Feature / Bridging the gap

NHS Redbridge is helping its GPs prepare for their new commissioning role with a new locality model and ‘firm’ budgets. Seamus Ward reports

Redbridge Primary Care Trust is at the forefront of the drive to introduce GP-led commissioning across the UK, having already transferred 80% of its budget to five area-based commissioning groups. And while this polysystem model may not be exactly the reforms envisaged by the coalition government, the seeds of GP commissioning are already bearing fruit in north-east London.

Conor Burke, interim chief executive of NHS Redbridge, says the process of putting GPs in control has taken more than two years of negotiation with clinicians and other local health professionals. He argues that putting GPs in the driving seat must be matched by a commitment to provide them with access to a comprehensive range of data covering every facet of patient care, together with genuine control of budgets, management of resources and responsibility for outcomes.

Polysystem impact

The PCT and its GPs agreed to move away from three practice-based commissioning groups to five polysystems that have their own board and clinical director nominated by local GPs and paid for by the PCT.

Each polysystem is responsible for the health of up to 50,000 people and collectively they report to a clinical commissioning board whose members include the clinical directors.

To date, the fledgling polysystems’ achievements include more effective referral management for first-time outpatient appointments, a 9% increase in use of the local independent sector treatment centre, two new care pathways for diabetes and coronary artery disease and new dermatology and ophthalmology pilots, which will have greater focus on treatment in a primary care setting.

Five community-led panels meet clinical directors bi-monthly to help shape commissioning. The Loxford Polyclinic now offers more than 30 services under one roof.  The polyclinic has attracted more than 1,000 new patients since it opened in June 2009 as well as accommodating up to 300 hospital-style outpatient appointments a week

However Redbridge, like so many other PCTs, faces big financial pressures. In the past year, the clinical directors have designed and agreed a plan to make savings of about £8m against the PCT’s budget of £440m.

‘Two GPs recently went before our non-executive directors to explain why they were committed to leading this productivity programme with the aim of balancing the finances by the end of the year,’ Mr Burke says. ‘They are clear about the financial challenge and are looking to us to help them with the information and the data analysis.’

Mr Burke says the GPs’ budget is ‘firm’, rather than ‘notional’ or ‘hard’, reflecting that, as with practice-based commissioning, there are no consequences for practices if they fail to live within their means.

There are other pressures to maintain downward pressure on spending. The PCT’s interim finance director Frank O’Neill says transparency is a key element of the Redbridge model, with the PCT sending practices reports not only on their own activity and resource use, but also others across the PCT. This allows for benchmarking and peer pressure, which incentivises GPs to improve their efficiency.

‘At the moment we are not at the point where there is a financial penalty for individual practices but they all know consortia are just around the corner. We are doing the ground work so they can hit the ground running when change takes place.’

Mr Burke adds: ‘A few years ago we tried saying to our practice-based commissioners they could keep 10% of any savings they made, but it didn’t necessarily work. Transparent benchmarking of each practice and polysystems does seem to work. If you agree a RAG rating system with them they move rapidly from red to green.’

The next stage will be to decide on the shape and size of local consortia. Mr Burke says this is entirely up to the GPs. But he adds: ‘If they were to ask me that question, I would say: “Why change something that seems to be working?”. I think you need commissioning at lots of different levels – commissioning at the level of a polysystem population of 50,000 up to the borough level of 250,000.

‘But the really big question, as the BMA has alluded to, is commissioning at the level of the acute hospital landscape of 500,000 people. I suspect we will need to establish agreements around how we commission and ways of working at all these levels.’