Back in May 2010 the professional executive committee and NHS Lincolnshire board agreed to delegate the management of the minor surgery local enhanced service to the practice based commissioning (PBC) Groups. A lot of discussion and analysis had taken place prior to this decision. Practices had said that the historical budget was insufficient to meet demand and that without investment GPs would be forced to make a referrals to hospital based services which would cost more. Concerns were raised about managing demand, the appropriateness of the surgery and whether increasing investment in primary care services would have any real impact on referrals into secondary care. Out of the debate emerged the “experiment” which the Board sanctioned.
Activity analysis suggested that if all recorded minor surgery activity was to be done in primary care, then the budget would indeed need to be uplifted. This was agreed. The budget was increased from £850k to £1.1m.
In addition a set of principles was agreed:
1. The PBC groups would manage within the allocated budget
2. There would be no referrals for these procedures to secondary care outside a prior approval process
3. Waiting times must reflect the 18 weeks standard as a maximum
4. The NHS low priority procedure (cosmetic surgery) Policy would be followed.
So, in essence, the PCT handed over the management of a real budget to a bunch of GPs.
Some interesting things happened subsequently:
Practices discussed and compared data. Collectively, practices agreed to adhere to thresholds to manage demand. There was acceptance and adoption of the low priority procedures policy to inform thresholds and ensure equity and fairness. One group decided to drop the price per procedure. Peer review ensured probity and governance of in-house activity.
The effect of all of this was a drop in minor surgery activity and an overall under spend (more than £200k) in 2010/11. Suspicious minds might wonder if that was achieved by offloading demand into secondary care. Yet like-with-like comparison showed a decrease in secondary care activity across the county, with only one PBC group showing an increase. Giving control to the clinicians had led to greater standardisation and demand management based on professionally determined quality standards.
This was only a small experiment, a small step. It was based on analysing need, creating an incentive for practices to work collectively and trusting that they would work in good faith. It could have failed. If it had it would have been survivable. It didn’t fail. It delivered an unexpected outcome.
If we are going to meet the challenges ahead then maybe we need to take similar and even larger steps?
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.