At a recent dinner party, a fellow guest, who happened to be a GP, said: “If I was to invite my colleagues to a meeting about practice based commissioning, I would be there on my own with the sandwiches” (well, actually these days it would be without the sandwiches.).
Of course, I know that this is not particularly true and could not be seen as wholly representative view of the world; but it does encapsulate the nature of the challenge wrapped up in the new government’s resolve to strengthen the power of GPs as commissioners.
In future, GPs will undoubtedly have greatly increased responsibilities to patients and to taxpayers to contain escalating costs and manage demand on hospital services, as well as cutting the costs of prescribing and reducing health inequalities. GPs also seem set to play an even more central role in assessing local patient needs and redesigning services.
Looking back, the original rationale behind PBC was to ensure a greater variety of services from a greater number of providers, bringing services closer to communities, enabling more local decision making by frontline nurses and doctors and more efficient and cost effective use of services. Can you see the join here?
Are we on the cusp of a brave new world, or another round of NHS “groundhog day”? I think the key to a brave new world really comes down to whether any new commissioning arrangements can achieve integration of care between health and social care and better facilitate co-ordinated care for the elderly and/or chronically ill. This is where the majority of the resources are and where the greatest growth in demand is likely to be.
Improving communications between GPs and specialists - reducing duplication of effort along the patient pathway - will help, as will integrating services at the interface between health and social care so that both sides understand the full extent of the patients’ needs.
We have been participating as a partner in the Durham and Dales Integrated Care Organisation - one of the 16 national pilots sponsored by the Department of Health - and these are the kind of things that this primary care-led initiative is trying to get to grips with. It is a really good example of what can be achieved by collective action.
There have been some notable successes. GPs have been heavily involved in the changes to rural transport arrangements as part of measures supporting the reconfiguration of local acute hospitals. They have also made a significant contribution to changes in adult mental health services and piloted dementia screening and advisory services at practice level. A major strand of work has been a locally focused fuel poverty programme in collaboration with Durham County social services. Resources have been shifted from hospital to community to fund development of an integrated pattern of working between local GPs, community services and acute services centred on urgent care and rapid access medical assessment services.
There is evidence that these measures are reducing emergency admissions to hospital. Plans are also in place to establish a GP ward, a community DVT pathway and more near-patient testing in local community hospitals.
The challenge is how to roll out these new models of service delivery across the whole area, while remaining sensitive to local needs and concerns. We have learned that working together to integrate services has helped us to see things from the patient’s perspective much more clearly. It has also helped shift our perspective from single episodes of treatment to being more appreciative of the overall wellbeing of patients and of locality priorities.
GPs are best placed to simplify and orchestrate relationships between differing providers so that quality is driven up and cost is driven down. Arguably, with strong clinical leadership and performance management in place, clinical pathways can start to be radically overhauled and new patient centred partnerships can be fostered.
The perennial million dollar question is whether such innovative changes in service delivery can be systematically implemented across whole health and social care systems. Can GPs leading together with other major stakeholders pick up the baton? Somebody once said: “There are two traditional ways to make a step change: you leap through, or you plough through.” Maybe for this one there needs to be a monster truck option. l
Stephen Eames is chief executive of County Durham and Darlington Foundation Trust.
- Acute care
- Change management
- Clinical Leaders
- Community services
- Conservative policy
- COUNTY DURHAM AND DARLINGTON NHS FOUNDATION TRUST
- Department of Health and Social Care (DHSC)
- Government/DH policy
- GP commissioning/practice based commissioning (PBC)
- Health inequalities
- Integrated care
- Mental health
- Public and patient involvement
- Service design
- Social care