A spirit of cooperation between clinicians has helped a London primary care trust improve productivity and patient experience by moving services into the community. Laura Guest explains how they achieved it

A new type of provider is delivering collaborative care to increase quality and productivity in north-east London.

Eighteen months ago, NHS Waltham Forest GP commissioners were encouraged to build on practice-based commissioning, having seen rapid changes in services with the opening of one of the first London polyclinics in Leyton.

This was in response to existing healthcare services not being configured to meet future population needs, and significant productivity opportunities. Many more people than the national average were going into hospital in this part of the capital, putting pressure on hospital services with increasing and unaffordable costs.

By shifting activity out of hospital and redesigning services under the Healthcare for London strategy of more accessible, high-quality primary and community facilities, we offer a wider range of services than is provided by most GP practices.

Strong start

The results show:

  • improved patient satisfaction, with 90 per cent good or excellent in an area where survey results were historically poor;
  • 700 unregistered and homeless patient attendances each month;
  • more seamless care in the one-stop shop service model by clinicians working collaboratively and no longer restrained by organisational boundaries.

This was an excellent start, but larger scale change was needed.

In planning to achieve transformational change in the local system, the PCT and GP commissioners reviewed services in partnership with hospital consultants and other clinicians through the lens of the PCT’s Right Person, Right Care, Right Place programme. They identified further opportunities to be tested and rolled out, with mechanisms to promote best practice, innovation and shared learning.

The collaborative service model is based on successful local experience of implementing a small number of community specialist services using a “see, treat and discharge under one roof” philosophy.

This led to the creation of 21 community and primary care specialty services in Waltham Forest using the community contract through various mechanisms, including limited company. This has provided improved quality and productivity.

Key to this has been strong clinical leadership and partnership, particularly between hospital consultants and GPs, but also between GPs and optometrists and allied health professions.

Strong clinical leadership

In 2009 the PCT identified six GP clinical directors responsible for strategic development. They would take the programme forward.

Using the experience of clinical leadership from Kaiser Permanente, GP clinical leadership is distributed not just at a strategic level but where clinicians actually work day-to-day, making it more effective.

Twelve GP clinical pathway leads are each responsible for identifying best practice in 12 care pathways to help ensure frontline commissioning decisions are made with a focus on quality and the needs of the patient. This focus of clinical expertise enabled a collaboration with the local acute trust in addressing care pathways and infrastructure across both primary and secondary care. This spirit of co-operation between clinicians has been welcomed by many hospital doctors, although not all, and successful partnerships have been forged in new types of collaborative care.

Programme management was introduced in the PCT, with each clinical pathway lead partnered by a programme manager supplying practical support, especially for analysis, programme management and delivery. The hospital and PCT medical directors and executive meet regularly to give top-level programme support.

Hospital consultants and GPs together identified which services could move from hospitals to primary and community settings. We have found the quality of these community services is often better, and, without hospitals’ overheads, cheaper at around 55-65 per cent of tariff. Other findings are:

  • Improving outcomes: diabetes blood sugar levels, early detection of bowel cancer up 1.38 per cent per month;
  • Increasing productivity: reduction in hospital first outpatient appointments by 11 per cent in some specialties (see graph), fewer steps in the patient pathway, reduced follow-up to first attendance ratio
  • Improved patient experience and choice: reduction in outpatient waiting times, for example dermatology reduced by 25 days and ophthalmology reduced by 15 days.

The shift of some services from acute to primary and community settings has achieved real change in Waltham Forest and in 2011 will comprise a significant new type of service provider.

However, the question of fundamentally rethinking the role of general practice and collaborative provision may need to be further considered in light of the white paper implementation. At the moment there are limited organisational mechanisms which allow plurality and patient choice through different provider business vehicles, such as social enterprises.

Laura Guest is deputy chief executive of NHS Waltham Forest.

21 community specialist services

  • Anti-coagulation
  • Cardiology
  • Carpal Tunnel
  • Colorectal
  • Tibial nerve stimulation
  • Dermatology
  • Diabetes
  • Endocrine
  • Direct access endoscopy
  • Direct access physiotherapy
  • Integrated urology
  • Deep-vein thrombosis
  • ENT
  • Glaucoma
  • Mental health
  • Musculo-skeletal
  • Integrated orthopaedics
  • Urology, general
  • Opthalmology
  • Sickle cell
  • Gynaecology