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News and analysis from Primary Care Commissioning CIC
May 2015
Commissioning
EXCELLENCE
Primary care commissioning
development events go live
Effective commissioning of
primary care services is a key
requirement of the Five Year
Forward View, as primary care is
at the heart of plans to provide
the integrated services that
people need.
PCC’s Primary Care Commissioning
Development programme provides
the regulatory context, technical
detail, knowledge and expertise
that commissioners need to make
confident well-informed decisions.
At the centre of the programme is a
series of workshops covering the main
contractor groups and the critical
finance, premises and procurement
levers available to commissioners.
These events are for primary care
teams in NHS England regions,
The Confident
Commissioner
Commissioning is changing and with it
the role of the commissioner, who is no
longer a solution creator but a system
enabler and leader.
A new PCC programme brings together
the two principal requirements
for change: understanding how
commissioning needs to change to meet
its full potential and the challenges of the
NHS in future; and support for individuals
to develop the insight and personal
qualities they need to be successful
commissioners.
2
HIGHLIGHTS FROM THE EVENT
CALENDAR
3
including CCGs who have assumed
delegated responsibility for primary
care and those working towards this
goal. They are free to attend for
existing subscribers.
Each workshop runs several times a
year in each part of the country. See
the table on page 2 for a partial list of
those that are live and booking now.
The Primary Care Commissioning
Development programme includes
access to our expert adviser team and
online helpdesk. The programme
is free to subscribing NHS England
regions and CCGs with existing
credit packages. It is also available
as a subscription service to any
organisation with an interest in
primary care or, for events only, on
a pay-as-you-go basis.
Case study: GP
extended access
The seven-day GP extended access programme
in Herefordshire, enabled through the Prime
Minister’s Challenge Fund (PMCF), was
established with two clear objectives – to
improve access to primary care in the evenings
and at weekends and to support the urgent
care agenda.
Established in July 2014, the service has three
hubs in Hereford, Leominster (in the north of
the county) and Ross-on-Wye (in the south),
offering a 6pm-8pm weekday and 8am8pm weekend service. Hub teams include
GPs, nurses, nurse practitioners, healthcare
assistants and receptionists. Patients can access
the service by phoning their GP practice or 111.
Continued page 2
Continued page 2
Participants attend approximately
one session a month for eight months
where they work in small groups of
peers supported by facilitators and topic
experts to gain knowledge and insights
in the following areas:
• The changing role of commissioning
and the commissioner
• Understanding people
• Commissioning for outcomes and value
• Using the NHS standard contract
• Working with patients and communities
• Influencing systems
• Building a culture for change
Participants stay in the same group
throughout the programme, with typical
group sizes of between eight and
NEW MODELS OF CARE UNDER
THE MICROSCOPE
5
TAILORED SUPPORT FOR YOUR
ORGANISATION
7
twelve people.
Aimed at directors of commissioning
and senior commissioners in CCGs, NHS
England teams and local authorities, the
programme is run in different areas of
the country according to demand, and
with some groups made up of individuals
from the same organisation and others
joining colleagues with similar interests
from neighbouring organisations.
The application process ensures that
participants have similar aims but bring
a variety of experience and personal
qualities to the programme, enabling
them to learn from and support each
other.
For more information, download the
Confident Commissioner prospectus:
http://bit.ly/1K6kddo
ONLY PATIENTS CAN CLOSE THE
FUNDING GAP
8
FEDERATIONS NEED THEIR OWN
FORWARD VIEW
2
Commissioning
EXCELLENCE
GP extended access
The 111 service and the local ambulance
trust can refer to the extended access
service based on their call handling/triage
processes.
Dr Richard Dales, finance director of
Taurus Healthcare and a partner GP in
Mortimer, Herefordshire, said: “Before we
embarked on the programme there were
two risks which I had concerns about.
One was whether the technology would
work and secondly whether we would be
able to fill the shifts. We have succeeded
on both matters and that is a credit to
everyone involved.
“During the appointments there are
very robust data-sharing arrangements.
When patients give their explicit consent,
GPs are able to pull up the patients’
medical records and see all their hospital
letters. The GP will then make a note of
the consultation and the message will
get back to the practice about what
has happened. The practices are all on
the EMIS system and this has supported
seamless information sharing.
“The service is provided by a mixture of GP
partners, salaried GPs and locums as well
as nursing colleagues, healthcare assistants
and receptionists. When you’re ‘out in the
sticks’ and there is a shortage of available
GPs, we have to find our own local market
rate to ensure there is a good supply for
the shifts.
“GPs are a disparate group, some are
extremely supportive, some are wary of
Continued from page 1
the changes and do not feel they have any
more time for this, there’s a mixed range
of emotions. What has been helpful is that
all practices are members of the federation
and that this is a new service, based on
new funding, so we have not had to take
a service away elsewhere. It takes time
to get a hub up and running but a large
number of GPs are involved, some regular
and some like myself who do occasional
shifts.”
Taurus Healthcare received approximately
£2.7m of PMCF funding to establish a
number of inter-linked projects with the
extended access programme due to run
for a year. It is now set to be extended
to December 2015 to link in with work
being completed on the local urgent care
programme. Promotion of the extended
access hours to patients has been via
media stories, leaflet door drops, bus
adverts and posters in GP practices.
“Levels of patient satisfaction with the
service are very high. We are collecting
a range of data but early feedback is
showing they like the service and we are
hopeful that it will show a significant
impact on out-of-hours and A&E
attendance. I’ve had patients see me
when I’ve been working in the hub who
have said it is convenient as they’ve been
working away all week. Herefordshire
is a large rural county but people have
said that with the three hubs they have
appreciated not having too far to travel
to their nearest one. Some practices are
a longer way away from the hub – the
current model is very much a north-tosouth model, ideally we would be able to
make it east-to-west as well.
“It’s been interesting to see how the
system is operating by actually working
within a hub. All the directors have been
keen to do some sessions. When you’re
hands-on you can see the operational
glitches, such as making improvements to
the electronic referral form and ensuring
the right information goes back to the
practices.
“In setting up our extended access
programme we’ve been fortunate to
have very strong leadership from nonNHS managers, from people like Graeme
(Cleland). GPs are used to working in
certain ways and it’s good to have people
from outside the medical world who have
expertise in management and leadership.
It’s been important to provide a high
quality service, so that patients are seen
only once, rather than continuing to be
seen across the system. Our IT governance
is very strong and it’s been important to
be prepared to go with the market rate
to obtain the staff. For anyone setting up
such a scheme I would encourage them to
speak to people who have already taken
on the challenges, rather than re-inventing
the wheel. For anyone, particularly in a
large rural area, they would be welcome
to get in touch with us and see if they can
learn from our experience.”
PRIMARY CARE COMMISSIONING DEVELOPMENT EVENTS
12 May
Effective negotiation: tapping your natural resources, London
20 May
Making sense of outcomes-based commissioning, Leeds
3 June
Processing applications for inclusion in a pharmaceutical list, Leeds
4 June
Influencing skills, London
10 June
The leader as coach - building stronger teams, Manchester
11 June
Making sense of outcomes-based commissioning, London
16 June
Eye health contracting essentials, London
17 June
The leader as coach - building stronger teams, London
17 June
Rurality and dispensing by doctors, Leeds
18 June
Dental contracting essentials, Manchester
23 June
Primary medical contracting essentials, Leeds
1 July
Working with patients and communities - the key to improving services, Birmingham
7 July
Determining applications for inclusion in a pharmaceutical list, Leeds
8 July
Making sense of outcomes-based commissioning, Birmingham
14 July
Effective negotiation: tapping your natural resources, Leeds
Existing customers or those seeking subscription information contact dot.walker@pcc.nhs.uk (north, midlands and east)
or claire.peer@pcc.nhs.uk (London and south).
3
Commissioning
EXCELLENCE
Clinical leadership
at the heart of new care models
High levels of clinical engagement
and clinical leadership are driving
forward the developing new care
models – much to the delight of
the NHS England team responsible
for supporting the ‘Vanguard’
communities.
Charlotte Williams, programme manager
for the national new care models team,
said. “It’s been very heartening to see the
enthusiasm of clinicians who have been
fronting up the Vanguard proposals.
During one of the Vanguard meetings
a GP said how excited he was by the
opportunity presented by the new care
models and that during the last six months
there had developed a recognition among
his fellow GPs that the current system
had to change. There seems to be a lot
of excitement, as well as goodwill and
enthusiasm, among clinicians about the
possibilities.
“It’s pleasing to see the high level
engagement of GPs. From a personal
point of view, primary care is the essence
of our work and is the place where we
look after most people. We cannot drive
this change nationally from institutions
- it has to be driven by those who are
accountable to their local population.
There have been some observations
that the new care models are too
organisationally focused but I don’t think
that’s at the heart of what we are trying
to do. It is all about understanding and
responding to the clinical needs of our
population.”
Williams is working with the new care
models team, having been on secondment
since February 2015 from her role as
chief of staff with UCL Partners, the
London-based academic health science
partnership. The team’s role is to oversee
implementation of initiatives emerging
from the NHS Five Year Forward View
which sets out how services need to
change and what models of care will be
required in the future. MCPs involve the
development of federations, networks
and super partnerships to enable general
practices to operate on the scale required
to deliver a wider range of services. PACS
are single organisations providing NHS listbased GP and hospital services, together
with mental health and community
care services. PACS might be formed in
a number of ways including hospitals
opening their own GP surgeries.
“There is no dominant model emerging,”
says Williams. “There were more
applications for MCPs than PACS - this
could be due to the similarity to existing
integrated care models and that they
required lower population thresholds to
be established. In terms of organisational
strength, some of the PACS bids brought
together eight or nine different partners
so there is a lot support for them on that
basis. There is also a great potential to
affect change in other areas like care
homes - there are three times as many
care home beds in the country as acute
beds.
“The choice of model will depend in most
cases on the drivers for change – local
health needs, population demographics,
the types of providers in place and
whether services are meeting needs in
areas such as primary care, urgent care,
and whether people are experiencing
care that is as co-ordinated as it should
be. The Vanguard sites we have talked to
are concerned about whether the current
services commissioned and provided for in
Experts debate MCPs
Earlier this year, Professor David Colin-Thomé
chaired a debate on the development of
multispeciality community providers (MCPs), one
of the new models of care proposed by the Five
Year Forward View.
Paul Smeeton, chief operating executive for the community
services division of Nottinghamshire Healthcare NHS
Foundation Trust, suggested the forward view was “quiet
on the importance of culture and history in local health
economies” and there was limited recognition of community
and mental health providers.
While recognising such concerns, PCC chairman David Colin-
their communities are sustainable in the
future. One Vanguard site representative
said ‘that for us to survive would
bankrupt someone else’, so we need to
look at the transactional drivers too. All of
this will lead them to one or other of the
models.
“Essential to the success of all the models
is engagement and the establishment
of a clear vision. They all require a good
understanding of the population’s needs
that they are serving. Measurement of
data very is important as the models
will impact on a range of factors so they
need to ensure they can measure their
success in terms of population benefit,
care, quality and experience. Leadership
capability and capacity will be vital to
their success and throughout all the
new models we have to remember to
ensure that patients are at the heart of
everything that we do.”
The new care models team will be
working with all the Vanguard sites in
the future to better understand their
specific needs to build an appropriate
support programme. They will also be
working with non-Vanguard communities
to ensure the learning and progress is
spread.
“We have to make sure that we test the
new models of care and see that the
Vanguard work is nationally replicable.
It’s not just about it working for 50,000
people in one area of Kent, it needs to
also work for a community of 50,000
people elsewhere in the country. This is
the exam question and we need to get an
answer that can be scaled up, it’s not just
about bespoke local solutions.”
Thomé, said that NHS England chief executive officer Simon
Stevens did not talk about prescribed models.
“We do not want to be told in a challenged health economy
that ‘this is the model’. That’s how we got into this problem
in the first place,” the former Department of Health primary
care lead said.
MCPs require genuine collaboration, but different professions
would need to earn their seat at the table.
Simon Mathias, service development manager with the
parent company of a large community pharmacy network,
said the profession had more to do to press its claim for parity
in the new NHS.
“Pharmacy has never said what it can do as opposed to what
it could do. It has never gone out and done the modelling.
What can we do to show we are able, capable and competent
in a relatively short space of time?” he asked.
Read the full text of this article: http://bit.ly/1xi9D0C
4
Commissioning
EXCELLENCE
TAURUS HEALTHCARE takes
bull by the horns
Leaders of emerging primary care
federations and similar networks
are being encouraged to face up
to difficult decisions and ”embrace
challenge”.
Graeme Cleland, managing director of
Taurus Healthcare, may be adopting
a ‘bull-ish’ characteristic from the
organisation’s name or it may be linked to
the fact that Taurus is led by a team that
includes two ex-military men, but Cleland
welcomes tough challenges – as long as
they lead to constructive resolution.
Cleland says: “The NHS isn’t particularly
good at challenge, people are always
worried about upsetting someone, but
through challenge, and as needs require
confrontation, you can achieve resolution
and that is healthy. The resolution of
challenge gives you the chance to move
forward and for behaviours to change. I
think it’s OK to disagree, it’s OK to not be
on the same wavelength, some people
will always be at the forefront of leading
change and some people will be followers
and that’s OK.”
Cleland joined Taurus in July 2012 at the
time of the GP federation winning its
first contract, a specialist assessment and
treatment service for musculoskeletal
conditions. Taurus is owned by all 24 GP
practices in Herefordshire and has been
set up as a limited liability company (LLC).
Buoyed by success in wave one of the
Prime Minister’s Challenge Fund (PMCF),
it has recently established a seven-day GP
extended access programme.
Cleland’s background is in industry but in
his early career he served in the Royal New
Zealand Airforce. Dr Nigel Fraser, Taurus
chairman, previously served with the
Royal Army Medical Corps. Their military
experience has relevance in healthcare
according to Cleland. “There is a synergy
between multi-faceted organisations
and a military model – both require
structured leadership and proper lines of
accountability. The difference is that we
have tried to keep Taurus non-hierarchical,
it has a very flat structure. A logistical,
structured mindset is helpful in the NHS
but you need balance, you need someone
who understands industry, understands
health and most importantly understands
people.
“Through my career I have learnt you
have to empower people to deliver results
– in the NHS we are not overly good at
doing this. The NHS tends to want to
micro-manage rather than letting people
thrive, we seem to be more comfortable
when people are kept in their place. We
need to learn from others and try not to
stifle them. You cannot underestimate the
role of good leadership and management
in the NHS. I always remember a saying
from one of my former colleagues –
management lights the fire underneath
you, leadership lights the fire within you.”
A maturing organisation, Taurus
has grown year-on-year since its
establishment. Cleland puts strong
emphasis on its positioning for growth
based on achieving the ”three pillars” –
registration/accreditation with the Care
Quality Commission, NHS information
governance and the NHS N3 IT network.
He is also keen to recommend to
emerging federations that they carefully
consider the form of organisational entity
that best suits their needs.
“We considered a number of different
types of organisational form and decided
that LLC provided the most suitable
configuration for ourselves. It did not limit
us to any particular types of contract and
the only one we have not held is a GMS
contract. Our federation is part of the NHS
family but not part of the NHS per se. We
are owned by the partners having raised
share capital on a capitation basis from
the partners.
“Some have suggested that our model
encourages profiteering GPs but that’s
incorrect. The way we are configured
is focused on a social and ethical
responsibility to re-invest into new models
of care and provide excellent services.
In delivering the PMCF programme we
were able to get moving quicker on our
work due to retained earnings and the
ability to re-invest in new services. The
take-up of our seven-day service has seen
97% utilisation on Saturdays by the local
community.
“For anyone considering establishing a
federation, setting it up correctly is key,
engagement with your shareholders is key
and good management is key. We have
been fortunate to have the support of
NHS England nationally and regionally they get it and they have provided good
counsel and tutelage. Taurus Healthcare
has been a great success story and for me
a fantastic pleasure to be a part of.”
Further information on Taurus
Healthcare is available from http://www.
taurushealthcare.co.uk/home.aspx
Tailored support for your organisation
As well as scheduled events, PCC runs workshops
on request to help commissioners and providers to
think through problems and work out solutions.
Here are some examples of recent work with
commissioners across the country.
Outcomes based commissioning
Sessions to explore outcomes based commissioning (OBC)
principles, allow commissioners to rethink how they approach
their role and start to get to grips with the practical problems
posed by OBC, such as how to develop indicators.
As a result of these sessions, several CCGs are in the process of
reviewing their existing change programmes to refocus them
on the patients and populations. Warrington CCG is reviewing
its ”out of hospital” programme to understand the key patient
populations driving demand. It is also reviewing other services in
light of the event.
Blackburn with Darwen CCG has begun a change programme
focusing on adolescents with respiratory problems. Following
a patient engagement programme, PCC is working with the
CCG to shape what the patient identified outcomes for services
should be.
At a similar session for Cumbria CCG, clinical leads and
commissioners were able to explore OBC together in a “crossing
the boundaries” exercise that helped participants to see
commissioning issues from each other’s point of view.
5
Commissioning
EXCELLENCE
STRENGTH IN NUMBERS
for aspiring federations
provider companies and others focused on
the ‘out of hospital’ sector.
David Pannell
“You need to have the ability to win
contracts in the face of the commercial
challenges that would confront any
independent organisation. There is quite
a spread in terms of the membership size
of federations and one current concern
is that some local groups are trying to set
up federations with just small amounts of
support from their member practices.
GP practices at the beginning of
their federation journey have
been encouraged to consider
organisational size and strength as
crucial elements to their plans.
A cross-section of healthcare
representatives – including GP practices,
CCGs, area teams, acute care, voluntary
sector and the pharmaceutical industry –
were able to learn from the experiences of
successful federation leaders at recent PCC
events in London and Leeds.
The Federating for the Future speakers,
with vast experience of leading
established provider organisations, shared
tips for success and spoke of potential
pitfalls.
“If you are setting up or thinking of
setting up a federation, you need to have
a considerable degree of strength, you
need to have organisational resilience,”
said GP Dr Phil Yates, chair of Bristolbased GP Care and chair of the recentlylaunched National Association of Provider
Organisations (NAPO), a network for GP
“Furthermore, commissioners should
not be afraid of providing support to
federations. There are examples of
bullish commissioners who have shown a
willingness to support federations in the
face of what some might perceive as risks
of challenge. Some federations have won
work but, counterintuitively, not from
their local CCG but from neighboring
areas. Commissioners need to learn to
trust their federations – at the moment
some seem to be paralysed over perceived
conflict of interest with organisations with
GP owners. As such, it is important that
federations work on their relationships
with commissioners.
“Leadership strength and capabilities in
those establishing federations are also
variable. The view from all speakers at
the events was that once you have put
in an operational management team or
development team, then you are able
to grow. However, some federations are
trying to get by with volunteers or a small
support team and the result of this will
be that they will struggle to get their
contracts over the line.”
echoed by fellow leading federation
expert, David Pannell, chief executive of
Suffolk GP Federation. “The main issue
is one of under-capitalisaton – many
federations do not have enough money.
For the Suffolk Federation our practices
put in 30p per patient, it’s a standard
model but we were fortunate because we
had an existing organisation and some
things in place like IT.
“Many of the federations being set up
appear to be too small and might fail
– you need to have a population of at
least half-a-million. Some federations are
looking at half or a third of the practices
in their area forming the federation and
there is simply not enough power in
there.”
Pannell also encouraged federations to
identify real and substantial sources of
revenue and to not only develop a robust
business plan but to test it out. Sound
financial management and planning is
essential and federations need to source
expertise in this area according to Dr
Mike Smith, GP and chief executive of the
Camden-based Haverstock Healthcare.
“They need a good money person,” said
Smith. “You cannot expect the finances
to be overseen by a practice manager as
part of their day job. The first person we
invested in was someone who understood
major NHS finance. I don’t think in terms
of profit, I know they call it the not-forprofit sector, but to me it’s about not
going bust. I think we’re all about ‘not-forloss’ and because of this we are very much
on top of our financial position.”
Strength in numbers and robustness
in resource are themes that have been
Working with patients and communities
Effective engagement with patients and communities is
more than a statutory duty for commissioners. It is the key
to good service design, an integral part of OBC and the area
commissioners need to focus on most to address long term
health and economic issues.
PCC facilitated a session with commissioners at St Helen’s CCG
to raise awareness of the strategic and operational issues
of engagement. We also ran a session for Southend CCG to
allow two groups of patient representatives to cooperate
more effectively to influence the work of the CCG.
We ran a workshop for Hillingdon CCG and local stakeholders
to launch a joint engagement strategy that all the borough’s
providers have now signed up to.
Co-commissioning
The 64 CCGs with delegated authority for commissioning
primary medical services and their NHS England colleagues
need to understand the regulatory and contractual context
for the decisions they are now facing.
PCC runs workshops for primary care commissioning
committee members and new commissioning teams covering
the different contracting forms (GMS, PMS, APMS), contract
management policy and procedure, management of contract
changes (eg practice mergers), finance and premises.
We have run these sessions for several areas including
Durham and Gloucester.
A scheduled event on conflict of interest is also now live for
booking. See the event pages of the PCC website for details:
http://bit.ly/1rTbhRN
How can we help?
For information about how we can support your
organisation, contact dot.walker@pcc.nhs.uk (north,
midlands and east) or claire.peer@pcc.nhs.uk (London and
south).
6
Commissioning
EXCELLENCE
Feeling the benefit from
a community model
not committed to the values of their organisation. On
principles and values, it is not up for negotiation. If
you don’t like the values, you know where the door
is. People may criticise me, saying you don’t know
how well staff are signed up to the values but that’s
not the point. They have signed up because they’re in
the contract of employment.
“After the first year the staff had a referendum and
they voted to make a rule change letting volunteers
and customers (we don’t call them patients) become
owners. We now have 160 volunteer owners but have
had less success with sign-up from customers.
Lance Gardner
“It’s about time
we took the
blinkers off and
saw the world
for what it is”
In his time Lance Gardner MBE has been
described as a ‘visionary’ and even a
‘futurologist’ – and it is clear that his
forward-thinking community benefit
organisation has something of the
‘vanguard’ about it.
But while the Grimsby-based Care Plus Group and
other local providers might be at the forefront of
new care models, their proposals for the future do
not fit into either the multi-specialty community
provider (MCP) or an integrated primary and acute
care system (PACS), and the organisation has not
been given NHS England vanguard status.
With the publication of the NHS Five Year Forward
View, visionary thinking seems to be the order of
the day. Publication of the Simon Stevens report and
initial progress since is timely according to Gardner,
chief executive of Care Plus.
“It’s about time we took the blinkers off and saw
the world for what it is. This is the first time we have
taken the brakes off the NHS since 1947. We need
to grasp the opportunities this presents to us. For
mavericks like me chaos breeds opportunity - and
we’re in chaos right now.
“To his credit Stevens has gone out on a limb, and
to be fair to the politicians, they have not got in his
way. This will only work if we are stop looking out
for ourselves – it is not about self-preservation for
organisations, it is about self-preservation for the
NHS and the care of our communities.”
Care Plus is an organisation rooted in the community,
a social enterprise formed in 2011, now with 890
staff covering a population of 156,000 in north
east Lincolnshire, providing a wide range of fully
integrated adult health and social care services, with
a £24.5 million turnover.
“It seemed natural for us to become a social
enterprise. We are staff-owned where every member
of staff is a member, whether they want to be or not,
it’s not an option.
“If you look at other similar organisations which do
not have auto-enrolment, about 70 to 75% choose
to be an owner, therefore about 25% of staff have
“I think it’s important, if the Care Plus Group goes to
the wall then their lives will suffer and I think they
should have a say in the running of the business. But
the customers are not that interested – their general
view is the fact that we have even thought about this
shows we are listening to them, and they just want to
concentrate on their lives.”
The Community Benefit model has not only provided
Care Plus with openness and accountability to staff,
citizens, and the community but has placed the social
business at the heart of the community.
“The care we deliver seeks to be regenerative, to aid
prosperity and build aspirations. We have worked
with the local college of further education to create a
care academy.
“Just like you normally have schools specialising in
technology or sports, for these kids, aged 14 to 16,
they can choose where they want to be educated.
In our care academy from Monday to Thursday they
undertake the usual plethora of GCSEs but on a
Friday we teach them care skills.
“We’ve set up a care environment to help the
teaching – it’s an old person’s flat rather than a
hospital ward which you normally see in training
scenarios as the majority of care takes place in
people’s homes. It’s a realistic flat, you can’t get the
wheelchair through the front door, there’s rugs to
fall over, all the realities which face our staff in doing
their work each and every day.
“Even our headquarters is a community facility.
It functions as a church on Sunday, it becomes a
buddhist temple at other times, we have a resident
artist, we host charities like the Fishermen’s Mission,
and all this time we’re running 24/7 services upstairs.
“We know we don’t fit the MCP or PACS model - we
fit us. When we started we modelled ourselves on
the Torbay model but it doesn’t look like the Torbay
model anymore. We are doing it this way now
because this is the Grimsby model and it wouldn’t
necessarily suit other care systems.”
Further information at www.careplusgroup.org
7
Commissioning
EXCELLENCE
ONLY PATIENTS CAN CLOSE
the NHS funding gap
cannot be improved indefinitely and there
are no safe assumptions to be made about
public spending, so something has to
change.
Commissioners spend most of
their energy and devote the lion’s
share of their programme budgets
to providing services to address
ill health. In a cash-strapped
NHS with spiralling demand, this
approach is no longer sustainable.
This was the main message of the
speakers at the Working with patients and
communities conference in February.
Only a fraction of NHS spending goes on
helping people to stay well, supporting
people to manage their own conditions
and tackling the issues that determine
health, all of which depend on engaging
patients and the public as partners in
the consulting room, in the planning
and delivery of services and in healthy
behaviour that will reduce their need for
services.
In 2002, the first Wanless report argued
that fully engaged patients could make a
difference of £30bn a year to the running
costs of the NHS by 2021/22. The report
was written at the start of a decade of
unprecedented investment in the NHS. By
coincidence, this is the same sum the NHS
needs to find by 2020/21 in order to keep
services running at current levels.
The solution proposed by NHS England
chief executive Simon Stevens in the Five
Year Forward View is to ask government
for part of the money in return for
efficiency gains of around 4% a year. The
government’s side of the bargain will
stretch public finances to the limit, the
NHS’s side of the bargain will take a bigger
effort still. The Nicholson Challenge only
achieved about two-thirds of its £20bn
target in four years. The second round of
QIPP will ask for £22bn of efficiency gains
in the next five years, and most people
agree that the easy savings have all been
made.
Even assuming heroic efforts to close the
funding gap by the end of the decade, the
deficit will continue to grow. Efficiency
A study of healthcare expenditure in the
US, published in 2005, backs him up. It
showed that while healthy behaviour
is the major determinant of health,
promoting healthy behaviour accounts for
just 4% of spending.
This mismatch demands a complete
change of thinking for commissioners and
providers of services.
“We need to invent a new metrics which
stops measuring by the number of
people in services but by their level of
involvement and engagement,” Russell
said. “It’s not a matter of how we make
people better clients, but how we keep
them out of services.”
These themes were also echoed by
Mark Duman, principal with Monmouth
Partners and chair of the Patient
Information Forum. “Eighty to ninety per
cent of care is what we do to ourselves,”
he said, “but individual participation is the
hardest bit”.
Telling patients what to do and asking
them what they think works up to a
point. “Complaints are good, they suggest
rising expectation,” said Duman, but he
also pointed to the danger of “feedback
fatigue”. Duman presented evidence to
show that “activated” patients, those
equipped to play an active part in their
care, cost the NHS considerably less than
His answer is to discover the resources
that produce health and develop them,
and he believes they are to be found in
communities.
“Health is happening all over the place.
80% of health producing activity can’t be
seen – it doesn’t end up in a GP surgery or
a funding application.”
Mark Duman
Cormac Russell
According to Cormac Russell, managing
director of Nurture Development,
institutions don’t determine health,
people do. “The primary drivers of health
are our own agency,” he said.
and they help to educate them about
a range of subjects like sexual health,
but the process is more important than
the products. “They get a feeling of
value generating technology that will
make a difference to their lives,” said
Sarah Fatchett, strategic lead for the
GP federation. “It’s about starting the
conversation about health in a
different way.”
The Five Year Forward View also
acknowledges the importance of making
better use of community assets. It says:
“Sometimes the health service has been
prone to operating a ‘factory’ model of
care and repair, with limited engagement
with the wider community, a shortsighted approach to partnerships, and
underdeveloped advocacy and action on
the broader influencers of health and
wellbeing.
“As a result we have not fully harnessed
the renewable energy represented by
patients and communities…”
West Wakefield Health and Wellbeing
showed how a group of GP practices is
starting to address some of these issues,
working with local people to design
more efficient services, such as video
consultations, but also working with them
before they need services.
For example, West Wakefield is working
with schools to develop health apps. The
apps are developed by children as part
of an initiative supported by Microsoft,
passive patients. Figures from KPMG
suggest that the difference in cost may
range from 8% to 20% depending on the
level of activation.
But despite the huge potential savings,
there is little evidence of investment.
“Health Education England spends
£5bn educating clinicians, but nothing
educating patients,” Duman said.
The event will run in Birmingham on 1 July
and in London on 1 October with new
presentations including the example of
a London Borough where commissioners
and providers across the health and
care system are working together on an
integrated engagement programme, and
a Midlands CCG which let patients choose
the provider of a £200m intermediate care
service.
To reserve a place, see the PCC website:
http://bit.ly/1rTbhRN
8
Commissioning
EXCELLENCE
“Setting up a
group of practices
as a federation
without a clear
idea of what
they are trying to
achieve is a recipe
for disaster.”
Phil Yates
“My view is that federations are not properly
considering their vision. They have all felt the need
to federate but they need to ask themselves what
is the purpose of federating. We have decided that
our purpose is to achieve three main objectives
– to assist GPs by way of resources in delivering
services, to look beyond traditional practice and
more towards what primary care does in terms of
the urgent care centre or a weight management
service, and finally, to support the organisation of
back office functions such as shared HR, learning, IT
and governance.”
Emerging GP federations seeking to
deliver against the NHS Five Year Forward
View need themselves to establish a clear
vision – that is the view of a number of
leading figures within the federation
movement.
“Those who are currently setting up federations
must agree a vision and ethos – what is it that you
want your federation to do? You cannot answer
any other questions before you have established
the vision,” said Dr Mike Smith, GP and chief
executive of Haverstock Healthcare, based in
Camden, London.
Smith recently presented at two Federating for the
Future events in London and Leeds, run by PCC that
looked at how general practice and other primary
care services could play a much stronger role at the
heart of a more integrated system of communitybased services.
“Federations being established at the moment may
have established a coalition of the willing, they may
have started bidding for contracts, but that is not
enough. I would hate in six to nine months or so
for people to say federations are being set up to
simply protect the model of primary care. It is up
to federations to consider their vision – what do
they want to do? If they can answer that, the rest
becomes a lot easier.
“Our vision in Camden is to have a primary care
service that is accessible, equitable and of high
quality for all patients. For all of our services and
any contracts we consider going for, we bring it
back to that test. If it doesn’t fit the vision we will
either re-negotiate or pull out. Our vision serves a
clear purpose - it is not just rhetoric.
The importance of a guiding vision is supported
by David Pannell, chief executive of Suffolk GP
Federation. Pannell, a keynote speaker at the
Federating for the Future event in London, said:
“In setting up federations, people tend to jump
in to forming the board or stating that they want
to do this or do that. We wanted to look to the
long term, to consider what were we trying to
achieve and how will we know when we get there.
Working in a federation will be different for GPs to
what they have done before.
“The vision for Suffolk is to have practices working
collaboratively and to have primary care at scale,
so that our impact is like that of a hospital across a
whole population, delivering parts of the system
that other areas of the NHS cannot deliver.
“My view, based on my business background,
is that primary care has lost its market share.
Hospitals have taken more and more of the budget
- our vision is for the expansion of primary care.”
Further support for a visioning approach came
from GP Dr Phil Yates, chair of Bristol-based GP
Care and chair of the recently-launched National
Association of Provider Organisations (NAPO).
Yates said: “Setting up a group of practices as a
federation without a clear idea of what they are
trying to achieve is a recipe for disaster. Time must
be spent with the constituent practices in the
development stage to work up a vision.”
Yates pointed to the support in this area that
is available to federations from NAPO and PCC
including events, training and networking
opportunities to share best practice and influence
policy makers. He said people could register their
interest for such opportunities by emailing napc@
napc.co.uk. See also the PCC website for details of
events and other services.
www.pcc-cic.org.uk/services
Commissioning Excellence is supported by PCC and NHS Networks. Contact julian.patterson@pcc.nhs.uk or visit www.pcc-cic.org.uk and www.networks.nhs.uk
Federations must establish
their own forward view