After my first year as a director of Bracknell and Ascot clinical commissioning group (CCG) I am optimistic about commissioning. We have had strong local leadership for three years and our GP council has been functioning well for several years with all practices having a say.
Our CCG is a cohesive unit of 15 practices bound into a corporate structure, which was developed locally and is effective in carrying out its functions.
Early in the process I worried about the possible collusion of GPs being providers and commissioners. However, this fear has been allayed. Rather than colluding, quite to the contrary, practices have been holding each other to account.
Referrals and prescribing
There have been some changes in referral and prescribing patterns in practices, where leadership was applied effectively. Peer pressure has been immense and practices not complying are feeling the heat. Buddy systems have led to internal critical appraisal of each other's referral patterns.
What has also been a real eye opener is how well-organised practices, working as cohesive units, are able to deliver common goals. Practices which don't work together are usually deficient in not only one but all areas, for example prescribing, referrals, acute admissions and elective procedures.
Practices have been bound into our structure with tight terms of reference they have all signed up to. We have just released an escalation process, which formalises sanction for lack of concordance with common goals of the group.
One of my major successes was the refocusing of our clinical education afternoons into upskilling GPs, nurses and primary care teams. Often these events were hijacked by third party organisations telling us what nobody wanted to hear.
We have now been able to change our education to focus on increasing our skills in areas where our referrals were too high compared with the national average and our primary care-based skills therefore too low. This has been successful and extremely well received.
The process has been supported by the development of an educational strategy, an educational policy with standards and an educational steering group meeting regularly to discuss primary care education.
Another milestone has been the completion of the corporate governance self-assessment toolkit by the DH, which has been a steep learning curve in what our organisation needs to succeed.
Another positive has been a local primary care-based paediatric evening clinic which has now been approved and will be started soon. We hope to reduce A&E attendances by children after school and nursery in the early hours of the evening.
However, we have also had failures. After years of work on a primary care-based health space in Bracknell, the political support for this project has been waning since the new government came in. This has been due to a variety of factors.
We have spent thousands of hours on this project, it would deliver huge savings and give modern premises and care to patients of highest needs in the area. But the project appears to have stalled.
One challenge for the next year will be to bring the remaining over-referring practices on board to make more significant commissioning savings and finally be in the position to reap the rewards of our work.
Another challenge will be to reduce consultant to consultant referrals, which are locally far above the national average.
Finally we will need to turn ourselves into fully functioning bodies, but strangely, this is the least of my worries due to the excellent team working with us.
Patient participation group
Overall my feeling about primary care clinician-led commissioning is extremely positive.
On 28 March, our patient participation group (PPG) will host the first self-care evening in Bracknell after a successful pilot in my own practice.
The PPG has invited me to teach parents with children of primary school age, who are high attendees with self- limiting disease, how to look after children when they are ill.
The first pilot evening was a huge success with parents commenting that they now felt much more confident and less anxious in looking after their sick children and if they had known this before they would not have to have seen the doctor so often. We are actively seeking to promote self-care in new and innovative ways in order to let our patients gain confidence.
Clinician-led commissioning is the last possible way to save the NHS. I am one of the many not so vocal GPs who feel the Health Bill has more positive than negative aspects. Patients do deserve value for money and local care close to home.
We will also not be able to keep every single small district general hospital going at the expense of quality and safety. Common interventions need to be delivered closer to home and in the community wherever possible.
Rarer and more specialist interventions need to be delivered at centres of excellence. There is so much heat in all the current discussion. What is needed is some pragmatism, common sense and trust.
- Dr Kittel is director of Bracknell and Ascot CCG, Berkshire