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How are we going to support GP commissioners in managing ‘quality’ in their member practices, and does this relate to commissioning quality or provider quality or to both?
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What could be the most appropriate process for the handling of individual commissioning requests as we move to the new commissioning system (this refers to exceptional treatments etc)?
Dr Mike Guy, Medical Director (joint position),NHS North of Tyne and NHS County Durham and Darlington
As you are probably aware currently each PCO cluster has a slightly different process for assessing and handling these requests variably involving NEDs, PEC clinicians, GP commissioners and PCO officers and that each process seems to operate effectively and as a result legal challenges to the process have all but disappeared in the last 2+years.
Whilst each PCO cluster has a slightly different process for the handling of these requests what is consistent is the regional suite of policies that support the process and that since 1/8/09 each PCO cluster has used with one set of amendments brought in on 1/11/10.
The consistency that these policies have brought to the process is very effective and my advice would be as this bit is not broken it does not need fixing it needs developing.
What it does need is a regular review and updating system which will
1. Review, update and amend the existing policies
2. Add new policies as required
During the teleconference last week we became aware that Mike Prentice has been having discussions with the vascular network about varicose veins and I have also been approached by the ENT surgeons in NuTHFT about their concerns relating to the policies on tonsillectomy and grommets. These policies are commissioning policies and therefore part of GP commissioning, the updating of the policies is a job for PH clinicians who are keen to be involved and have the added advantage of still being around, albeit in LAs, after 31/3/13.
Could I suggest that the coordination of review of these policies going forward is led by the PH clinicians who are already discussing how this will be done and following a chat I had with Mike Lavender (CDD) last week it is clear that each PCO cluster has PH clinicians with the expertise Ie Mark Lambert (SoTW), Bharat Sibal and Sue Gordon (NoT) and Toks Sangowawa (Tees), I also understand that this PH group has already developed a work programme to this end. Secondary care clinicians will of course be consulted as part of the formal process of review and development.
Assuming we maintain this policy consistency then the management of the assessment of these IFRs can be handled initially at GP consortium/PCO cluster level-level 1- with only truly exceptional cases being passed on from the clusters to a single NHS NE exceptional treatment ‘panel’-level 2.
For this to work though needs more policies to be developed, a review process in place and the willingness of GP commissioners to get involved, accepting of course that for the next 2 years PCOs are still accountable for the system.
Essentially what we need to ensure is consistency of process and outcome and prevention of the rebirth of the postcode lottery where the only winners will be the lawyers and the losers will be the patients.
What do you think of my suggestions of
1. The principle of consistency
2. The policy review process
3. The 2 level assessment process?
Stewart Findlay, Bishopgate MC, PBC Chair Durham Dales Locality
I agree and if we can all agree on a single policy for excluded and prior approval procedures across the North east this will help everyone. I know Mike Lavender has been keen to set this up for some time.
I wonder how you see level 1 working - it seems to me that this might best be done at a County wide level as it is now rather than by each individual GP consortium and would hope that this can still be led by public health?
What is the next stage? would our public health consultants be able to draw up a proposal for a NE wide policy and could we then get each GP consortium to sign up to it. They would be mad to want to do this themselves and so sign should hopefully be easy!
Carl Parker
Hope I'm not too controversial here.
For me the really important thing is how do we stop postcode lotteries in availability of care developing and I think this is the task we have been set by the RAG. For me the following are important
1/ what existing practices/structures should be maintained as core to all. What new ones should be developed?
2/how do we get all consortia to agree to abide by them
3/how do we get consortia to take ownership of them and responsibility
4/ what representation will be necessary in each group from consortia- could there be lead consortia/clusters of consortia that will represent all. Currently each PCO cluster has representation on each group but it would not be efficient for each consortia to be represented.
5/ how do we get policies updated eg exceptional treatment policy. will clusters commission public health to do this, will they want to do it themselves, who will search the evidence base, where is the expertise, how will they know they are getting a defensible product?
6/ how do we ensure they are implemented in primary care and secondary care in a consistent fashion.(Even though we've had an ETP for 2 years it hasn't been consistently implemented across the NE.)
7/ what will be done at a consortia level, consortia cluster level or NE level.
In summary I think we need to work on the high level strategy and delivery rather than the individual content which as Mike points out is not broken. I would caution setting public health off at this stage to rewrite anything as unless we have buy in from the consortia and have answered the above points it may all be in vein. ( How many consortia have even considered their relationship with public health at this stage- let alone what that relationship will be like when public health is in the LA.)
Finally the TORs should set out what we're expected to do.
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How can GP consortia engage with patients at an appropriate scale to inform commissioning decisions?
Dr Jane Weatherstone at Engage Health
Patient engagement is always really difficult. For many years GP surgeries have had patient involvement groups - these have often been small self-selecting groups of interested patients, sometimes with an axe to grind.
However we have noticed that these groups are changing- our consortium now have patients who sit in waiting rooms and talk to patients about their experience at the surgery. Those waiting often feel more comfortable talking to other patients and we sometimes hear the ugly truth. This is powerful stuff which we able to use to inform our decisions regarding patients care.
More recently, as we have been developing our consortium, we have developed a patient board. This is composed of a patient from each member practice, and there is representation on the main board. this group can be used to discuss initiatives, ratify decisions and suggest new ideas. This is still a developing piece of work- we hope that there may be patient "working groups" which can feed back into the board and further patient involvement. This is not revolutionary but a step forward for patient engagement.
Dr Ashley Liston at Encompass GP Practice
Agree with Jane that patient engagement is not easy to achieve. Good general practice should be constantly seeking to achieve a patient centred approach to care. It is something we aspire to in the consultation and something many practices also seek to achieve in their practice planning. Patient participation groups can certainly be poorly representative of the needs of all patients of the practice with many ‘hard to reach’ groups such as teenagers and men being conspicuously absent.
The real challenge is to avoid tokenistic efforts in representing patient needs or being biased by the views of those who are chosen to represent their community. The challenge that GPs have to represent their patient lists will now be extended to the need for them to have local communities represented. I do believe that GPs could be very well placed to engage effectively with patients and community through their role of trusted advocate for patients and knowledge and links with the local community.
It does seem essential that patient engagement should involve going out to the community to find effective patient representation rather than simply expecting the patients to come to us. The concept of ‘community champions’ who can effectively listen to and communicate with the community might complement the GP advocate role. With larger consortia which might represent several communities this approach might be especially valuable.
The real challenge will be for clinicians to see patients not only as allies but also as equals. We have really appreciated having a patient rep at all our practice exec meetings and also at all GP and nurse interviews. It has been a revelation to have the honest comments and views of patients at this level of practice planning and developing this culture from the start should be an aim for all GP led commissioning groups.
Rachel Chapman, Director of public engagement and communications at NHS North of Tyne
It’s true that there are challenges around engaging patients and the public in commissioning, particularly in terms of ensuring a proportionate response to meet the requirements set out in sections 242 and 244 of the NHS Act.
However, it’s important to remember that a wealth of information has been gathered over the last few years on what local people and communities want from their local services. Some GP practices, primary care trusts, local authority partners and the community and voluntary sector already have a depth of understanding about the views of local communities which can be built upon.
The real challenge is building trust with communities to sustain their interest in taking part in engagement activity on commissioning. This is best done by engaging people at the earliest opportunity when considering developments or change, being honest from the outset about how much influence they actually have (to avoid building unrealistic expectations) and then showing how their comments have made a difference.
Generally, how difficult or easy it is to engage people will depend on a whole range of factors, including the actual topic, understanding how this could impact on particular communities and whether the proposal is locally or nationally driven.
In terms of the actual method of engagement, there are many different ways to do this. Involvement starts with understanding what information already exists, engaging groups and mechanisms that are already out there and working with key partners, using their structures.
The best place to start is by referring to existing information – this may be relevant to a local community and practice population(s), or it may apply to wider populations, regionally or even nationally. There may be local projects which provide background, or partially cover a topic, or which relate to general views of a community, for example, about transport, access to urgent care or attitudes towards health prevention initiatives.
For engaging groups, there are currently a number of very successful projects that have been initiated or started which can be learned from such as working with patient or community groups and developing ways of encouraging participation alongside people’s own natural interest in their own health. Experience shows that one of the most successful ways of doing this is not necessarily by establishing new groups or structures to apply to everyone but through existing mechanisms. This means going to places where people are already meeting and using tried and tested or new and innovative ways to begin discussion. A real advantage that GP consortia have is that many local people are accessing their services regularly and members of the public identify with them.
For wider engagement some consortia will already be developing relationships with local authorities, local involvement networks (LINks) and the community and voluntary sector. Such dialogue is crucial and should be ongoing to ensure that people of influence within the community are well informed and to avoid duplication of effort and over consultation.
Finally, as we all know, the national direction is ‘no decision about me without me’ which means that the emphasis on engagement is not going to diminish any time soon but rather, it is likely that it will grow. While it can’t be denied that meeting statutory requirements and national directives in this area of work is time-consuming and needs careful planning, we know that listening to and responding to the public is vital to ensure a patient centred health service. There will be opportunities in the coming months for previous and ongoing work to be shared with GP consortia. This will help ensure they receive the right level of support to embrace the challenges that lie ahead.
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What will you as a pathfinder take on from January to April 2011 and be accountable for - be meaningful in terms of impact on patient services and create a ‘positive tension’ in the system.
David Thorne on behalf of Newcastle Bridges
To address prescribing we'll need PCTs to support us in unpicking the current support infrastructure and improving the reporting systems in some areas - clearly we're looking to manage to budget but feel a case can be made for investment into prescribing to save on admissions, although that doesn't mean that the overall prescribing budget needs to increase.
Welcome the progress through recent shared contact so how can we develop that recognising that we are in danger of being overwhelmed by meetings and can't get away from the reality that no local potential pathfinder has infrastructure in place that is anywhere near ready - a true transition plan has to run at the same pace.
The Pathfinder application and feedback shows the required pace and extent of change. Much that is unknown is outside our influence - eg future role of commissioning board in local contracting.
We're up for developing programme budget areas that can be applied to new contracting forms through flexibilities of currencies etc - ones are proposing are COPD for non electives, MSK for electives, pathology tests for non-PbR and care homes expenditure as a whole economy programme linked to the local authority. The change required to manage such development in even one of those is intimidating but the changes to PbR and shared jeopardy re inappropriate admissions and extended LoS are certainly striking a chord with our main provider.
Our position is a little unusual as 98.7% of our elective work goes to Newcastle Hospitals - unusual in proportion but also because we use them as a DGH (so do other consortia of course, including N Tyneside and Gateshead as well as some parts of Northumberland so could we consider the following:
1. We openly share lessons learnt from the various aspects that we develop early on - ie your equivalents of COPD, Care Homes etc.
2. A regional training/development programme is commenced for tactical commissioning to support innovation
3. A regional network is established for consortia contract leads.
4. Each consortia takes lead responsibility for specific agreed areas/themes - eg specialties or providers.
5. We consider co-funding of shared expertise - eg technical PbR function, data validation, north east procurement of a common system re Dr Foster, MIDAS et al.
6. Consortia are grouped in hubs to agree strategy and collaboration around major acute centres such as Newcastle, Sunderland and South Tees.
Alistair Blair - Northumberland
Agree with much of what David said - however I do wonder if having lead consortia for specific providers is the way forward, if something goes wrong then one consortia will be blamed by many and it could quickly get divisive. It would be possible for example for us to create specific commissioning boards, with proportional representation (according to spend in the sector) from each of the groups. That would encourage groups to share ideas etc and also then all the groups would have a collective responsibility and buy in to the negotiations. That way for example Newcastle groups would have the largest representation on Newcastle trusts negotiations for example but other consortia would (eg Northumberland, N Tyneside and Gateshead) have input too, vice versa for other trusts. Regional negotiations eg Ambulance could be tackled in a similar manner.
This doesn't mean we have to have an enormous number of individuals on the commissioning negotiations - several consortia could give there proportionate share to the same individual (transferrable vote/responsibility) , but all would have a sense of buy in....
Stewart Findlay - Durham Dales
I am not sure that model would work any better. The consortia with the biggest spend would still dominate. The power of GP commissioning is having smaller consortia who perhaps don't get the best deal from a particular provider and who are able to undertake their own direct negotiation. That creates a real market and drives up quality. I know that makes life harder for our big FTs but we should not let them think that once they have a deal with their main customer they can forget about the rest of us? We perhaps need to nominate one cluster to take responsibility for performance management but we may want to do that ourselves too in the future.
Glenn Carroll - Intrahealth - Durham
I think we would agree.
David Thorne
I strongly agree with Stewart on the smaller, marginal purchasing power. This was my argument back in the autumn when size was being pushed by articles in Pulse and the HSJ. But, does that mean we work in isolation like fund holding was in the main, or do we discuss tactics? What are the implications for consortia where their local FT becomes squeezed and they are left with the consequences as the majority buyer? My instincts support some form of shared discussion across hubs even if it is to agree to disagree. One of my criticisms of the last 10 years in general is the lack of any apparent masterplan for tactical commissioning across the matrix of acute hospitals that dot our patch.
County Durham PCT
The model of contract negotiation could be changed to have one or more GP as ‘joint lead’ but we would need to agree this quickly. We will consider with GPLC leads how they can best partner with the PCT through the acute contracting round for 2011/12. We would expect that the pathfinder sites in the north east are all significantly influential in the future shape and content of contracts. We will agree how best we include GP colleagues in the contract negotiations – either as part of the pre-meet briefing sessions where we agree approach/tactics/freedom to act or as part of the small team that actually meets to discuss initial issues (operational group, not director led). Another option would be to include in the escalated discussions – we try to avoid these and for issues to be resolved through negotiation at the operational group.
We could involve GP leads in setting the framework for negotiations and they would be involved as the representative GPLC lead, but as yet they have not wanted to get involved in the entire contract. The practicalities of the negotiations are also problematic, in that they can be very time intensive, particularly in the last month, but happy to explore how we could work around this.
We need a regional definition of what a delegated budget is otherwise this could be a recipe for chaos. We could do with this sooner rather than later. Extremes range from freedom to shift to alternative provider to work within an agreed limit/trajectory as part of agreed demand target. Whilst Durham Dales may take on a delegated budget from January 2011, its size is unlikely to be able to cope with financial risk. How will risk be managed? We have already started work on financial frameworks and governance issues. Our understanding is this will not involve real money being transferred but clear accountability for the Dales budget. We will performance manage through our programme delivery board and will determine risk management across the whole of the CD budget.
This will be good pilot work for us to build on in April 2011. The pathfinder applicant has a good grasp of a whole range of initiatives for the quality and efficiency agenda. For the first 12 months of the pathfinder being in operation, we would determine early priorities and successes. We would like to see early real cash savings from the initiatives and evidence of changed contracting patterns as a result of the initiatives.
