The ambitions of a group of GPs to radically redesign A&E back in 2007 can teach the new wave of commissioners valuable lessons, write Martin McShane, director of strategic planning and health outcomes at NHS Lincolnshire, and Jerry Clough, director of Atlyric Limited.
Making GPs the leaders of commissioning for the NHS raises questions and concerns. Will GPs want to do it? Will they really make change happen on the size and scale needed to tackle the problems the NHS faces? Will they engage other professionals and the public in their commissioning decisions?
In Lincolnshire, there are excellent examples that give positive answers to these questions. We supported local GPs to lead a major programme of transformation in Louth. This process has been refined and improved in two further localities, where GPs have taken charge of major commissioning processes.
We now have a handbook that sets out locally how GPs can lead publicly engaged commissioning.
Following the 2006 reorganisation, NHS Lincolnshire emerged as one of the largest primary care trusts in the country. For practice based commissioning, the GP practices elected to work in eight clusters. Each had a dedicated cluster based manager with access to support from other PCT staff - akin to a commissioning support unit.
Rurality and transport are big issues for the county, especially in an area like Louth. This market town had a small hospital that was part of United Lincolnshire Hospitals Trust. For local people and the 14 practices in the cluster, the hospital seemed under constant threat of cuts and attrition.
In 2007, GPs from the cluster approached NHS Lincolnshire with a vision. They wanted to redesign A&E and 60 medical beds in Louth County Hospital, a traditional acute, trust-managed model, to a primary care-led model, while retaining most of the acuity on site. In short, to have the same flow of patients treated by a different clinical model.
In delivering the Shaping Health for Louth County Hospital programme, NHS Lincolnshire decided to invest in external programme support to augment the local management and chose a partner skilled not only at programme management but also at executive coaching.
This is probably the biggest lesson learnt from our work in the town. We needed to support the clinicians to deliver, rather than jumping in and doing it ourselves: our choice of partner gave us someone who could sit alongside clinicians, help them with their programme and support them as leaders, clinical architects and key links to the local community.
The first principle we adopted was that GPs should lead the process. The second was that the public must be fully involved from the outset. This approach was not natural for the GPs, but the support gave them the skills and confidence to talk openly in public about changing services.
They discovered they were exceptionally good at it and we have learned to invest even more time in subsequent programmes on relationships at the outset; an apparently slower start pays huge benefits later.
During Shaping Health for Louth, GPs were supported to:
- lead the process, with strong partnerships with local NHS organisations and clinicians;
- engage with local stakeholders and ensure the programme was embedded in the community;
- develop and articulate their vision for the local hospital;
- analyse and review patient activity information;
- form a clear consultation proposition;
- lead a consultation with the public;
- create a commissioning specification;
- document a robust and in-depth clinical competency framework;
- implement the changes that were required.
Alongside the usual documentation, the public consultation took the form of sessions where people could view storyboards and have one-to-one conversations with clinicians and managers. This proved a powerful approach as time could be tailored to individuals’ concerns. Presentations to groups were also arranged where requested.
The outcome of the consultation was 90 per cent public support for the transfer of acute care to an integrated primary and community care model. The model was swiftly implemented. By April 2009 the new urgent care centre was operational and the acute wards changed in August 2009 - see box below.
Meeting local needs
The cluster - and emerging consortium - is looking at how it can make even better use of Louth County Hospital to manage emergency admissions.
The process and model of care used for Louth have been subject to external scrutiny. In giving an amber/green rating the Office of Government Commerce gateway review stated:
- Support from GP commissioners was fully demonstrated as this project is clearly led by the local GP practice based commissioning group. The policy of clinical leadership and accountability was clearly embraced.
- Public and patient engagement was extensive, effective and ongoing and there was clear evidence of support from the local authority.
The National Clinical Advisory Team concluded that the new way of working was safer and better meeting the needs of the local population.
In finishing the Louth project we held workshops to capture experience and learn lessons. We made mistakes along the way and made some things harder than they should have been, but the results have been compelling.
We then shaped a revised process and looked at two further programmes in Skegness and in Mid Kesteven.
Shaping Health for Skegness Hospital concluded a public consultation in December 2010 following 15 months’ work to find and develop local GP leaders, establish a vision for the hospital, work with local stakeholder groups and have a meaningful consultation with the public.
Of particular note in Skegness were the relationships formed with the Skegness Hospital watch group. Working with them as members of the programme board led by local GPs they trust, it was possible to create unanimous board support for the consultation proposals.
On the face of it, the key consultation proposal and board view of the best way for the hospital to develop may be seen as controversial. The A&E service does not operate as an A&E unit in a large hospital, so our approach was to be honest with local people, rename it as an urgent care centre and make it a single, integrated service with out of hours that is currently located some miles away in Boston.
It was hard to imagine building better success than in Louth, but this key consultation proposal received over 95 per cent public support.
The OGC Gateway review for Skegness noted:
- This process of engagement has allowed cohesion to develop between stakeholders, including commissioners, GPs, clinical staff and the public, which will hold the local health economy in good stead when undertaking future healthcare planning exercises.
- Public and patient engagement was extensive, effective and ongoing and there was clear evidence of support from the local authority. The programme was considered by the review team to be an exemplar of effective engagement.
The National Clinical Advisory Team reported on the sustainable future for Skegness Hospital and commended the model to the future GP consortia.
Shaping Health for Mid Kesteven started in March 2010. It has made great progress with stakeholder engagement and the development of exceptional GP leadership is testament to their ability when given a supportive environment.
Our handbook Publicly Engaged GP Commissioning is a summary of the process we have developed in Lincolnshire:
- start with good programme management;
- find clinical leaders;
- develop and support them to determine a local vision;
- work with stakeholders to create a positive environment for change;
- work openly and honestly - people respond if the work is locally and clinically led;
- coach, develop and support;
- consult and deliver.
The right skills are critical - local GPs, cluster focused managers, determined leadership within the PCT to facilitate local change and programme management, combined with behavioural understanding and development support, are all part of the mix.
You have to believe in the approach. You need to believe local GPs can come up with sustainable solutions; that they can manage process and expertly work with the public. Every time it gets difficult, it is even more important. That belief rubs off, GP leaders flourish and the public are open to discussing their local services.
Results of the Louth consultation
|Consultation Proposal||Level of Public Support in Consultation (agree or strongly agree)|
|To create an integrated primary care led hospital||89.4%|
|To commission an A&E service that is led by GPs and nurses.||92.3%|
|To commission an integrated inpatient service provided by nurses with medical input from GPs supported by specialist consultants||92.6%|
The Model of Care
The final model in Louth is an integrated urgent care service.
The previous A&E service is now delivered predominantly by nurses, nurse practitioners and GPs with staff grade doctors working together, with a primary care emphasis and access to consultant support. Lincolnshire Community Health Services is the main employer, with Louth and District Medical Services (a GP owned company) providing most of the medical input.
The locality uses SystmOne in all its practices, in A&E, in out of hours, on the wards and through community services; the benefits of a single information systems is very close to being realised in Louth.
The acuity of medical admissions is being maintained based on extensive work done on protocols, led by local GPs, which included the ambulance service and specialists. It is underpinned by a competency framework, also developed locally.This has meant more activity has been safely retained in the hospital than expected.