What we do

Main activity
Principia designs and delivers local health services in Rushcliffe, a borough of Nottinghamshire, on behalf of the NHS. The company brings together 16 General Practices, community health staff, patients and the public to ensure local health services are designed around the specific needs of the local population.

Number of employees
None – all designated staff are employed by NHS Nottinghamshire County, the organisation that oversees and supports Principia. GPs are self employed and staff attached to practices are employed by them.

Number of members
These consist of GP members (every practice in Rushcliffe is a member of Principia), provider members (provider staff who have applied to be members) and community members (lay people who have applied to be members).

Turnover
£100,001 - £200,000

Location
The company HQ is located in Ruddington, Nottingham; GP practices that are members of Principia are located across Rushcliffe.

Trading area
Rushcliffe – a borough of Nottinghamshire

Date established
August 2006

Finance
NHS Nottinghamshire County provides an indicative budget to Principia to cover the costs of medicines, hospital care and community services for its patients.

GPs within Principia have also agreed to pool their managerial allowance given to them by the Primary Care Trust to ensure delivery of Practice Based Commissioning.

This makes up the company bank account and real monies for Principia to use for its development.

What does the social enterprise – Principia – do?
“Responding to the expectations of patients and the public of a more personalised service by challenging and empowering NHS staff and others locally to deliver them”.
Our NHS, Our Future – Lord Darzi

Principia is a Practice Based Commissioner (PBC) within the NHS. It brings together a powerful coalition of 16 local general practices, community health professionals (including nurses and therapists), and the local registered population (122,000 patients), in a social enterprise vehicle which is grounded in public service values.

Commissioning is the process of assessing local health needs, identifying the services required to meet those needs and then buying those services from a wide range of healthcare providers, which can include hospitals, pharmacies and voluntary organisations.

Practice-based commissioning (PBC) offers front-line clinicians, such as doctors and community nurses, the opportunity to play a major role in the development and delivery of strategies and activities that improve local health and well-being.

Practice based commissioners are able to commission services across a range of providers and settings, often moving services typically delivered in a hospital environment into more local settings. This means more convenient, more joined-up care for patients.

An example of this could be that a greater range of services are made available within GP surgeries, or in other local settings such as community pharmacies, and in people’s own homes.

Services for both specialist care for particular conditions such as diabetes or heart failure, and health and wellbeing services for people with long-term conditions are being reviewed and redesigned by commissioners, patients and clinicians.

For example, Principia has set up a specialist heart failure team within the community so patients can be managed within the community and access care closer to home.

Principia has also worked with patients, partners and clinicians to develop a scheme where GP practices are incentivised to offer improved services for diabetes patients within their practice. These patients would have otherwise been treated in hospital. The scheme offers practices three levels of involvement – from allowing a diabetes specialist nurse from the local hospital to hold a regular clinic in their practice to investing in specialist training for a GP and nurse within the practice to deliver a clinic.

These initiatives, and the overall PBC model of working, reduces the number of avoidable hospital admissions because more care is delivered in the community and patients are empowered to take responsibility for managing their own health before hospital intervention is necessary. This also saves funds which can be reinvested directly into local health services.

Due to it’s status as a social enterprise, Principia has managed to ensure that patients are represented at every level of the organisation, with members of the public on the Principia board, the Patient Reference Group (a group of patients that steers the work of Principia from a patient perspective) and a wide-reaching Health Network of members of the public that have an interest in local health issues.

How did it start?
Following the government publication ‘Commissioning a Patient Led NHS’ in July 2005, members of the former Rushcliffe Primary Care Trust (the organisation that delivered local health services in Rushcliffe before Principia) met with GPs in the borough to discuss the options for the delivery of local primary care services.

There was a shared understanding that the existing way that health services were being delivered was not sustainable and that the NHS policy agenda, which was becoming increasingly focused on patient choice and patient-centred care, meant that a new approach was needed for the provision of primary care within Rushcliffe.

This was intensified by frustration with the amount of resources diverted away from primary care and into secondary care. Year on year increases in emergency admissions had created enormous pressures within local hospitals. Consequences of this were unacceptable cancellation rates and longer waiting times – more prolonged and expensive care that was not patient centred. The inevitable response was to hugely increase spending on hospital services, while spending on community services remained virtually constant - deeply frustrating for both the public and the primary care clinical community.

Both patients and clinicians perceived that at times their care was poorly co-ordinated – and there was growing recognition that some of the care didn’t need to take place in a hospital.

With the anticipated slowing down of investment in the NHS and a period of further organisational turbulence along with demographic, consumer and technological pressures, it was agreed that a comprehensive redesign of how services were delivered was both the essential and only realistic response. And it had to be done with some urgency.

The decision was made to explore a ‘mutual’ model of healthcare, in which the local patient population had a meaningful and direct say in the planning and delivery of services, and a planning group was formed to develop a proposal. The group was led by GPs, staff within the former Rushcliffe Primary Care Trust and the Rushcliffe Patient’s Forum, with the determination to devise a coherent response to changing government policy that would enable GPs, health professionals and local people to truly work together.

Over the following six months, the planning group developed its thinking on governance, business development and service delivery under the banner of a proposed ‘Rushcliffe Mutual’.  It held numerous events bringing together GP practices, PCT staff and patients as well as seeking external support and advice from a wide range of people and organisations including lawyers, the local MP, the Council’s Overview and Scrutiny Committee, the King’s Fund, the Strategic Health Authority and the Department of Health. 

Finally, a proposal was put together that sought to blend social ownership, enterprise, empowerment, accountability, employee participation and high quality local services. In September 2006 the new organisation signed a three year contract with NHS Nottinghamshire County, the new Primary Care Trust (PCT) that oversees primary care across the whole of Nottinghamshire County, with an indicative budget worth the value of the aggregated Practice Based Commissioning budget for the 16 member GP practices.

To ensure the new company had sufficient funds for its start-up phase, the GPs within Principia agreed to pool some of the money they received from the Primary Care Trust. To have this level of backing from GPs at such an early stage was a huge boost to the establishment of Principia and the result of much engagement work with the practices during the planning stages. Every GP practice within Principia was involved with the company and Practice Based Commissioning from the start – a feat not readily achieved nationally.

It was anticipated that the general practices, community services and patient representatives would work together as a group around common and shared objectives. This clinically and patient led organisation would ensure greater strength of voice in discussions and negotiations, and have greater influence in service development in a changing local NHS.

What is the governance structure?
Principia’s governance structure ensures that key stakeholder groups are engaged at all levels and that patients and the public, as well as health professionals, are firmly embedded in the process of shaping local health services.

The company is governed by a board where patients are in the majority, demonstrating true commitment to patient and public involvement. It is made up of a Lay Chair and six patient directors, who must be registered as patients with Principia GPs; three clinical directors, who are GPs that practice within Principia; and three provider directors, who must have a role that is dedicated, for at least 50 per cent of the time, to the care of Principia patients - e.g. community nurse, therapist, health visitor.

Beneath the board, Principia has a Clinical Commissioning Forum (CCF) and a Patient Reference Group (PRG).

The Clinical Commissioning Forum is made up of Principia GPs, provider staff, the chair of the Patient Reference Group, one community director and the General Manager of Principia.

It meets monthly and steers the clinical work that Principia does. Therefore, if there are any issues around how certain services are delivered or how Principia looks after, for example, patients with a long term condition such as diabetes or heart failure, the CCF will discuss the way forward with inside knowledge of how things work within practices and where the problems lie.

The CCF also looks at how money is spent on clinical services within Principia and ways of changing services to reduce spend while actually delivering better and more community-based care for patients.

The Chair of the Clinical Commissioning Forum is also the clinical lead for Principia and represents Principia at County level and higher in the NHS from a clinical perspective.

The Patient Reference Group is made up of patients and steers the patient and public involvement and engagement work that Principia does. The PRG meets monthly and the agenda focuses on areas of concern for Principia patients.

The group consists of two community directors, two community members and four patients who are active beneficiaries.

Both the CCF and PRG have a representative that sits on the Principia board to feedback any issues that arise from their groups.

All of these groups are supported by staff employed by NHS Nottinghamshire County, provider staff and staff from the GP practices.

Company membership
The company is made up at present of 126 members – 63 GPs, 42 provider staff (usually community clinicians) and 21 lay people.

An audit is carried out annually to review the number of members required. This is calculated according to the number of GPs practising within Principia. If this changes, then the number of members must be adjusted to ensure the balance of membership is correct.

While GPs are the largest membership group because of their accountability for practice based commissioning, patients are tax payers and Principia is ultimately accountable to the population of 122,000 patients. For this reason the chair of the company who is a patient would be able to exercise a casting vote, although this has not happened.

Active beneficiaries
Any Principia patient that is involved with Principia at any level, whether as a member of a Patient Participation Group within a practice, or as part of the wider Health Network, is known as an active beneficiary. Active beneficiaries have an input into the work Principia does by highlighting where there are issues for patients and the public.

How does Principia engage with stakeholders?
Principia has a wide range of stakeholders including GPs, community health professionals such as community nurses, pharmacists and therapists, health professionals in secondary care (hospitals), patients and the public.

The governance structure of Principia ensures we are constantly engaging with our stakeholder groups. We have monthly board meetings and our Clinical Commissioning and Patient Reference Groups meet monthly and feed back to the board, ensuring staff and patients are fully engaged in the organisational development of Principia.

As GP practices are still independent businesses in their own right, it is a constant challenge to ensure they are engaged with and supportive of Principia. The structure of the company ensures that GPs have input into all business decisions, and Principia has devised a Success Scheme that offers incentives for practices to engage in certain ways, such as holding team meetings across disciplines to ensure there is joined up working and that information is shared.

Principia has a number of members and communicates with them via newsletters, regular email and members events – for example, Principia held three provider member events during 2009 hosted by provider directors (provider staff that sit on the Principia board) where the provider members learnt more about Principia and were given the opportunity to ask questions that were important to provider staff.

Principia is also recognised nationally for its patient and public involvement and engagement work. Due to Principia’s status as a social enterprise, there are patients at every level of the organisation and the public voice penetrates right up to the top of the company. This is virtually unprecedented in the NHS.

As part of its commitment to public involvement, Principia runs the Principia Rushcliffe Health Network, which brings together patients from across the borough that have signed up to receive information and be involved in local health issues.

Principia communicates with these patients regularly, at quarterly open events, through regular emails and through update newsletters. These patients are available if Principia needs to consult on any aspect of the health services that are currently delivered, or are being proposed, in Rushcliffe.

Issues and concerns raised at Health Network meetings are taken forward to the Patient Reference Group, a group of Principia patients that feeds directly into the Principia board. Principia is known for listening to its patients and the clear line from the Health Network right up to the board is very important in this process. Recently, the Health Network initiated the production of a leaflet to be distributed across the borough with information on how to access out-of-hours health services, which they felt was an important issue for patients.

Due to discussions within the Health Network, Principia has also set up various forums and groups to engage with patients further. These include a cancer forum, a diabetes forum, a 50+ health sub group, a mental health and well being partnership and a stroke survivors group. These are well attended and have had a real impact on services in the area. For example, a member of the cancer forum was involved in the commissioning of a new screening service for bowel cancer, the group has developed a bereavement letter for GP practices to administer and the group has developed a cancer booklet designed to be given to newly diagnosed patients and their carers.

What are the keys to Principia’s success?
The social enterprise model is key to Principia’s success so far. It gives the company the flexibility it needs to respond to the government’s patient-led NHS vision. Patients are involved at every level of the organisation, with patients on the board, on their own Patient Reference Group, and feeding into the workings of Principia through the Principia Rushcliffe Health Network, a wide ranging group of patients with an interest in local health issues. Although other NHS organisations are increasingly focusing on patient and public involvement, very few have patient engagement so deeply embedded in their structure.

The social enterprise structure also gives staff and stakeholders a sense of ownership over their local health services. This helps to build strong relationships between the different groups and to build a culture of working towards a shared goal. Within Principia there is a feeling that change can always happen and that the stakeholders and staff are ready for it.

This culture has been fostered due to the engagement work that Principia has carried out with staff and stakeholders, another factor that is paramount to the company’s success.

The level of engagement that Principia has achieved is virtually unparalleled in the NHS and is the reason that change is able to take place across local health services. Because of Principia, health services are working together to provide integrated care for patients close to their homes. For instance, a community ward model has been bought together by Principia which offers the same breadth of care that a patient would receive in hospital, but in a community setting. Patients who would have previously attended Accident and Emergency (A&E) and/or admitted to hospital are finding that, through the close working relations between GPs and community specialists and services, some hospital admissions are avoidable and the patient can receive the appropriate care while remaining in their own home.

Before Principia was set up, primary and secondary care were virtually estranged. Principia has worked hard to build links with secondary care organisations to create more joined up working and greater coordination of care for patients.

The company’s partnership work is also a key aspect of its success. Principia links with a wide range of organisations, such as Parkwood Leisure, the company that manages leisure centres on behalf of Rushcliffe Borough Council. Principia also works with the Borough Council on joint events and communications and has jointly funded the Rush 4 Health festival in Rushcliffe – a family festival with a health focus.

The company has been praised by the Department of Health for its innovative approach and many other Practice Based Commissioners, GPs and Primary Care Trusts have contacted Principia and are looking to replicate the model in their own areas.

What are the key challenges Principia faces?
Principia faces a number of challenges: some due to its status as a social enterprise, others due to its position in an ever changing NHS and political context, and some due to both of these factors combined.

These include:
The budget – Currently, as a PBC organisation Principia does not hold an actual budget. However, through continued close working with the Primary Care Trust, NHS Nottinghamshire County, it is hoped that the indicative budget will move, in time, to a real budget, in addition the overall economy means that the NHS is facing slow or reduced growth at a time of an ageing population who take the bulk of NHS resources

The company structure – due to being a company limited by guarantee and having patients as directors, if Principia were to employ its own staff, those staff members would lose their NHS pension and terms and conditions. This is something that many staff are understandably reluctant to do. Therefore, Principia staff are currently employed by NHS Nottinghamshire County. This continues to be a national issue and something that the Department of Health and the Treasury are reviewing.

The governance – Principia has to ensure the governance structure strikes the correct balance between the interests of GPs, provider staff and the community it serves. Finding a structure that achieves this balance is a political challenge due to many factors. For example, GPs are responsible for delivering Practice Based Commissioning but are also accountable to patients and the public, who are the taxpayers. Patient input is therefore seen to be important at all levels, however the independent business units of the GP practices need to feel that they have some control and autonomy over the work they provide. It is very important for Principia to get the governance structure right as this facilitates successful engagement with staff and patients. If the structure was wrong or ceased to be effective, this could have a very negative impact on engagement and the success of the company.

Real change – moving from the short-term challenge of ensuring continuity of care in community settings for patients to achieving real change in the way care is delivered is a challenge for Principia

The complexity of the challenge – Without an actual budget and with no actual employees traditional approaches to management are not in the grasp of Principia.  Our achievements have mainly come about through shared values, ongoing clinical and patient relationships and a sense of social purpose to improve services for a community.

Communicating Principia – Principia needs to communicate with staff, the public and a wide range of stakeholders successfully so that they understand the concept of the company and engage with it.

What lessons has Principia learnt?
The importance of engagement - Principia could not function in the way it does without successful engagement with staff and the public. Engagement is difficult. It can be sensitive and political but always paramount to the success of a social enterprise such as Principia. It is also important to communicate the outcomes of engagement with all involved and to ensure that those that are engaged are informed from the beginning to the end of a project.

Don’t lose heart when the pace of change is not as fast as anticipated – the company is full of ideas with enthusiastic staff and strong leadership, but a range of constraints means that change is not as quickly achieved as anticipated. It is important to keep staff, stakeholders and patients interested, engaged and with the company and to constantly remind them of the strides that have been made (which can be easy to forget).

What is the company’s vision?
A patient-centred NHS, integrated GP and community services, and a culture of communication across all staff groups to ensure patients are given seamless care in the way that is most convenient and appropriate to them.

A can-do culture where staff are constantly looking for better ways to deliver patient care and sharing those ideas with colleagues and organisations to ensure change is possible.

Principia aims to, and already does:
Reduce the reliance on secondary care
Principia aims to shift large volumes of currently hospital-based activity into primary and community care settings through managing demand, increasing productivity and reducing delays, duplication and inefficiencies.

This means looking at why patients are admitted to hospital and where this can be avoided by setting up services and clinics in community settings, educating patients on managing their own health conditions, and designing innovative care pathways for patients that don’t involve admission to hospital.

Improve patient satisfaction and experience
Principia is committed to involving patients and the public at every level of the organisation to ensure that the local population has a say in their health services.

Address variations in prescribing patterns and implement best practice
Because GP practices are independent businesses, when Principia was set up there was no joint approach for prescribing treatment. Since Prinicpia has been operating, GP practices across Rushcliffe now share referral pathways, which are documented instructions on how to deal with patients with certain conditions. This ensures joined up working and a common understanding across GP practices in Rushcliffe.

Ensure value for money
Principia constantly uses data to monitor where spending can be better invested. Also, because Principia brings health professionals from across the NHS to work together, it is much easier to identify where there are problems with services and where money is being spent unnecessarily. It may not seem it, but this is a fairly radical way of working for the NHS.

Examples of work or success stories
Principia has already delivered a long list of achievements with direct benefit to patients and staff. Since 2006:

• Principia, Partners in Health, announced as successful pilot for DH Integrated Care Organisation pilot programme. The pilot is designed to help create more informed and empowered patients, to improve co-ordination of care, increase patient satisfaction and reduce hospital admissions. It involves partners working through two projects - Community Wards, building on the strengths of team working in hospital wards, and Chronic Obstructive Pulmonary Disease (COPD) – to integrate care along a long-term condition clinical pathway.

• Community Ward concept launched; the three virtual wards ensure the care patients receive from their General Practice is closely coordinated and integrated with that received from the community services. This is reinforced by the regular multi-disciplinary care meetings that are held at each practice to discuss and review the most vulnerable patient group.

• Community Diabetes service launched, offering management and insulin starts for Type 2 Diabetic patients in their GP practice.

• Commissioned additional pharmacy support specifically for Rushcliffe practices.

• Developed an eye chalazia service in the local area where patients who have small benign cysts within their eyelids can be referred. The service consists of counselling, surgery, advice on after care, and follow-up where necessary. Patients can expect an appointment within two weeks of referral.

• Expanded a community heart failure service to support Principia practices and patients.

• Appointed additional nurses for patients with Chronic Obtrusive Pulmonary Disease (COPD) and heart failure to enable Principia to offer services in the community.

• Installed ScriptSwitch in all Principia practices – a system which automatically recommends any clinically comparable and more cost effective drugs to the prescriber.

• Installed a software tool in all Principia practices which scores the risk of patients being admitted to hospital. This allows practices to look at different ways to care for these patients before hospital intervention is necessary.

• Secured funds through a PCT innovation fund, which was spent on: equipment for practices that allowed them to offer more services in the community; Met Check subscription for patients with COPD, which is a service provided by the Met Office that alerts patients when a change in the weather could affect their condition; and the Principia Success Scheme, which is a way of financially rewarding GP practices for engaging with Principia.

• Developed a number of referral pathways with GPs across Principia, which are documented paths of care for patients with certain conditions that can be used by all practices to ensure consistency in approach. 

Development of Clinical Relationships
Principia has worked hard to develop clinician-to-clinician working practices but also to secure clinician engagement in service redesign. Examples of this include:

• Community Wards Launch programme underway

• Success Scheme in third year

• Practice performance reviews conducted by peer clinicians and patients

• Programme of PLT education events agreed with clinician and practice manager input.

• General Practice and multi-professional representation on all Task & Finish Groups.

• Scores of involved clinicians

• Clinical Commissioning Forum established and attended by all practices.

Principia Profile
Principia has benefited from extensive local and national media coverage. It has worked hard to raise its profile and engage with the local community at numerous events. Highlights include:

• Principia, Partners in Health selected as a DH Social enterprise pathfinder.

• Three successful Principia Healthy Living Festival promoting healthy activities and health messages and 10K runs, now rebranded Rush4Health to reflect the partnership working with the Borough Council.

• Principia Health Network and Network Newsletter launched to widen engagement across the patient population.

• Principia website launched and has over 3084 registered patient users

• Principia stand at West Bridgford Christmas Light Switch-on for three consecutive years

• Cited in HSJ as a positive example of patient and public involvement

• PharmaTimes Pharma Award Winner – Partnership Working

• Acorn Award Winner -  Social Enterprise Excellence

Three interesting facts about Principia

1: Principia was awarded pathfinder status by the Department of Health in 2007 for its social enterprise model. This means that it is an example of success and innovation within the NHS and one for other organisations to follow.

2: In April 2009, Principia was one of only 16 organisations in the country chosen to be an Integrated Care Pilot site. Integrated care is when health and social care services work together to ensure individuals are given the care they need for their health concerns. Principia was chosen from over 100 applications and will carry out the pilot programme over the next two years. It focuses on providing better and more localised care for patients with Chronic Obstructive Pulmonary Disease (COPD) and on developing a Community Wards model, which aims to deliver care in the community that equals care that patients could access in a hospital.

3: Principia currently has over 750 patients on its Principia Rushcliffe Health Network. These patients are involved with the company at many different levels. Some simply receive information from Principia, others have been instrumental in setting up patient forums.

Over 800 members of the public had registered on the Principia website before it was even launched and there are now over 3,084 people registered.