How our passion for innovation has made us a quality care provider

Posted on December 7, 2009. Filed under: News stories | Tags: Horizon Health Choices Ltd, Provider-commissioner |

Pulse | Practical Commissioning | Focus on…..Becoming a provider | 7 December 2009

John Rooke, chief executive of Horizon Health Choices, explains how this GP-owned private provider company has developed innovative ways to offer patient care.

When the Department of Health launched practice-based commissioning in March 2005, GPs in the 26 practices in North Bedfordshire were particularly passionate about working together as commissioners. At the same time we realised that the local providers might not be able to give us all we required. The solution lay in actually providing the local services needed ourselves.

We considered several models for how we might go about this – for example, setting up a limited liability partnership. But we decided on a limited company principally because of speed. It was going to be quick and straightforward to set up as a company and we wanted to get up and running as soon as we could.

So in May 2006, Horizon Health Commissioning and Horizon Health Choices Ltd were launched simultaneously – the former for commissioning, the latter for provision, covering a combined patient list size of more than 160,000. On the commissioning side, we are lucky enough to enjoy excellent working relations with local NHS organisations such as Bedford Hospital Trust and Bedfordshire PCT, which creates an atmosphere in which improvement flourishes. We also operate cohesively with our neighbouring practice-based commissioning groups to share ideas and strategy for patient services that transcend our own boundaries.

Setting up the company

Horizon Health Choices Ltd – the provider company – is owned equally by all the practices, which together represent about 40-45% of the PCT (now NHS Bedfordshire). To get started, we needed a business plan. This set out the articles of association, including that the company would be owned equally by the practices and that all practices would be represented on the board by a director. In practice, that director is the shareholder on behalf of the practice. We also mapped out in detail our safety processes, clinical governance and so on. The company is overseen by a six-strong executive team – half of them GPs.

The share issue generated hundreds of thousands of pounds from the practices, giving us enough capital for initial investment and the various administration and other costs involved in starting up.

At present, we do not have NHS pensions status, which means NHS clinicians working for us can’t pay into their pensions – which is a drawback in terms of our ability to attract people. But we have submitted an application to the DH so they can see we are part of the NHS family and we are hopeful that it will soon be sorted out.

A key difficulty we faced at the start was the focus you have to place on quality. It’s great for patients but very time-consuming getting all the governance processes in place. Other GPs thinking of starting up an enterprise similar to ours should be aware of that – it’s the really onerous part.

Conflict of interest

We have been aware from the start that in providing care for profit as well as commissioning, we could be seen as having a conflict of interest. However, this is taken care of by the PCT because if we write a specification from the commissioning point of view and say we want a specific service, they will scrutinise the need for that service before any discussion takes place about who provides it. Also, there are clear GMC guidelines about conflicts of interest.

Our PCT is very sensible about the fact that our commissioning body and provider company are ‘coterminous’. We all want the best for patients. In fact, if we bid for a service and don’t get it, we’re glad because it means someone better than us will do it.

Finances

Financially, we have made surpluses but the shareholders haven’t yet taken dividends. All the profits have so far been ploughed back into the business. There are people within the NHS who are uncomfortable with taking profit from providing care but we feel that the model sits comfortably alongside general practice because GP practices themselves make profits.

It is difficult to put a figure on our annual running costs, but our turnover for 2007/8 was about £70,000, for 2008/9 it was about £600,000. In 2009/10 it will be about £1m.

Staff

Back in October 2006, it was just me. Now we employ more than 40 people, including the clinicians working for our services. We have seven or eight administrative staff including operational managers. We are also recruiting a quality and patient safety manager who can take on the quality control work. This person will also help prepare our application to register with the Care Quality Commission.

Our services

We launched our first service – a community gynaecology service – in April 2007. We learned a lot from this, getting the right processes in place. We used an APMS contract, which took a while to get sorted out. This service is still running, based in the Wooten Vale Healthy Living Centre, a GP practice near Bedford. We employ a consultant gynaecologist who works at Milton Keynes Hospital.

The service covers pelvic pain, vulval problems, fertility and preconception advice, and recurrent miscarriage advice. The decision to launch it was opportunistic. It needed doing, the right consultant was available and we happened to know a nurse specialist who was perfect for the role.

Then in January 2008 we launched our musculoskeletal triage and treatment service. Our local hospital department was extremely busy and needed help so we went for it. Patients are referred by their GPs and then assessed by a multidisciplinary team, including musculoskeletal medicine GPSIs and extended scope physiotherapists, and are directed to the most appropriate treatment. Our guesstimate is that this has saved the NHS £250,000 so far.

In May 2008 we added our community chronic pain service. Our consultant is an anaesthetist and pain specialist with expertise in managing chronic pain and offers a one-stop assessment of patients’ needs at our treatment centre at Bedford Hospital. There was basically no chronic pain service before and patients had to travel long distances for care. In addition we were able to offer care on Saturdays and in the evenings, rather than just nine to five.

GP referrals to these services are by proforma which are available on our website http://www.horizonhealth.co.uk. The community gynaecology service has just been launched on Choose and Book.

We try to ensure patients are ‘worked up’ before they are referred to keep within 18 weeks. For example, GPs will order X-rays at the time of referral.

Taking services further

In September 2008 we were asked to pilot an Improving Access to Psychological Therapies (IAPT) service as part of a national pilot in collaboration with Bedfordshire Community Health Services and the Bedfordshire and Luton branch of mental health charity Mind. IAPT is not normally covered by practice-based commissioning as there is no tariff for it, but in this case there was a combination of national and PCT funding available. It is part of the scheme launched nationally by the DH in October 2007 with £170m nationwide funding and the aim of training 3,600 therapists, treating 900,000 patients and allowing open access to GP referral.

Patients are offered an initial assessment and are recommended a course of treatment based on their needs and pre-determined pathways defined by NICE guidance. Mind offers telephone-based advice and support including computerised cognitive behaviour therapy to people with lower levels of need.

Working with Mind has been excellent. The scheme is due to end in March 2010, but it currently looks as though that might be extended while the PCT tenders to take it on permanently.

Other things we have been doing include offering health checks for hard-to-reach groups – for example, in sheltered housing for Bangladeshi people.

Outcomes

It is very important to keep track of what we are achieving so we can continue to improve. We survey every single patient to try and glean as much feedback as possible. We also seek feedback from referrers and routinely audit incidents and complaints.

Headline outcomes include:

• waiting times are now only two weeks for both our musculoskeletal service and community gynaecology service

• our IAPT service has halved levels of anxiety and depression among our patients, helping them back to work in the process.

Future plans

Since taking on the IAPT work, we have been consolidating our other services.

We’re also looking to get involved in new services where we can add value, working with a variety of different partners. We certainly wouldn’t rule out offering our services further afield too.

These are tough economic times, so where we can use our existing infrastructure to expand, it makes sense to do so. Among a number of other possibilities, we are looking at launching an out-of-area musculoskeletal triage and treatment service down the road in Luton. We have also been thinking about launching an obesity service offering personal plans and dietary support – not exercise on prescription but more of a multidisciplinary approach.

We have been and continue to be innovative. I’m not aware of any other provider body that has gone as far as we have in terms of what we offer. The basis for this is that the PBC side of what we do is as good as it gets. We have some extremely dedicated and passionate practices and that has engendered an atmosphere that makes things happen.

John Rooke is chief executive officer of Horizons Health Choices Ltd

john.rooke@horizonhealth.co.uk

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