Published: 10/02/2005, Volume II5, No. 5942 Page 29 30 31

GPs in Surrey are collaborating to exploit the opportunities of practice-based commissioning. Ann Dix explains

One of the big hopes for practice-based commissioning is that it will deliver where primary care trusts have failed - a shift away from hospital-dominated care towards localised provision better tailored to patients' needs.

It is a challenge that GP practices in Epsom Downs - poised to take on practice-based commissioning this April - believe they can meet.

Between them the 16 practices, in East Elmbridge and Mid Surrey PCT, lay claim to what is possibly the largest range of extended primary care services in the country, delivered through personal medical service contracting arrangements. They now plan to take this forward by using practice-based commissioning to liberate the contracting opportunities of newer, more flexible forms of PMS (see box, page 30).

Involving a level of co-operation rarely seen between GPs, let alone 16 different practices, they have joined together and set up an NHS limited company, which brings a range of NHS professionals across the locality into one specialist PMS (SMPS) provider-contracting organisation.

GP and director of Epsom day surgery Dr Tim Richardson has been in the vanguard of developing innovative primary care-based services in the locality, formerly through GP fundholding and total purchasing, and more latterly through PMS plus (see box, page 30).

He explains that the practice managed to retain services developed under fundholding because it had 'the foresight' to switch to PMS early on. 'We managed to keep most services by switching them to PMS plus.' It has resulted in more efficient and costeffective local services, with significant benefits for patients. 'For example, we can offer our patients a colonoscopy in four weeks', while those going through the hospital system elsewhere in the locality 'will have to wait for up to a year'.

'We now want to extend these benefits across the locality, ' he says, and PBC, combined with the flexibilities of SPMS, are a chance to achieve this.

Partner up SPMS encourages groups of health professionals to set up as partnerships or limited companies 'with the intention of moving non-critical services out of hospitals into the community', he explains.

'We are negotiating a contract with the PCT to take over a range of diagnostic and day-case activity.' At the same time they are seeking to become a locality for PBC. 'We have always seen ourselves as providers of services, and getting the budget is a mechanism for doing this.' Under these arrangements indicative budgets will be devolved down to individual practices, which will work together in a co-ordinated way, he says.

But he stresses that PBC 'is not just about purchasing services, it is about redesigning them'.

The main advantage of setting up a locality-wide SPMS, he explains, is that it gives economies of scale, increasing the scope for extending services.

'As an individual practice you can't really invest in all the equipment you might want at a primary care level. You might manage an ultrasound machine, but you wouldn't be able to fully utilise it. You wouldn't manage x-ray and certainly not a treatment centre.' Epsom Downs Integrated Care Service will serve a patient population of 120,000, providing 'the critical mass' for that investment. But it is also a 'vehicle' to bring together professionals from different parts of the NHS, 'to work together to deliver services in a flexible way', he says.

All employees will have share options. But there will be no outside investors. 'We hope this arrangement will be accepted as an NHS body as our practice is through PMS, ' says Dr Richardson.

NHS terms and conditions would therefore apply, including pension rights, which will be 'key' in recruiting and retaining staff.

This new SPMS provider will offer the same range of extended services currently delivered under PMS plus by Epsom Downs practices - which include routine outpatient services, diagnostics, endoscopy, day surgery and management of long-term conditions.

But it would also seek to extend those services across the locality, and develop new forms of service delivery with hospital clinicians.

Initially consultants would be sub-contracted to provide components of care, says Dr Richardson, but in future they could choose to be employed by the SPMS provider or set up their own chamber under SPMS arrangements. 'Consultants could decide that they will no longer be employed by the hospital trust, ' he says. 'We have a number who are expressing interest in SPMS'.

The idea has the support of the British Medical Association. Consultants committee chair Dr Paul Miller says it 'has value particularly under choice, payment by results and diversity of provision'. 'It is quite appealing to some consultants, ' he says, who believe it will give them freedom to innovate.

'It is fairly easy to see how virtually all outpatients could become unbundled from the main hospital.' GP Dr Anne Hollings has played a major part in putting together the SPMS bid at Epsom Downs. The idea is to find 'more economic and efficient routes that are better for patients', leaving hospitals to concentrate more on providing critical care, she says. 'We would aim to deliver services more efficiently, largely because we would be keeping them in the primary care environment.' Nor will they be restricting themselves to elective care services. Dr Richardson says two areas for future development are likely to be emergency care and medical admissions.

'Sixty to 70 per cent of activity in accident and emergency relates to primary care-type needs', he says, a situation which has been exacerbated by GPs opting out of out-of-hours care. 'We think the time has come to merge the out-of-hours private services with accident and emergency where we know patients do not need the back-up of a major hospital.' GPs triaging patients in A&E would speed up diagnosis and reduce the need for specialist care.

Another idea is for primary care to run medical assessment units which are costing PCTs dear because of the rise in emergency admissions, due to 'scams' by hospitals to meet A&E waiting targets, he alleges.

Finally, he says, there are plans to look at how 'we deploy resources to keep more people closer to home for the chronic elements of their acute healthcare needs' - in particular elderly people. A lack of community provision means that money is being wasted on acute beds for people who do not need to be in hospital, he says.

Referrals management But he stresses that the SPMS is not just about service delivery. A key component will be setting up a referrals management system to reduce referrals to secondary care, with more diagnostic tests done in a primary care setting.

'There are an awful lot of referrals that go straight through to secondary care which can actually be handled in primary care if you have the appropriate diagnostics or skills without needing to touch secondary care.' So the idea would be to develop the necessary diagnostic tests in primary care to establish whether patients really need to be referred on, he says.

For those patients who need referral to a specialist, the SPMS will also manage patient choice, he adds. It is important to implement choice at the point at which the SPMS contact is awarded as 'we will be one of the provider organisations within that choice arrangement'.

PCT chief executive Alan Kennedy says it is embracing practice-based commissioning having seen the benefits of fundholding in its patch and because, with a PCT deficit of£1.25m, under payment by results 'the old tricks to reach financial balance will not work'.

The PCT has divided its patch up into three localities, which will be responsible for commissioning services and managing local providers. GPs as the main referrers will have the majority vote on the three locality teams, which will be sub-committees of the PCT accountable to the PCT board. A devolved PCT management structure will provide support for the localities.

But as Mr Kennedy explains, 'it became obvious to us' that PBC on its own wouldn't be enough to achieve the 'radical redesign of services' needed to meet new and increasing demands on services.

'We are very lucky here in that about 80 per cent of our practices are PMS and a large proportion were fundholders.' This has allowed the PCT to fully explore the possibilities of SPMS, he says.

'We believe it gives a flexible organisation that is better able to respond to choice, ' and attract nursing and therapy staff, he claims. Under the Epsom Downs arrangement, '95 per cent of any surplus would be invested in service improvements, with a maximum of 5 per cent available to stakeholders', explains Mr Kennedy.

The board will make a formal decision on the Epsom Downs SPMS proposal next month, but 'in principle we support it'.

'Epsom Downs is the first, but we expect that in less than one year we will have three predominantly medical SPMSs. We are also supporting the nursing and therapy staff to explore SPMS, with the aim of getting it up and running by April next year.' All this is against a backdrop of a major reconfiguration of acute hospital services in favour of more local provision.

He believes the whole package 'will get us off to a cracking start' in transforming services across the patch. 'I think we will see some magic happen here.' Dr Hollings says the combined experience of fundholding and PMS, together with 'terrible' local economics causing 'services to be pulled out from under patients left, right and centre', has led to an unusual degree of consensus among local GPs, who 'are itching to get the benefits of PMS plus to a wider group of patients'.

The net result, she says, 'will be services moulded, not to the needs of institutions, but to what patients require'.

Dr Richardson puts it more starkly. 'The NHS can no longer afford to put all its money' into hospitals that are 'no longer financially or clinically viable', he says. But 'change is more likely to be driven by primary care than by PCTs and hospitals whose real interest is achieving financial balance and holding on to the money.' 'The government has bitten the bullet and given back fundholding in a different format. We have to take that opportunity and make it work, or continue to battle with a situation where the trust is in deficit, the PCT is in deficit and the patient is not getting results.'


Personal medical services: an alternative to the new national general medical services contract. First piloted in 1998 to give primary care professionals the freedom to provide services that better meet the needs of the local population. More than 40 per cent of GPs in England now work under PMS.

PMS plus: A variation of PMS that allows GPs to provide a wider range of services.

Specialist PMS: a new model with the flexibility to develop a wide range of community and primary care services free from the obligation to provide essential primary medical care services.

Find out more

Sustaining Innovation through New PMS Arrangements www. dh. gov. uk

National Primary and Care Trust Development Programme www. natpact. nhs. uk

National Association of Primary Care www. primarycare. co. uk

Key points

Sixteen GP practices in Epsom Downs have formed an NHS limited company, bringing them together as one provider-contracting organisation.

Practices and the PCT hope to use these new flexibilities together with practice-based commissioning to redesign local services.

By pooling resources, the practices can treat more patients within primary care, keeping expenses low.