Pathfinder's progress - Salford consortium forges ahead

How we started, our successes, what's next. By Dr Hamish Stedman, Fiona Moore and Scott McKenzie

Dr Hamish Stedman and Fiona Moore: five-year plan is consistent with the White Paper and Health Bill (Photograph: Mike Poloway/UNP)
Dr Hamish Stedman and Fiona Moore: five-year plan is consistent with the White Paper and Health Bill (Photograph: Mike Poloway/UNP)

Our GP consortium in Greater Manchester is called Hundreds Health-Salford (HHS). It was launched in April 2008 and became a pathfinder in December 2010.

HHS includes all bar one of the city's 55 practices and has a patient population of 240,000.

We have been shadowing our PCT's commissioning work and evolved from eight practice-based commissioning (PBC) clusters - until recently, we were called Salford PBC Consortium.

Maintaining an identity
The clusters' areas were coterminous with the local authority's health wards. Building on this arrangement enabled the clusters to maintain their identity and population-specific requirements, while optimising the benefits of being in a larger commissioning group, with an increased powerbase, risk pooling and sharing.

When HHS (as Salford PBC Consortium) launched in 2008, it did so with a five-year development plan it had agreed with NHS Salford - see box below.

Five-year plan

2008/9: Deliver year one goals and get new goals for year two.

2009/10: Deliver year two goals, including making certain savings, and the PCT will respond by working to help the consortium convert to a corporate body.

2010/11: If more goals and savings are achieved, the PCT will second staff to work in the consortium.

2011/12: The consortium will get a real budget.

2012/13: Commissioning services for the city's patients will be completely devolved to the consortium. The consortium will directly employ the PCT's commissioning staff.

Coincidentally, this matches the timeline for PCT disestablishment and is consistent with the White Paper Liberating the NHS: Equity & Excellence so leaving HHS well placed to meet the requirements for consortia set out in the Health Bill.

Business advisers to NHS organisations, the Scott McKenzie Consultancy, helped us develop our governance arrangements with the PCT and between the consortium and its 54 member practices. The arrangements make clear that all parties are aware of their responsibilities and how they will be held to account to deliver improved health outcomes for the population of Salford.

HHS will need to review its governance framework in the light of the Health Bill and the envisaged changed responsibilities and authorisation rules for consortia.

Since April 2008, approximately 70 per cent of the PCT's funding allocation has been devolved to GP commissioning (about 40 per cent at practice level and 30 per cent consortium-wide).

In general, all local health service budgets can be devolved except those outside the scope of GP commissioning. These are PCT headquarters funding, public health, hosted budgets, pooled budgets and independent contractors.

The decision to keep some budgets at consortium level, as opposed to devolving them to GP practices, was based on:

  • Level of financial risk and volume of patients. For example, some specialist services are high cost and low volume so the risk cannot be managed at individual practice level.
  • Lack of adequate data to underpin devolving to practice level. As an example, this applied to mental health budgets.

The consortium is currently (in 2010/11) held to account for the total indicative budget delegated to it. Supported by the PCT, we have developed high-quality activity and financial management reporting. This has enabled us to actively manage resources, resulting in cost-reduction programmes and achieving financial objectives.

HHS has established a formal and effective means of addressing adverse performance and variances. This involved establishing a number of exemplar models at practice level in relation to 'recovery plan' development and delivery.

Our governance arrangements and the embedding of clinical commissioning throughout NHS Salford's area has enabled HHS to be involved in, or to lead on, all service improvements and commissioning decisions made in the past two years - see the box below.

Service improvement and commissioning examples

Clinical engagement

  • Internal - each practice has a clinician as its commissioning lead who attends a monthly commissioning meeting and feeds back commissioning information and requirements to the practice. The consortium has increased the number of clinicians leading commissioning, service improvement/redesign and performance monitoring of providers.
  • External - establishment of clinical engagement groups with major providers; increased external clinical engagement on improvement; commissioning strategy groups.

Commissioning skills

  • All practices have received training on activity and finance data analysis - skills they must use on a monthly basis.
  • The outcome from gaining this knowledge is a reduction in variation consortium-wide. All practices were offered services improvement training.

Unscheduled care

  • Our integrated care programme is aiming for savings of £7.2 million by 2013.
  • This will be achieved through unscheduled care service redesign across the health economy.
  • It will include processes to educate/redirect patients to self-care/primary care and significant communication with the public and patients.

Referral management

  • Reviewing referrals - all practices undertake referral and outpatient follow-up (OPFU) review. From 2008/9 to 2009/10 the mean spend per 1,000 population was reduced by £40 for outpatient first appointment and by £70 for OPFU.
  • Consultant-to-consultant referrals - a protocol was developed in collaboration with our main provider and implemented without adversely affecting GP activity.


  • OPFU - worked with main provider to agree a protocol. This reduces clinical variation by providers and ensures patients benefit from all attendances.


  • Practice-based commissioning incentive schemes undertaken by all practices contain prescribing components based on improving quality and efficiency. The prescribing spend per 1,000 population was reduced by £10,000 from 2008/9 to 2009/10.
  • Best value prescribing savings were £1 million in 2007/8, £1.6 million in 2008/9 and £800,000 in 2009/10.

Data quality

  • A component of each practice's monthly data analysis is the challenges/validations process when practices validate activity data and analyse the quality of information received from providers. This produced £76,000 in refunds for August 2010, for example.
  • Challenges/validations process is supported by the PCT's contracting unit, which undertakes additional analysis and pushed up the August 2010 refund total to £980,000.

Redesigning patient pathways

  • Pathways changed include diabetes, dermatology, musculoskeletal, anticoagulation, heart failure, AF, diagnostics, ophthalmology, community services, unscheduled care, neurology, respiratory, OPFU scrutiny and many others.

The Hundreds Health–Salford team wants to develop relationships with providers and local authority

Pathfinder status
When the opportunity arose, HHS applied for pathfinder status to share with others the commissioning knowledge we have acquired. We also thought it was important for our member practices to have their huge efforts recognised and to encourage them to take forward future plans with renewed enthusiasm.

We now need to achieve some short-term goals to progress further with GP commissioning, including an implementation plan to take HHS from its current position to one able to deliver the Health Bill requirements for a clinical commissioning consortium from March 2013.

We also want to develop new clinical lead roles as we will be recruiting people for posts over the next few months. We will continue to develop relationships with providers and, most importantly, with the local authority with the establishment of its health and well-being board.

Last but not least, we need to develop a management structure to support us through the coming transition period and beyond. We must decide whether this is generated in-house, shared with other consortia or bought in from commissioning support organisations.

  • Dr Stedman is the lead GP and Fiona Moore is head of clinical commissioning at pathfinder GP consortium Hundreds Health-Salford; Scott McKenzie is a business consultant specialising in GP commissioning support -
  • The authors will be providing updates in GP on Hundreds Health-Salford's progress at intervals during the months to come

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