Last month, the first wave of GP consortia to take the lead in commissioning were announced.
The government has selected 52 groups of practices to be the first in the GP pathfinder consortia programme to pilot the new commissioning arrangements as set out in the White Paper, Liberating the NHS: Equity and Excellence.
They will test concepts for GP commissioning, explore how emerging consortia can best set up and identify support that may be needed in future.
In total, the pathfinders encompass 1,860 GP practices providing care to 12.8 million people - about 25 per cent of the patient population in England.
Health secretary Andrew Lansley says he has been 'delighted' by the 'evident enthusiasm' shown by groups of GPs who came forward to join the pathfinder programme. A rolling programme of pathfinders will be announced up to April 2012 when consortia will start to be formally established.
The pathfinder consortia will be supported by the National Clinical Commissioning Network, the National Leadership Council and by primary care bodies.
A pathfinder learning network online hub will also provide support and resources.
This consortium in Huntington, Cambridgeshire, is one of the smallest in England, comprising 10 practices with a patient population of 82,000. But this has not stopped it from making impressive progress in the few months since its start.
In four months it saved £200,000 by working with the acute hospital to improve discharge planning and avoid unnecessary admissions. This was achieved by the consortium pushing for a more robust model of discharge planning, which involves daily meetings about all patients on all wards.
GPs have worked in A&E, seeing patients and sending them home if they have no medical need. This has been made possible by commissioning additional services in the community to support patients at home.
Dr Simon Brown, lead GP for the consortium, believes that one of its strengths is its size, in spite of the GPC having said that a patient population under 500,000 is too small.
'I think that's too big because you lose the possibility of reacting to local stuff with the same fleetness of foot. We've only been live since August and already we're seeing positive impacts. There's a widening gap between our cluster and the rest of the PCT - we're under budget and it is looking at an overspend,' he says.
Dr Simon Brown: saving funds (Photograph: Simon Barber)
However, the consortium is likely to grow.
Although a merger with another consortium is not on the cards, Dr Brown says practices in the area are queuing up to join.
The consortium is a limited company with a board of six comprising three GPs, chief executive (a physiotherapist), a practice manager, and a patient representative. Its annual budget is £103 million.
Hunts Health is simplifying the patient flow and repackaging some care, such as multiple visits back to hospital following elective care. The consortium is also looking at shared work across agencies.
Local health needs include obesity, diabetes and alcohol-related diseases in deprived areas, and work is afoot to look at new ways of tackling such problems. These include the use of voluntary agencies and expert patient programmes.
Data is now available on practice performance with a first meeting on clinical variability taking place in December.
Dr Brown admits that the board was 'girding its loins' but says there has been collaborative discussion with practices keen to support each other to improve.
The consortium is looking to put in place a 'buddying' arrangement to facilitate this.
Name: Hunts Health
Structure: Limited company with a board of six: three GPs, chief executive (a physiotherapist), a practice manager and a patient representative.
Budget: £103 million
Immediate plans: Increase GP involvement in A&E, case finding work in which the consortium liaises with community services, such as matrons, to look at being more proactive in identifying vulnerable adults and working with different agencies to improve patient pathways and care.
WEST CHESHIRE HEALTH CONSORTIUM
Executive director Alison Lee says the consortium's approach is 'a dual focus on delivering today while also looking to tomorrow', and it is taking time to get things right.
To that end, the consortium is assessing the PCT's strategies before it decides on its own commissioning priorities. It is also working with accountants KPMG on understanding the finances it is inheriting from the PCT. It is also looking to amend its structure to ensure post holders are fit for purpose.
At present, the consortium, which comprises 38 practices covering a patient population of 260,000, is run by a management board, comprising executive director, a chairman and deputy, eight GPs and three practice managers representing the three localities, plus the co-opted chairman of NHS Western Cheshire's clinical executive. Only the executive director post was appointed; the remainder were elected.
Chairman Dr Jeremy Perkins says that an organisation with responsibility for an NHS budget of between £300 million to £350 million needs to have the right skills: 'It's not enough for it to be someone who gets on with people. We're working on the competences needed at the moment so we'll have a split between appointments and elected members.'
Dr Jeremy Perkins: right skills
To accommodate the differences across the area, the consortium operates through three geographical localities - rural (11 practices), Chester City (14 practices) and Ellesmere Port and Neston (13 practices).
As well as ensuring the needs of the various populations are met - such as obesity, alcohol-related problems in deprived areas of Ellesmere Port and travel distances to hospital in the rural areas - this set-up means practices have their voices heard.
'Even GPs who are reluctant speakers feel comfortable sharing their views because in the localities, among the 11, 13 and 14 practices, there is quite a tight bond,' says Dr Perkins.
Although the consortium has yet to finally decide what services it will commission and decommission, it is clear that prescribing, planned and unplanned care will be important.
The consortium was first set up in October 2006 and in 2009/10 achieved a saving of £200,000 in prescribing. This money was put into an innovation fund so practices or clusters could bid for money.
Already, the localities have made use of this fund, including a pilot where general practice and secondary care work together to improve diabetes care.
Name: West Cheshire Health Consortium
Patient population: 260,000
How set up: Run by a management board comprising: executive director, eight GPs and three practice managers representing the three localities, plus the co-opted chairman of NHS Western Cheshire's clinical executive.
Immediate plans: Assess the PCT's priorities and decide on their own. Prescribing, planned and unplanned care are almost certain to be priorities.
Budget: £300 million to £350 million of NHS budget (to be confirmed)
Management allowance: £30 per head (to be confirmed)
As one of the larger consortia in Somerset, Wyvernhealth.Com is determined to avoid being seen as 'another PCT'.
With 76 practices and more than 500,000 patients, lead GP Dr David Rooke says there is awareness that this is a danger.
'A sceptic would say we'll turn it into another PCT but we're trying to work out a way whereby we can really empower localities to make changes without having to go through a bureaucratic process,' he says.
Dr David Rooke: COPD improved
It is not yet clear how this will happen, but the consortium may be divided into nine localities.
The aim is to talk to the different areas and iron out the possibilities as the consortium moves through a transition period into shadow form. Smooth management of this process is the consortium's first priority.
A transition group has been set up that has members from the consortium's board, the LMC and the PCT. In the next few weeks, the plan is to appoint a programme director to help take the consortium into shadow form.
As a limited company, the consortium is run by a board comprising a general manager, seven GPs and a practice manager.
Each board member holds a portfolio that includes long-term conditions, mental health, cardiology and community services.
Budgets and management allowance are uncertain as yet with the PCT still holding the reins. But the omens for Wyvernhealth.Com improving care and efficiencies are good.
Since it began in August 2007, the consortium has made savings for the NHS. In three years, it has shaved £1 million off the prescribing budget and saved £3 million in emergency admissions.
'We've also improved COPD services and put the Gold Standards Framework into more than 30 nursing and residential homes,' says Dr Rooke.
So far this has been funded by practice subscriptions and the PCT. At present, the health system is about performance targets and ticking boxes rather than the effectiveness of the care pathway.
Once the consortium has a budget and a free hand, Dr Rooke says there will be a greater focus on patient outcomes 'with the beans and the widgets in the background'.
Big though Wyvernhealth.Com is, he does not rule out working with other consortia. And working with private companies is also a possibility.
'I expect we'll be outsourcing some functions and others we'll be sharing with neighbouring groups.
'There's an idea of sharing financial risk between consortia and specialist services,' says Dr Rooke.
Patient population: 520,000
How set up: A limited company run by a board comprising a general manager, seven GPs and one practice manager.
Immediate plans: Appoint a programme director to the transition group, which comprises members from the consortium's board, the LMC and the PCT, to take the consortium into shadow form.
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