died while waiting for an emergency delivery of oxygen that took nine hours to arrive.

For full report click here

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Practice win integrated health awards from Prince Charles

Posted on May 21, 2009. Filed under: Integrated care, News stories | Tags: , |

Healthcare Republic | 20-May-09

Winners of the new NHS category of Prince Charles’s Integrated Health Awards have received presentations from the royal.

The winner of the GP practice category was Patford House Surgery in Calne, Wiltshire, which devised an imaginative project to tackle childhood obesity through local primary schools.

It invited 200 Year 4 children to a Fun Fitness session in January and found that nearly one in four fell outside weight guidelines. This was followed by a 12-week programme. Parents take part in healthy eating sessions, there is even a Michelin-starred chef to advise on tasty dishes, while the children are simultaneously involved in fun physical activities.

The best practice-based commissioning group was STAHCOM, based in St Albans, Hertforshire, which provides a high-volume acupuncture service for osteoarthritis of the knee. Treating four at a time, most patients are 50-80 years old, some previously relying on physiotherapy and lifestyle advice but others facing knee surgery.

Only four out of 42 patients taking part needed to be re-referred for further treatment.

Dr Michael Dixon, The Prince’s Foundation for Integrated Health’s medical director, said: ‘Both these projects are wonderful examples of what integrated health really means – not just treating people when they are sick, but helping them keep as healthy as possible.’

neil.durham@haymarket.com

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Integrated care will be tested by only 16 organisations

Posted on April 18, 2009. Filed under: Integrated care, Journals, Providers | Tags: , |

Just 16 organisations have made it onto the Department of Health’s integrated care pilot scheme.

The department had originally said it would select around 20 bids from more than 100 applicants.

Three strategic health authority areas – NHS South Central, NHS South East Coast and NHS West Midlands – have been left without a pilot scheme.

There were 36 organisations on the shortlist published last year, including bids representing all SHA regions.

NHS North East and NHS South West have four pilots each and the East Midlands, East of England and North West regions each secured two.

London and Yorkshire and the Humber have one pilot each.

A DH spokesperson said: “It was always intended there would be around 20 pilots.

“The chosen sites cover a range of diverse models, focusing on innovation and delivering an improvement in outcomes, quality and service user satisfaction.

“The selected sites provide an appropriate range and spread to conduct a robust evaluation.”

Pilot schemes

The schemes range from a primary care trust-led collaboration between GPs, public sector organisations and the third sector to improve dementia care for older people in Bournemouth and Poole to a scheme to help patients with chronic lung disease led by Northumbria Healthcare foundation trust.

Social care, the third sector and local authorities are also represented in pilot schemes.

Clinical areas include older people’s care, long term conditions, dementia, end of life care, cardiovascular disease, mental health and substance misuse.

The pilots were first proposed in Lord Darzi’s primary and community care strategy.

The announcement followed a King’s Fund debate where experts evaluated the lessons the NHS could learn from US healthcare, where integration is more established.

UnitedHealth executive vice president Simon Stevens, a former adviser to Tony Blair, said while it was important to create systems that were integrated through teamwork and infrastructure, no US integrated scheme was a local monopoly.

He said: “If you think about any of the leading integrated systems, there is a third party purchasing system.”

Sites selected by the DH from the shortlist of 36

  • Bournemouth and Poole PCT
  • Cambridge Assura LLP
  • Church View Medical Practice, Sunderland
  • NHS Cumbria
  • Cornwall and Isles of Scilly PCT
  • Durham Dales Integrated Care Organisation
  • Nene Commissioning CIC
  • Newcastle upon Tyne Hospitals foundation trust
  • NHS Norfolk and Norfolk county council
  • Northumbria Healthcare foundation trust
  • North Cornwall Practice-Based Commissioning Group
  • Principia – Partners in Health, Rushcliffe, South Nottinghamshire
  • NHS Tameside and Glossop
  • Torbay Care trust
  • Tower Hamlets PCT
  • Wakefield Integrated Substance Misuse Service

GPs to front integrated care pilot schemes

Pulse | By Nigel Praities | 1 April 2009

GPs will work with care homes, social services, acute trusts and charities to improve patient care under a range of pilot schemes to begin today.

The £4 million scheme involves 16 integrated care organisations in different areas of the country, focusing on health and social care professionals can work together to develop services for patients.

After 100 applications to run the schemes, the winning 16 pilots range from improving the co-ordination of end-of-life care, preventing cardiovascular disease and encouraging more self-care for people with long-term conditions.

The pilots begin today and will run for two years and will be evaluated for their effect on health outcomes, improved quality of care and service user satisfaction.

Health Minister Ben Bradshaw said this was an opportunity for patients to get all the health and social care they need in one place.

‘This programme provides an opportunity for clinicians – working closely with the community more widely – to use their on the ground knowledge to design services that are flexible, personalised and seamless,’ he said.

Integrated Care Pilots – Pilot Summaries

1. Bournemouth and Poole Teaching PCT

This pilot will be exploring a new model for delivering care for older people with dementia, involving collaboration between GPs, public sector organisations and third-sector services. It aims to provide a single point of access to an integrated community team.

2. Cambridge Assura LLP

This pilot will look at how different organisations across the health, social care and third sectors can better communicate and co-ordinate end-of-life care to enable people to be cared for and die in the place they choose. The pilot will also be improving public and patient engagement to ensure services are fully sensitive to user needs.

3. Church View Medical Practice, Sunderland

This pilot will improve quality of care and experience of services for the area’s population of older people. The local acute trust and GP practice will work together as an integrated organisation, and will work in partnership with the PCT provider arm, social services and the patient practice group. The pilot will aim to provide an improved, personalised experience through active management of long-term conditions.

4. NHS Cumbria

This pilot will be exploring a new approach to helping patients with chronic diseases to manage their own care. It will be focusing on increasing the collaboration between GP and patient. It will aim to move care into a community setting and reduce hospital admissions.

5. Durham Dales Integrated Care Organisation

This pilot will involve seven partner organisations working together to meet the needs of a rural population, provide continuity of care and reduce health inequalities. It will explore a number of different care pathways aiming to improve planning information, move care into a community setting, increase patient/carer satisfaction and reduce hospital admissions.

6. Nene Commissioning CIC

This pilot will develop new models of long-term condition management to help patients remain independent for longer and have more choice in their end-of-life care. It will create personalised care plans for high-risk individuals and aim to reduce admissions to hospital.

7. Newcastle Hospitals NHS Foundation Trust

This pilot will provide an improved preventative service for over 60s at risk of falling by broadening the current falls and blackout (syncope) service provision. It will enhance provision and access to care and establish a network of community-centred training services led by clinicians, in partnership with the third sector and other agencies. By developing these community services the pilot aims to reduce the number of falls and admissions to hospital.

8. Cornwall & Isles of Scilly PCT

This pilot will unite primary, secondary, health and social care services by setting up a GP-led memory clinic supported by a team of practice-based case managers and dementia care advisers. It will seek to increase the number of people receiving an early diagnosis, reduce admissions to hospital and care homes and see people maintaining independent living for longer.

9. NHS Norfolk and Norfolk County Council

The focus of this pilot will be on integrating care services for the elderly. Joint working between the PCT and the County Council will identify people in need of support and then work with them to develop personalised care plans. It aims to help elderly people live fulfilling and independent lives and to form care plans that meet the needs of both patients and carers.

10. Northumbria Health Care NHS Foundation Trust

This pilot will be exploring a new approach to helping patients with Chronic Obstructive Pulmonary Disease (COPD) to manage their own care. The pilot will ensure providers work together to co-ordinate care, provide consistent information and education and help patients manage their own care (with assistance from their key worker).The pilot aims to increase patient satisfaction, reduce hospital admissions and reduce the length of stay in hospital when admission is required.

11. North Cornwall Practice-Based Commissioning Group

This pilot involves 10 GP practices in North Cornwall working together to integrate Mental Health community teams, based in a rural location, with a single point of access from GP practices. It will integrate Mental Health acute and social services. The pilot will aim to dissolve boundaries so patients can more easily navigate through the system and ensure they ‘only have to tell their story once’.

12. Principia – Partners in Health, Nottinghamshire

This pilot is designed to help create more informed and empowered COPD patients. It will involve partners working together through two projects to identify ‘at risk’ patients, and work with teams in community wards and with other partners involved in COPD treatment to integrate care along the clinical pathway. It is designed to improve co-ordination of care, increase patient satisfaction and reduce hospital admissions.

13. NHS Tameside & Glossop

This pilot will be seeking to change behaviour amongst people at risk of CardioVascular Disease (CVD). It will involve developing partnerships to identify ‘at risk’ residents, supporting them with diagnosis/treatment but also promoting self-care and behaviour change. The aim is to reduce the risk of CVD (and reduce mortality rates for patients who have contracted it), improve the patient experience and reduce visits to Outpatient clinics.

14. Torbay Care Trust

This pilot will be integrating care for the elderly so that it is personalised and tailored to individual needs, secures best possible outcomes and ensures best use of resources. It will involve partner organisations across primary, secondary, social care and mental health services focusing on the whole care pathway, seeking to deliver high-quality, safe, and reliable services for patients across the spectrum of care.

15. Tower Hamlets PCT

This pilot will be helping patients with long-term conditions to manage their own care. It will help patients make their own choices, with support from a range of diverse services and specialists locally. It will aim to improve health and well-being for patients with long-term conditions, increase uptake of services from targeted hard-to-reach groups and reduce the expected trends in long-term conditions.

16. Wakefield Integrated Substance Misuse Service

This pilot will integrate care in the context of a substance misuse and social reintegration service for vulnerable people. It will involve a partnership of NHS, third sector and wider stakeholders and aim to make measurable improvements in the “care experience” for substance misusers, creating integrated pathways that are both personalised and cost efficient.

Pilots welcome as no one model of integrated care will work everywhere

King’s Fund Press Release | date: 01.04.09

Commenting in response to the Department of Health’s announcement today of new pilot schemes trialling the integration of different patient services including health and social care, The King’s Fund’s Chief Executive, Niall Dickson, said:

‘Bringing different services together in this way offers great potential for improving the quality of care patients receive. Too often boundaries between health and social care prevent people getting the care they need. Patients have to find their way around a complex system of doctors, community health workers and social care services when they should be able to talk to a single person about all their care needs. Some patients can end up blocking hospital beds when what’s best for them would be more support at home. And poor co-ordination between health services in the community and hospitals can mean unnecessary admissions and poor aftercare.

‘As more people live with long-term conditions, the challenges posed by chronic disease management and care planning will require services that are able to respond to the range of needs each patient has. Having a clear single point of contact for all services and ensuring better joint working between local health services and local councils should help people manage their conditions more effectively and receive more personal and convenient care.

‘The major challenge will be getting different health professionals – generalists and specialists, social care workers, community and hospital-based staff – to work more closely together. New and better types of care cannot be delivered simply by housing different professionals under one roof or merging multiple organisations. It requires bringing teams together, integrating the way staff work and creating new relationships between organisations.

‘It is also important that we do not create new monopoly organisations around the NHS that deny patients choice – we need services that are responsive and understand that either patients or commissioners may decide to go elsewhere.

‘It’s also important to recognise that there is unlikely to be one model that will work everywhere. That is why these pilots are to be welcomed but it is also why they will need to be thoroughly evaluated. The government has a habit of setting up pilots and then rolling out before lessons are learnt – that must not happen this time. This is a chance to learn genuine lessons about the best way to organise services.’

Notes to editors

  1. For further information or interviews, please contact The King’s Fund press and public affairs office on 020 7307 2585, 020 7307 2632 or 020 7307 2581. An ISDN line is available for interviews on 020 7637 0185.
  2. The King’s Fund is a charity that seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.
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