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The crucial commissioner

14 October 2011

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Liz Brimacombe is the managing partner of an innercity practice and has a key commissioning role. This Plymouth practice manager is not one to coast…

The EuroMillions winner of £165m is someone in the UK…” I hear over the radio as I start my drive to work. “Wouldn’t that be lovely?” is my first thought; quickly followed by the frequently heard, designed-to-make-you-feel-better refrain: “Yes, but what would you do with all that money? You’d be bored!” I start to ponder as I make my way to the practice.

St Levan Surgery is a five-GP, 7,000-patient practice in innercity Plymouth. We have a very strong ethos of equity of healthcare for all. This ethos, together with our location and resulting practice population, provides for an interesting, challenging and diverse group of patients.

St Levan was a two-sited surgery until 2009 when the two sites finally merged into our new build, which opened in 2004. Our commitment to team working was recognised in May 1998 when we became the first practice in the southwest to achieve the Investors in People award. We have continued successfully to maintain this award.

My NHS career began in 1992 at the local Community Services NHS Trust, managing a range of non-clinical staff across numerous community-based sites, including secondary-care services. After establishing the post of Litigation Manager for the trust (I studied law and social policy), a move to primary care was suggested to widen my experience and I joined St Levan Surgery in 1996 and the partnership in 1998.

Being a partner brings a 24/7 commitment, but also a sense of ownership and pride in a business that I have played a part in creating. We have seen so many changes and developments that sometimes I think it would be quite nice to be bored for a while!

Our practice partnership team’s 360˚-appraisal process, in which each of the partners appraises each other’s performance – has been running since 1997. This has admittedly brought with it some tensions, but in the main has provided a strong foundation and basis for the respect and close working relationships between the partners and practice team, as well as other health and social care professionals. Core to our approach is the belief that investing in staff is of paramount importance in developing a friendly and responsive approach to patients.

Patients and patient needs
The practice is located in a significantly deprived area of Plymouth. Our patient list includes a high proportion of ethnic minorities and asylum seekers, and we see high levels of unemployment, substance misuse, teenage pregnancy and associated physical and mental health issues, many of which are masked by or seen as secondary to the social issues.

We have a commitment to opening up access for all, to meet and identify needs rather than wants. Often to our own detriment, current guidance, funding streams and governmental policy are either out-of-date or simply do not recognise the needs of specific practice populations.

Deprivation has come a long way since the ‘Red Book’ weighting but funding policy still fails to recognise the workload associated with patients such as those previously described and the families that live with them.

The ’80/20 rule’ – the notion that 80% of healthcare costs are incurred by just 20% of patients – may well be applicable across the whole of the city but totally out of kilter in a single practice. Our practice, along with others in this area, has a far higher proportion of those 20% of patients and not enough of the 80% to fund them. Systems are outdated and fail to acknowledge the workload in settings such as ours.

Many of the current hoops we all jump through are about patient wants, not needs. In a resource-limited environment this is a huge distraction to what we are really here to do. An example of this is the national patient satisfaction survey. The results of this feed PE1 and PE2 quality indicators. But the wording of the survey questions suggests to patients that they can and should have access to a GP of their choice within a specific timeframe. But what if that GP works only two days per week? The answer has to be to bring those wants and needs together.

Following our belief in ‘access for all’ (and rather more pragmatically thinking, “Well, we are seeing them so may as well get paid for it”) we took on the Violent Patient DES (directed enhanced service). A quality, approved alarm system, decent training and back-up from initially the police and latterly a local security firm have allowed us to provide care to this group of patients.

Often owing to mental health issues, these patients can find themselves unable to express their needs in an eloquent and acceptable manner, and fall back on aggressive and sometimes threatening outbursts. However, the numbers who have actually committed an act of violence on practice staff prior to being placed on the scheme are very limited, and have invariably resulted in a mental health section rather than a criminal conviction. Touch wood, no significant incidents have occurred in the practice.

We have also supported our Primary Care Addiction Service in developing a Substance Misuse LES (local enhanced service). By bringing this specialist care into primary care we can link substance misuse with chronic diseases and associated health conditions, providing joined-up care and treating the whole person. This brings about far better outcomes for patients. For example, uptake for cytology monitoring, childhood immunisations and other target areas is far better because patients see their GP and drugs worker in the same place. All GPs have completed their level 1 training, and some have completed level 2, in the Royal College of GPs’ Certificate in the Management of Drug Misuse.

Commissioning vision
The insight this work brings is invaluable to my role as a board member on the local Clinical Commissioning Executive. Three years ago, practices in Plymouth formed a community interest company (CIC) called Sentinel Healthcare South West CIC. All GPs and practice managers in Plymouth are shareholders in this not-for-profit organisation. We have an APMS (Alternative Providers of Medical Services) contract with the primary care trust (PCT) to provide commissioning input and, where need is identified, primary care based services.

Our vision was one of a “healthy system”. Prior to the change in government and the launch of the white paper Equity and excellence, Sentinel recognised that the only way to address the financial problems Plymouth faced was to bring primary and secondary care together in a way that had not yet succeeded in the city. We were collectively committed to redesigning the way healthcare is delivered and provided.

We asked ourselves: if we could lose the historical tensions, detach ourselves from our commitment to our organisations, were given the total budget for a clinical area (for example, diabetes) and brought everyone to one table and gave them a blank piece of paper to design how best to provide care to the people of Plymouth, would it look different to what we currently have?

The answer was: yes it would! The commissioner/provider split does not help but we continue to hold on to our vision and are working our way through the ever-changing landscape. The PCT is supportive of this vision and is trying to find ways of implementation without destabilising existing services.

Sentinel was then given the mandate to develop our clinical commissioning group, which became one of the first 40 pathfinders in England. We are currently in the process of addressing the need to separate the CIC from the commissioning group.

Our value
I believe the role of the practice manager is crucial to this work. Who else really understands how the business of general practice works? Who else can cultivate and motivate general practice to be involved in something that is still so vague and such a ‘moving feast’? Practice managers are the link, the key to this relationship between the commissioning groups and the practices working in harmony.

In my working memory, the NHS has regularly swung from being clinically led to management led and back again – both at national and local level. Never has anyone truly provided the chance to put both GPs and practice managers around one table on the same level, making decisions collectively. Now that Sentinel has provided us with that opportunity, we hope the emerging commissioning group statutory structures do not inhibit this innovative and forward-thinking approach. Primary care groups (PCGs) and the white paper put GPs at the centre of commissioning boards, but how many GPs have retained the truly effective roles they had in the early days of the launch of PCGs? Or did these roles just get drowned in the new system?

Speaking from our personal practice experience, the GPs got bored with being hamstrung by bureaucracy – no one harnessed and directed their skills. GPs found themselves doing work that could be done better by a practice manager on the board. We all have different skills and it is to find this balance and mix of skills that will help practices to succeed.

To my knowledge, very few PCGs had the foresight to recognise this. Now, sadly, many PCTs seem to see practice managers as somehow less competent. I’d like to see them handle many of the things we do on a daily basis, without the support of financial, HR, estates and other directorates. I do hope those lessons have been learned – I am ever the optimist!

Hmm… perhaps I should go and buy a few more of those lottery tickets?