More than ever, the need is to develop the NHS as a service primarily designed to care for people with chronic illnesses, say Michael Dixon and Cyril Chantler
As ever greater financial challenges emerge this year, the NHS must get serious about changing its system and culture. The advent this year of clinical commissioning groups, health and wellbeing boards and the new imperative of localism, clinical leadership and providing care closer to home all provide the perfect backdrop for some very necessary changes that have been held up for far too long.
Stephen Dorrell, the chair of the Commons health committee recently spoke of the need to reimagine healthcare as a care service dealing with both health and social care.
‘The cost of chronic illnesses alone in the NHS accounts for over 75 per cent of it the expenditure’
He said the responsibility for creating such a system rested with the new commissioners and went as far as to say that if they failed to meet this challenge it was difficult to think why they were being paid. This challenge needs to be met with boldness. It is time to be radical and ambitious and to recognise that nothing less will enable us to continue to care for our patients as we and they would wish.
Such thoughts are not new. Hospital Doctor responded to the suggestion 10 years ago that we should give up the word consultant and recognise that specialists need to work in the community as well as hospital. This notion was part of a larger argument for the decentralisation of health care including the development of community centres to act as a hub between general practice and hospitals serving populations between 50 and 100,000 people.
The need then, and even more so now, was to develop the NHS as a service primarily designed to care for people with chronic illnesses; the cost of which in the NHS alone accounts for over 75 per cent of it the expenditure.
‘It is not necessary for a common model to be introduced everywhere’
Chronic illness is rarely about cure. It is about reducing symptoms and progression, improving function, quality of life and a sense of achievement. These require good medicine and good care. Obviously this cannot be done unless health care and personal social care are brought together at locality level. It requires general practitioners and specialists to work closely together. There have been many examples of attempts to do this.
It is not necessary for a common model to be introduced everywhere, rather that local commissioners should respond to local circumstances but with the fresh eyes that are needed to create more appropriate, effective and coordinated services that value good care every bit as much as good medicine.
It is now possible to identify the health status and the needs of all patients registered with a GP. This enables a care plan to be developed for each person and this can be costed for a year period. The components of this plan need to be commissioned or provided at practice level working with colleagues in secondary care or in other professions.
By starting with the patient and their needs the components of the care to be provided can be identified and costed. Capitation payments can therefore be adjusted according to the intensity of the care that needs to be provided both in general practice, in social services or in hospital.
Escape the dysfunction
Therefore we can escape the divisive dysfunction and eternal push me/pull you of our current system that pays conventional secondary care work by activity while frontline primary care is paid through a capitation based system and health improvement depends upon the meager scraps that are left.
Implementing this effectively requires a new culture that will enable commissioners to plan services and innovate alongside their potential providers and which will encourage local providers to work together. It will mean less emphasis on the correctness and details of the commissioning process and a far greater focus on improved service and health outcomes for patients.
‘The priority now will be to get care and services properly organised, integrated and paid for at local level’
When this is done in the full gaze of transparency, involving local people and frontline clinicians, both generalists and specialists working together, then there should be no obstruction from others − whether they be national regulators, local representatives of professional or organisational interests or anyone else with an axe to grind. The usual voices will advise caution but the rest of us must support the new clinical commissioners and the government in holding their ground.
Large scale hospital reconfiguration will require its own separate mechanisms and procedures. The priority now, however, if we are to improve care and health for the greatest number and make financial ends meet, will be to get care and services properly organised, integrated and paid for at local level.
The pressing task for the new CCGs and their primary care clinicians will be to work with colleagues on health and wellbeing boards, with medical specialists and other professions to create these new services built around the need to provide care as well as treatment and to promote health and wellbeing in local communities. Nothing else will suffice if the service is to be affordable and fit for purpose. The need is very urgent.
Michael Dixon is chairman at the NHS Alliance, Cyril Chantler is chairman at UCL Partners