Frontline clinicians who have grasped the nettle of practice-based commissioning (PBC) are showing that it is possible to deliver significant improvements in patient care while also saving the NHS money.
The early adopters who have succeeded are being championed by the Department of Health (DH) and the NHS Alliance as beacons of good practice.
"PBC has liberated frontline clinicians to deliver the best for their patients – the best is very good indeed," remarked NHS Alliance chairman Dr Michael Dixon recently.
But he also cautioned that PBC has yet to be universally implemented, that PCTs need the will to devolve commissioning to the frontline, and that GP practices need the enthusiasm to take onboard the opportunities on offer.
Management in Practice has talked to three practices in the vanguard of PBC about their early gains and the challenges they faced.
Mount View Practice, Lancashire
As soon as the DH guidance on PBC was published in 2004, the Mount View Practice in Fleetwood, Lancashire, which serves 13,000 patients in an area of high deprivation, recognised the opportunities it had to offer.
They adopted a policy of engaging all practice staff in the enterprise and gave PBC priority by setting aside protected time and holding "away days" and regular Wednesday afternoon sessions in order to brainstorm and develop their plans.
Under PBC, the practice has developed:
In the first year, the practice took on a fulltime pharmacist to improve the management of patients with long-term conditions and manage the prescribing capital. They also recruited a mental health nurse and a mental health counsellor to
establish the new mental health team.
An independent medical adviser is paid £9,000 a year to help implement referral and prescribing protocols, and analyse emergency admissions data. A community nurse now works with a community matron, who is employed by the primary care trust (PCT), to focus on the provision of care for housebound patients with long-term conditions. A further £30,000 funds additional GP and practice manager time for administration and data analysis.
During 2005–06, the practice slashed outpatient referrals in dermatology and general medicine by more than 30% and referrals in orthopaedics by 15%. Fracture admissions were cut by 11%, and acute medical admissions by 3%. Prescribing spend was reduced by 8%, and net prescribing savings alone totalled £185,000. Overall, they reduced their spending in 2005–06 by more than £500,000 compared with 2004–05. This saving would have been greater had it not been for the £190,000 that was invested in increased use of medicines for heart failure, COPD and osteoporosis.
The expansion of services was not an issue because four years previously the practice had already begun to open during evenings and weekends in order to accommodate routine chronic disease management clinics.
"We are really, really proud of the services we provide for our patients, many of which they can't get in other practices," says PBC Lead Dr Mark Spencer.
Team building, communication and a culture of providing regular protected time for service development within the practice have been key to the success of the venture, says Dr Spencer. All staff, right down to the receptionist, are aware that they have a role to play.
An early challenge in 2004 was the time-consuming and complex process of scrutinising the Dr Foster data and cross-referencing it with the practice Read-coded data, as well as the need to train admin staff to do this. Dr Spencer also recalls that the PCT took some convincing that there were significant resource implications around data analysis.
Initially, the practice team also lacked the necessary business skills for this venture. As this expertise was not available through GP education, the practice had to think outside the box, eventually sourcing the training needed from the pharmaceutical industry, which is more geared up to operate as a business. Now, says Dr Spencer, this type of expertise can be more readily accessed through organisations like the NHS Alliance.
The services are all now well established and running smoothly, but plans to expand and roll further services have been stalled by PCT reconfiguration.
"A lot of our plans for roadtesting initiatives that we had with the old PCT are currently on hold, so we are still fairly small-scale and looking at things on a practice basis, rather than a consortium basis," says Dr Spencer.
The practice has made a conscious decision not to join their local PBC consortium. The consortium has to prioritise data collection and analysis over the next 18 months, as opposed to
The practice feels that they already have these systems in place, and are keen to work jointly with the PCT on various service development initiatives, such as how they can make better use of a community hospital on their doorstep.
Claremont Practice, Exmouth
Claremont Medical Practice used PBC to develop its existing integrated nursing team, so that it could focus on reducing emergency admissions.
Concentrating initially on patients with long-term conditions, the nursing team's aim was to promote an ethos of collective responsibility for patients' needs. This has now adjusted the culture across the whole practice team (see Figure 1).
This integrated approach, developed over a period of five years, was initially established under a personal medical services contract. Under PBC, an "invest to save" business case was approved by the PCT to fund extra staffing costs. The nursing team are now employed by the PCT – the practice reimburses the PCT for some nurses, including the nurse who is funded through PBC. The team works collaboratively, both in the practice and in the community, and there are no boundaries between the practice and district nursing roles.
Gaps in the team were identified, and a community pharmacist now works one day a week with the nurses and spends a further half-day in the practice working on the prescribing budget. A social worker also spends 20 hours a week with the nurses, because the practice recognised a need to engage with social services at a practice level.
All GPs are now engaged in the new way of working. Instead of automatically admitting patients to the local acute hospital, they now consult with the duty nurse who considers other options, including: intermediate care; calling in the rapid response team; a homecare package; and referral to the local rehabilitation unit or community hospital.
After the second year, the practice achieved:
The surgery was also extended to provide two new consulting rooms and a new room for the nursing team. The integrated nursing initiative saved the PCT £220,000, and, after deducting upfront costs, the practice saved about £150,000.
Last year, progress was held up by PCT reconfiguration and financial cutbacks. There were cuts to the practice budget, bed closures in the community hospital, and staff vacancies were frozen – at one stage reducing the nursing team from 14 to six. As a result, the practice saved nothing during 2006–07.
But practice manager Hazel Hunt says they are now slowly getting back on track, and they are in the process of finalising a contract to become a provider service.
The team will continue to work alongside other practices, now formed into clusters, and a range of new complex care teams, including physiotherapists and community psychiatric nurses, which the practice will be able to access and further speed up care for their patients. The practice is now working with a local PBC group of practices, in order to reduce emergency admissions by preventing falls.
Mrs Hunt commented: "There has been a great deal of professional satisfaction for everyone in the practice as a result of this work. It has very much been a whole team approach. There were also huge rewards for the PCT that invested in us because we produced the goods. But PBC is still very slow, and we don't yet know how it will develop in our patch of the woods or how any new schemes will be funded or taken forward."
Chilcote Surgery, Torquay
Chilcote Surgery has demonstrated how partnership working and effective service redesign under PBC can transform the lives of patients with COPD.
Nurses from the practice were already working with the Improvement Foundation's Long-Term Conditions Collaborative to reduce hospital admissions and improve the quality of life for COPD patients when an opportunity arose to work with the Met Office.
Using Met Office twice-weekly forecasts, nurses – who had already developed a COPD register and formed a specialist team to care proactively for patients – were able to help patients identify weather conditions that may exacerbate their symptoms. They could then help patients to take the appropriate actions to manage their condition. Patients were provided with information packs, including room thermometers and advice on how to prevent symptoms from worsening and when they may need professional help.
Some patients were also provided with personal management plans alongside their medication. When symptoms occur, patients can start to use their medication far more quickly, alerting their nurse or GP as soon as they do so to ensure that they are effectively monitored.
The work of the practice has been supported by Torbay Care Trust, which has established special procedures and appointed two community COPD nurse specialists to integrate services across the region. This proactive approach resulted in an 82% reduction in COPD-related hospital admissions between September 2004 and 2006.
Due to the success of the project, a local enhanced service (LES) commissioning framework for COPD has been developed to incentivise practices to implement this model throughout the PBC budget.
Sue Finch, who joined Chilcote Surgery as practice manager 21 months ago, says the PCT is very supportive of PBC initiatives, and has simplified the process as much as possible. The trust developed two other "off the peg" LESs – one for fitting coils and another for initiating insulin.
Having previously worked in banking, Ms Finch says PBC is a very different working environment. She is also involved in a PBC group of practices that is putting forward a business case trust funding, in order to employ a PBC manager to take over some of the extra workload.
Hot spots of good practice
NHS Alliance PBC lead Dr David Jenner says innovators are demonstrating that services can be improved and reshaped through PBC. But the reality is that very little is happening across the country except in these "hot spots" of good practice. The challenges are: continuing turmoil from PCT reorganisation; excessive bureaucracy; problems with inadequate hospital activity data; a lack of new money and incentives available to make PBC happen, plus the fact that PBC is really hard to "sell" in deficit areas. A small number of PCTs may have been reluctant to get behind PBC – likewise some GP practices are slow to get engaged.
The DH claims most GP practices do back PBC. A recent DH survey shows that 57% of practices support the policy, and a third of practices have commissioned one or more new services through PBC.(1)
But while more than half (56%) of practices have received an indicative budget for 2007–08 from their PCT, most believe it has yet to make a difference to the way they operate. Less than half of the 1,198 practices that responded to the survey said they had agreed a commissioning plan with their PCT.
Even though 72% of practices say they have a good relationship with their PCT, more than half say management support and information is poor.
Dr Jenner says the survey confirms the NHS Alliance's own on-the-ground intelligence: that most practices are keen on the idea of PBC, but are frustrated by the lack of implementation progress. "This is our biggest worry," he comments. "Ministers are giving a very clear message that they support PBC, but that message seems to get lost by the time it gets to PCT managers at the frontline."
But Dr Jenner is optimistic that the DH's next quarterly survey will show improvements. He says the ingredients for practices that have achieved success with PBC are always the same – good relationships between the practices and the PCT, based on a clear vision and aims for PBC, plus management support with good-quality financial and activity information.
"There is wide agreement that we have the right policy – and there are areas where it is already working well," he says. "Yet in other places, PCTs and strategic health authorities are in denial over real problems with implementation. If they continue to maintain the mistaken belief that all is well, PBC will fall apart."
But he concludes: "There are a lot of problems, but I would not say there is no chance for PBC as a policy to succeed. These three case studies show that when practices and PCTs talk to each other, they can make a great difference to
1. Department of Health. Practice-based commissioning: GP practice survey: Wave 1 (June 2007). London: DH; 2007. Available from: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=15274...