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'GPs are generally very pragmatic people who recognise that if they don't embrace the national PBC agenda it will not be to their advantage', he said. 'But I think they're genuinely starting to see some of the perceived benefits come through and that will hopefully give them added impetus in achieving wider redesign'.

Nevertheless, the PCT is having to do a lot of work to engage and support clinicians and frontline staff, whom it recognises are best-placed to map existing services and challenge the status quo.

This work has included establishing two commissioning clusters for the PCT's 11 GP practices, both of which have held brainstorming sessions to gather ideas of where service changes might take place.

The PCT has also developed an incentive scheme that rewards practices for work validating hospital data on service usage to give an accurate picture on quality, timeliness and costs.

Continues Davis, 'As an incentive, we're offering the average practice of 5,800 patients payment for four hours of clinical time, plus GP time to do the data validation. Many GPs have been horrified at some of the costs of outpatient follow-ups, such as in urology, and are beginning to appreciate how much money could be saved for other things by transferring the post-treatment monitoring of patients back to the community.

'We have also developed a Primary Care Incentive Scheme which operates very much like an extended Quality and Outcomes Framework (QOF) in that it gives GPs financial rewards for developing a unique care register of patients with long-term conditions who need to be case managed.'

The PCT sees peer recognition as a powerful driver and has begun circulating a monthly PBC report to practices. This not only enables them to keep up-to-date with developments across the PCT but also to compare their performance with that of other practices.

Respiratory disease has been identified as a key area in developing the case management of long-term conditions. Consequently, the PCT has appointed a respiratory nurse specialist who is working across all 11 practices to identify patients with COPD (chronic obstructive pulmonary disease) and/or asthma who are frequently admitted to hospital.

The respiratory nurse is also working with practices to review cases and support the five community matrons across the patch in pro-actively managing the care of these patients to prevent unnecessary hospital admissions in the future.

The PCT has also started to look at chlamydia screening and sexual health services generally, aiming to establish a more robust and accessible service with potentially significantly improved public health outcomes.

Davis said; 'Because we're a rural PCT, we sit on the catchment areas of three acute hospitals. The difficulty is that the sexual health services at these hospitals are overburdened and patients often have to wait for appointments.

'This obviously constitutes a public health risk because we need patients with STIs to be seen immediately in order to minimise the spread of infection.

'We're looking at setting up a drop-in community-based chlamydia screening programme and possibly other aspects of genitor-urinary medicine provision, which would open from late afternoon into the evening, making services more accessible for London commuters.

'We already have GPwSI and specialist nursing skills in this area and it may be that we could set something up at the Saffron Walden Community Hospital or another established community facility.

Discussions are at an early stage and the PCT is mindful that some patients may feel uncomfortable about accessing sexual health services closer to home.

Saffron Walden Community Hospital has already been identified as the preferred base for localised cardiology services, including echocardiograms (to start in the new year), and for gynaecology, with future plans to develop rheumatology services in the community.

We're also keen to improve local access to diagnostics generally, and are currently doing a baseline assessment of current access and waiting times', said Davis. Community provision could ultimately be through GPwSI working on behalf of a cluster of practices, or even through a clinic operated by an independent healthcare provider.

'I think we have made a good start on PBC. We now need to work some of our ideas into more robust plans. There is little doubt that PBC is driving innovation by recognising that clinicians who make the day-to-day decisions about patient care are best-placed to know what changes to the system will most benefit patients.'