Long-term conditions are likely to take centre stage as GPs get to grips with commissioning - but reforming care for patients with chronic diseases may require changes closer to home, says Alison Moore.

Improving the care offered to people with long term conditions – and reducing its cost – is likely to be priority number one for many commissioning consortia. But many will face a crowded agenda and financial constraints as they begin to reform services.

While GPs might see numerous opportunities to improve care, they may lack the capacity to tackle them at the same time. They also will not have the financial freedom to put in place new services ahead of disinvestment, while building new relationships with partners such as social services.

Shane Gordon, co-lead of the NHS Alliance’s practice based commissioning federation, says that while tackling long term care may not solve the financial issues facing consortia as demographics change, technological solutions become available and money is squeezed, it will be an important part of it. “If you don’t tackle long term conditions how are you going to square things?” he says. “Long term care is top of the agenda.”

While dealing with the issues surrounding urgent care is important, Dr Gordon points out that many urgent admissions are due to patients with long term conditions deteriorating. “When you ask ‘how are you going to fix long term care?’ the answer is principally long term conditions,” he says.

His practice based commissioning group in Colchester has been working on services for patients with diabetes, chronic obstructive pulmonary disease and heart failure.

Most at risk

Consortia are expected to focus on stratifying patients with long term conditions to identify those most at risk of deteriorating and requiring unplanned admission. This will let them concentrate resources to improve patient care and pathways for the most vulnerable. This approach is being developed by the Leodis practice based commissioning group in Leeds, which will become a pathfinder consortia.

GP chair Andy Harris says the next task will be to work out how to respond to these groups – which might include greater use of telehealth and social marketing, better integrated care with the community sector and social care, and pathways into primary care.

But that raises questions  about whether community services and social care will be to equipped to develop integrated approaches. Some GPs see mergers of acute trusts and community services as detrimental to this end, and would have backed some form of link between primary care and community services instead.

Local authorities are also under severe financial pressure and may look for savings on social care budgets. Where interventions can help avoid admissions, some imaginative funding may be needed. Some PBC groups are thinking about joint commissioning with social care. Steps have been taken to align social work with practices in Leeds, says Leodis Community Ventures joint chief executive Chris Reid. “But we have to build relationships before we can pool budgets,” he adds.

A change of approach

GP Niti Pall’s Smethwick practice has pioneered risk stratification to identify those groups of patients most at risk of unplanned admissions. She says a change of approach will be necessary for GPs. They will need to think more about the whole patient community they are serving, rather than just the patient in front of them, and adjust their offering accordingly.

The Smethwick practice identified patients most at risk and found no single long term condition made its patients disproportionately more likely to access care – it was having any long term condition, including lack of mobility. This surprised partners at the practice and made them re-examine how they were dealing with such patients. “What can we put in to stop patients getting to the point where they bounce in and out of hospital?” she asks.

Access to a GP has been redesigned to encourage patients to access the surgery rather than going to A&E and a case management approach adopted for some. “We said let’s look at our house and put it in order first,” says Dr Pall. The practice made substantial savings in admission costs – although system set up was expensive – and the approach is now being rolled out across other practices in the area.

This move towards micro-commissioning relies on GPs’ willingness to change their practices, and it is far from certain that all GPs will be happy to do so – even when encouraged by their colleagues. And some of the mechanisms for encouraging them to provide better care may need to change.

The Policy Exchange, in a publication called Incentivising Wellness, criticises the care many diabetic patients receive in GP surgeries. Although nearly all GPs meet the standards to get quality and outcomes framework payments for their diabetic patients, only a minority of them receive all the gold standard care processes, while inpatient admissions have been increasing.

The report suggests the move to commissioning consortia should also look at what the system prizes. “GP practices aren’t rewarded for providing improved services to people with diabetes, but perversely hospitals receive payments when patients become sicker,” the report says. Will consortia lead to greater rewards for better health outcomes, rather than processes? It urges greater investment in telehealth to help patients self-monitor and ensure a quicker response to changes in their condition.

Dr Gordon suggests that exception reporting means a substantial number of patients with long term conditions can be excluded from the quality and outcomes framework data. In many cases, these patients may be at high risk of deterioration, are not accessing services and may have a chaotic lifestyle. Engaging with them can bring significant benefits.

“That group of patients may require different approaches to managing them than the traditional way of engaging with them in the surgery,” he says. That includes text messaging and using social networks, such as Facebook, but also support and buddying approaches.

“I think there’s a high productivity opportunity in dealing with that group. I suspect, for many of them, their needs are not met at all. There is a cohort of patients who are not being caught,” says Dr Gordon.

Long term investment

In the short term, seeking out these patients and offering care may cost money, but, viewed longer-term, it will be an investment which avoids additional costs, he says.

The King’s Fund senior fellow Nick Goodwin also points out that care for patients covered by the quality and outcomes framework has improved, but general practice does not connect well with the rest of the system. There is a need for greater co-ordination, which would have to be addressed if consortia commissioning is to make an impact, and people would need to be supported to self-care in their own homes.

“Should GP commissioners be better at doing this? The answer is ‘maybe’,” he says. But GPs may be good at improving the medical aspect of care and may not address the other aspects – such as personal or social care – which also contribute to whether someone stays out of hospital and lives independently. This is “disease management versus long term conditions management”.

GPs must also understand and value the other staff involved in this, such as community matrons and social services, and work well with them. Relations are currently variable, says Mr Goodwin. “It’s my fear – and not my prediction – that while GPs and consortia are looking to improve aspects of disease management for specific conditions, especially those incentives through the quality and outcomes framework, it is less likely to tackle those with complex co-morbidities who need support. They don’t recognise it is the non-clinical aspects of care which are important,” says Mr Goodwin.

An area often overlooked is long term mental health. The Mental Health Foundation points out that PCTs have sometimes struggled to have in depth knowledge of mental health commissioning and that many GPs feel they lack the knowledge to do this. But policy director Simon Lawton Smith says GPs are aware of the extent of long term mental health problems and the link between mental and physical health.

Commissioning may give them the opportunity to address this. “We are cautiously optimistic that GPs will, through their personal experience, understand that patients need interventions and then provide them with appropriate treatments,” he says.