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Monday 26 September 2016
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From PBC to "polysystems" – a new commissioning model in east London

CONOR BURKE
Borough Managing Director
NHS Redbridge

NHS Redbridge has introduced a new model of healthcare in east London that has taken practice-based commissioning (PBC) to the "next level".

The PCT has spent the past two years working alongside local clinicians to establish five area-based "polysystems" – GP-led networks of care professionals – that will be increasingly be responsible for the health needs of their respective communities.

The GP-led polysystems will have sweeping new powers to decide how and where money is spent improving health outcomes. This move could eventually mean that clinicians gain control of an annual budget of more than £400m.

This role has traditionally been held by the PCT, but at NHS Redbridge we took the decision to disband the borough's three existing PBC clusters last year in favour of the new model.

It's no secret that many GPs felt frustrated with PBC and the fact that the PCT ultimately made the decisions.

The polysystems differ in that GPs now have real financial and decision-making power to effect changes, such as the redesign of care pathways as well as commissioning services on both a local and borough-wide level via a clinical commissioning board.

It makes sense that clinicians are in the driving seat, given the intimate understanding of their communities. This will help them design and deliver healthcare measures that not only address current need but also anticipate future health trends, such as diabetes.

Another important facet of the polysystems work is to bring more health services closer to home so that people can be treated for a wider range of conditions within their neighbourhood.

A super health centre, or polyclinic, will eventually sit at the heart of each polysystem, providing a wide range of services under one roof. Each polyclinic will be linked to surrounding surgeries and pharmacies that can refer patients for treatment.

This inevitably calls for greater partnership working between primary and secondary care, as many traditionally hospital-based services, such as a diagnostics and outpatient appointments, will move into a community setting.

Below are two case studies from local GPs who are also clinical board members of two of the new polysystems. They share their insights into the challenges and successes of this commissioning model.

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Case study one: Dr Narinder Shah

Narinder Shah grew up in Redbridge and has worked there as a GP for the past 10 years. He is Clinical Director of Loxford Polysystem, home to the capital's first purpose-built polyclinic. The polyclinic offers more than 20 services under one roof including GPs, an inhouse pharmacy, diagnostics and hospital outpatient appointments. It is located in one of the most socially and economically deprived areas in London, where male life expectancy is eight years less than in other parts of the borough.

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"I come face-to-face with a lot of poverty and hardship as a local GP, both in my surgery and during house calls when patients are too sick or infirm to leave home.

Loxford suffers high unemployment and has a large ethnic community that presents a unique challenge in terms of education and access to health services.

There are many factors that affect health, such as poor-quality housing, education, unemployment, and cultural and language barriers that require a more focused multi-agency approach.

Local issues include a higher-than-average prevalence of chronic heart disease, diabetes, obesity and teenage pregnancy, together with high emergency admission rates.

The polysystem is a step in the right direction because it is drawing local health professionals into a collective where we begin working alongside one another instead of independently.

It puts GPs in the diving seat, giving us a major say about how and where money is spent in our polysystem. We know the local issues and what concerns patients have, and that will allow us to provide a more effective responsive service.

I chair the Loxford Polysystem board, which comprises of GP representatives from local practices. We meet regularly to discuss local health needs and services we need to be commissioning to best address these problems.

In future, we aim to work with other partners, such as other health professionals and voluntary and community groups, to ensure wider stakeholder investment.

In addition, the clinical directors of the respective polysystems sit on a clinical commissioning board along with PCT directors. This overarching body is responsible for taking forward the borough-wide strategic commissioning agenda.

Our first challenges include tackling the variation in referral rates to secondary care between practices and inappropriate A&E admissions.

However, some straightforward changes have already taken place and are already beginning to have an impact on patient experience, such as the availability of diagnostic tests that patients can access quickly and conveniently, closer to where they live.

It's all about providing greater access to more services closer to people's homes. A good example of this is the polyclinic that has been open nine months. Anecdotal feedback is positive because it is minimises the need for hospital visits and is more convenient for patients.

My biggest concern is trying to operate effectively within the current financial climate. Polysystems will have to work within the tough financial constraints now placed on the public sector.

The other issue is whether the PCT will deliver on its rhetoric about polysystems and the promise that GPs and fellow stakeholders have a real say about what happens.

We have had disappointments in the past. PBC started with good intentions then fizzled out. I hope and expect that we will be given the support to make this work.

The bottom line is that I am involved in this because I think it's an opportunity to make a positive difference to the health of the local community and to patients' experiences of the health service.

There are no quick fixes, but greater GP involvement in the commissioning services and redesign of care pathways will have a big impact in the long-term."

Figure 1 (below). Diagram of the Loxford Polysystem structure.

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Case study two: Dr Sarah Heyes

Sarah Heyes is one of five GPs appointed as clinical directors to oversee the work of each polysystem. Sarah works three days a week as a GP at one of the borough's most successful practices. The mother-of-four originally qualified as a dentist before moving into surgery and her current role.

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"I see my job as the link between GPs and the PCT. Both sides have skills to bring to the table and it is important we have a good working relationship.

Previous interaction could be frustratingly one-sided, which initially left many GPs sceptical about polysystems and how much influence we'd have.

Polysystems are a big step forward and will give GPs far-reaching decision-making and financial powers that are currently held by the trust.

It's a bold move and one that should be applauded because it has huge potential to really improve health outcomes across this part of north-east London.

GPs have long said that they have the grassroots knowledge and experience to really make a difference in primary care, and we now have the opportunity to do that.

This includes everything from reconfiguring services and redesigning care pathways to simpler practical measures, such as introducing a local blood-testing service.

It's about partnership working – each polysystem is made up of a collective of local health professionals including GPs and pharmacists. We are also committed to forging stronger links with secondary care and community and voluntary organisations.

It's an exciting time but also a very busy one. The trust is providing each polysystem with ongoing support on the business side of things, such as commissioning and governance.

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

I'm personally responsible for Wanstead Polysystem, which includes 14 GP practices. We meet once a month to discuss what needs to be done and see how each practice is performing against pre-agreed targets.

One of our first challenges is looking at ways of reducing the number of first-time outpatient referrals and inappropriate use of A&E.

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

The polysystems collectively aim to reduce unnecessary first-time referrals by making a £3m saving across the borough. It's a great opportunity to put our heads together and share what does and doesn't work.

For example, the surgery I work at already has a low first-time referral rate because we club together to try and find an "inhouse solution" or ring a hospital consultant asking for advice before even considering a referral.

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

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

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

These are small but practical steps that can make a big difference, and we are now sharing that with other practices in the polysystem.

Working smarter can save a lot of wastage. Our initial incentive has been: the more we save, the more money comes back into the polysystem.

I think the recession has had a positive effect in that it has given people a renewed sense of urgency and focus to get things done.

Each polysystem will eventually have its own polyclinic, which will offer a broad range of services under one roof.

This will be linked to surrounding surgeries, pharmacies and hospitals to ensure that patients can be treated for the majority of their conditions in the community.

An important part of the polysystem's success is the input of its community panel: a group of local residents who meet on a monthly basis to make suggestions and provide feedback about the polyclinic.

Similar panels are in the process of being set up in the remaining four polysystems, and will ensure that patients have a strong voice about how healthcare needs are addressed in their area.

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

NHS Redbridge

Related stories:

Budgetary handover period begins at Redbridge PCT

First seven polyclinics in London now open

Tories plan to give GPs new patient budget powers