Last year, Hillingdon, in north-west London, hit the headlines twice. Both times the publicity was unwelcome.
First, Hillingdon PCT achieved notoriety by forecasting a £65 million deficit in 2006/7, more than any other NHS organisation in England.
Then a terminally ill patient wrote up her excruciating experiences at the acute trust in Hillingdon Hospital’s overworked dual-sex medical assessment unit and her sister, media figure Janet Street-Porter, published them in the Independent on Sunday.
This is not a situation where GPs can usually help. But in Hillingdon, GPs have been preparing not only to take the pressure off A&E but in the longer term ‘significantly’ to cut the debts of the PCT.
GPs plan to run an urgent care centre alongside the acute trust’s emergency department and to operate a GP-based referral management system.
Dr Mitch Garsin, Uxbridge GP and chairman of the Hillingdon Commissioning Confederation, a group that includes each of the 56 Hillingdon practices, said: ‘We can make economies which will save the PCT enough money to contribute significantly towards restoring financial balance.’
The GPs will be running with the DoH’s invitation both to commission and provide services.
To protect themselves from increasing commercialisation and the government’s intention to open up services to the private sector, local GPs have formed a private company — Hillingdon GP Limited.
Working with Harmoni, the large west-London out-of-hours provider, this company will form Hillingdon Healthcare Limited, a joint venture company, to provide GP and other services using APMS contracts.
In part due to its woeful finances, Hillingdon has had more chief executives in the past year than most patients pay annual visits to their GP.
The chief executive before last, Ian Ayres, was keen for practice-based commissioning (PBC) to help the PCT deliver its recovery plan. There were two cornerstones to the delivery.
Firstly, GPs were to use practice-based commissioning (PBC) to help reduce admissions from A&E. These had increased significantly over the previous two years, and each one cost the PCT on average £1,500, sometimes for a stay of just 12 hours.
In parallel to PBC, GPs in Hillingdon were to develop a community assessment and treatment service (CATS), effectively developing referral pathways and extending the delivery of secondary care services within primary care.
As a result the Hillingdon Commissioning Group is establishing an urgent care centre that will open imminently at Hillingdon Hospital, staffed by local GPs, sessional GPs and possibly doctors from Harmoni, all under contract to the joint venture company Hillingdon Healthcare Limited.
They will work together with specialist nurses and emergency nurse practitioners and an A&E consultant employed by Hillingdon Hospital. The care centre will effectively be a GP-run walk-in centre, accepting ambulant patients between 8am and midnight and bound by the same four-hour targets as secondary care providers.
As a walk-in centre, the urgent care centre will see the 60 per cent of A&E patients who could be seen in primary care. Some will be rerouted to their GP the next day. The rest will be assessed by a GP and treated.
Using GPs will reduce overall costs because, Dr Garsin said ‘GPs admit less and investigate less.’ The GPs will also not be bound by Payment by Results tariffs, increasing possibilities for cost savings.
Alongside emergency care, Hillingdon Healthcare Limited will run a community care service whose aim is to redefine care pathways to shift services from secondary to primary care. PCT-run referral management centres have had a bad GP press, but the Hillingdon version, due to start in spring 2007, will be GP-run.
‘All referrals will go to an assessment centre, using paper records at first, soon electronic, to be triaged by a GP and then assessed by a clinician who may be a consultant working sessionally, a GPSI, a GP or a therapist,’ said Dr Garsin.
While all referrals that go into secondary care will be subject to Choose and Book, those that stay in primary care will not.
Service specifications pathway management for patients with COPD, diabetes and musculoskeletal or skin conditions were ready last September.
With contracts still to be signed, Dr Garsin is hesitant to name a figure for what the schemes will save Hillingdon PCT.
Commissioning GPs such as himself are aware of the dangers of removing the distinction between commissioners and providers, so he will be distancing himself as far as possible from the provider arm.
Nonetheless, ‘the government has said go ahead and be both commissioners and providers’.
‘It’s about GPs beginning to take control once again of the NHS to make it more efficient and fit for purpose,’ said Dr Garsin.
‘It will protect the core values of core general practice such as practice lists and independent contractor status and make available to patients services that have been difficult to access. We are local GPs running a local service and helping local people nearer to where they live.’
Top five deficits
PCTs with the largest forecast deficits for 2006/7:
- Hillingdon PCT: £65.6m.
- Kingston PCT: £17.2m.
- North Norfolk PCT: £16.6m.
- Carlisle and District PCT: £16.1m.
- Cambridge City PCT: £13.7m.