GPs in Essex were stimulated by the arrival of an alternative provider contract in their patch, say Hilary Ayerst and Paul Corrigan

Creating and maintaining change in an environment that seems stuck in the past is one of the main challenges for change management in the NHS. To those of us championing change it may seem so obvious, but to others delivering services, the case for change seems to have little impact. What is important in those circumstances is to find the external catalyst that unfreezes the present and then to keep the pressure on for change until movement becomes normal.

Three years ago, Barking and Dagenham primary care trust was characterised by a generally low standard of primary care, with most GPs practising single-handed in poor quality premises, and list sizes significantly higher than the national average. The public was dissatisfied with the quality and accessibility of primary care services, leading to high attendances at accident and emergency.

Weak attraction

It looked as if Barking and Dagenham was a striking example of the inverse care law in practice - of poor people inevitably getting poor services. So the PCT was struggling to attract new GPs to the area.

Now, in 2008, the picture has changed. Current GPs are much more enthusiastic about new ways of working and the PCT's annual health check ratings continue to improve. The borough is still rated as the most under-doctored in England, recording the lowest number of GPs per head of population, but the number of GPs is rising and the quality and range of services has increased. The average quality and outcomes framework score for Barking and Dagenham practices is increasing faster than in many other PCTs, meaning the local practices are improving more quickly.

Patients can see and appreciate the difference. The Healthcare Commission's patient experience rating shows year-on-year improvements in the PCT's relative ranking.

Perhaps the most significant catalyst in this change was Barking and Dagenham PCT's selection as one of the first-wave alternative provider medical services sites in July 2005. This allowed the PCT more freedom to develop plans for a walk-in service, offering unscheduled care away from A&E; a new GP practice for up to 8,000 patients; specialist nurses and GPs; clinics offering minor surgery and phlebotomy; and a diagnostics service to reduce travel to hospital.

These service plans initially caused concern among the GP community, and scepticism about whether they would work. This intensified in May 2006 when then health minister Lord Warner announced that the contract for providing some of these services at in Barking had been awarded to Care UK, an independent sector provider. This government-brokered deal was the first in the country to allow an independent company to run traditional GP services under an alternative provider arrangement.

Local GPs' response to the challenge of the independent sector was to offer a wider range of services and introduce some opening hours flexibility. Since July 2007, 29 of Barking and Dagenham's 43 primary care practices have been taking part in a pilot scheme to extend their opening hours. Under this scheme, 140 hours' additional clinical time is available each week throughout the borough.

Three years ago, the GPs would have been reluctant even to trial changes, but seeing new ways of working on their doorstep acted as a spur. The number of patient complaints about appointments has fallen with the extended-hours pilot scheme. This year has also seen a reversal of the upwards trend in A&E attendances and emergency admissions from the borough.

The PCT drove a range of other developments, including:

  • two nurse-led walk-in centres;

  • a GP access clinic, to provide additional capacity for routine GP appointments;

  • widening community pharmacy services, including the Pharmacy First scheme for minor ailments and emergency hormonal contraception;

  • health promotion and patient education programmes;

  • commissioning translating and interpreting services;

  • introducing a contract with the independent sector to provide services for refugees and asylum seekers;

  • ensuring all practices benefited from advances in IT.

Lift off

And all this was taking place within the context of an extensive and ambitious premises modernisation programme, mostly under the Department of Health's local improvement finance trust umbrella. In the past three years, five new health centres have opened, with another two due to open next year. These centres provide a wide range of services, from traditional GP services and unscheduled care, to minor surgery, blood testing, diagnostics and other outpatient services, in purpose-built premises.

If the NHS promise of equal access for all, free at the point of need, is to mean something, then deprived areas such as Barking and Dagenham have a responsibility to do a lot more. The PCT is concentrating on six key areas:

  • extending access to existing practices;

  • extending access through the procurement of new practices;

  • extending access through new and alternative services;

  • strengthening the GP and nurse workforce;

  • improving the patient experience and public perception of access;

  • focusing on schemes aimed at preventing ill-health and managing demand for services.

The PCT is establishing a pool of salaried GPs, with administrative and practice nurse support, allied to a neighbourhood of practices. The posts will include locum cover, research projects and development of specialist sessions, and sessions in non-practice settings like the new Barking Learning Centre.

The PCT will offer the best practices the option to move to an alternative provider contract and will expect practices moving into new PCT premises to demonstrate that they can offer an alternative provider medical services level of service. The PCT is also developing a public communications strategy promoting access options in primary care.