Delivering the QIPP targets is proving a tough challenge for GP practices. Paul Cook offers some practical ideas on how to remove the obstacles in the way.
The publication of the Deloitte report Primary Care: today and tomorrow – improving general practice by working differently is timely in the context of the current overhaul of the NHS. There is a certain irony that, following the eventual passing of a bill giving GPs control of the NHS budget, many feel less in control of their workload and their practices than at any time in recent memory.
There has been a large amount in the press about how GPs will commission services and lead on pathway redesign but while most GP leaders are engaged in setting up CCGs and taking them to authorisation, pressures continue to grow on actual practices to do more work for fewer resources. These pressures are considered in the report, including changes in demographics and patient expectation.
The requirement of all commissioners to deliver on a demanding QIPP programme requires fewer admissions to hospital, shorter lengths of stay and an assumption that “managed in the community” is a better and cheaper option.
Unfortunately for primary care it is one of the few remaining block contracts in the NHS and in the small business model of provision we operate, where staff time equates to money, there is only so far that this can be pushed.
Commentators have rightly suggested that GPs should be required to deliver efficiency savings like everyone else in the NHS. The reality is that it is already happening but it is difficult to measure.
If it is accepted that there is a need to invest in primary care services to deliver the challenging QIPP targets we need to consider a number of approaches in combination. First and perhaps most challengingly for my GP colleagues, we have to question how efficient our current model of provision is.
The commonest model based on most clinicians doing morning surgery, visits, clinics and administration, evening surgery and over to out of hours for the majority of hours of the week leaves much to be desired. It is well known that most GPs making visits between 12pm and 2pm creates a logjam for ambulance services and has patients arriving at acute hospitals at a time when diagnostic services are often winding down, leading to a greater likelihood of an overnight stay.
I believe resources (ie staff time) are being wasted in every practice. The challenge for CCGs going forward will be how to help practices identify them and become more productive. One key area of support should be funding protected time and the purchase of improvement tools such as the NHS Institute’s Productive General Practice package, together with CCG staff dedicated to supporting this work.
The aim should be to develop a culture of continuous improvement in every practice that is as much about quality and efficiency as clinical matters.
A cornerstone of such improvement must also be GPs asking what we can stop doing clinically. We need to question our follow-up and investigation rates and streamline our recall systems. We must challenge the National Institute for Health and Clinical Excellence to ensure impact on primary care is taken into consideration when developing its guidelines.
Most importantly, we must ensure the right clinician deals with problems commensurate with their skills.
It is interesting that the very low levels of funding allocated to out of hours services relative to mainstream general practice have seen them need to introduce more telephone triage and address the skill mix issue, with nurse practitioners dealing with a wider range of presenting conditions. Both of these approaches are proposed by Deloitte as ways of reform. There are many lessons for mainstream general practice to be learnt from the best OOH services and indeed from other health systems further afield.
While acknowledging that general practices have to be more productive, there is still a need for further resources. CCGs should be looking for ways to invest resources in primary care now. It is here that the distinction between general practice and primary care becomes important.
The current climate will not allow GPs to be paid more but CCGs can still invest in services to support primary care without creating conflict of interest. Community matrons, prescribing support staff and enhanced community nursing teams all add value already and this list should grow as a way of moving resources into primary care.
We need to take the patients with us in this debate. Patient groups resent waste of NHS resources and if we engage them actively in CCGs to make the case for investing money, staff and time in primary care we will have a powerful ally in the new NHS.