Published: 24/02/2005, Volume II5, No. 5944 Page 30 31 32
Locally enhanced services are intended to increase community provision, but how successfully are they working on the ground? Below, Nick Summerton reports on a national survey of PCTs, while opposite and overleaf Ann Dix talks to those involved
The new general medical services contract is intended to widen the range of services available to patients in primary or community settings.
A mechanism for achieving this is ear-marked funding for enhanced services, flagged up as a way of shifting activity from secondary to primary care.
Services under the new contract are classed as essential (provided by all GP practices), additional (provided by most practices) and enhanced.
Enhanced services are those not provided through essential or additional services, or delivered to a higher specified standard.
Enhanced services pave the way for more innovation by opening up community-based clinical care to a range of NHS and nonNHS providers, including less traditional routes such as pharmacists and the independent sector.
There are three types: directed enhanced services (DES), which all PCTs must commission to national specifications; national enhanced services (NES), which are optional, but must follow minimum specifications; and local enhanced services (LES).
There is no clear definition of what a local enhanced service is, but the British Medical Association's GP committee has suggested some examples: care of asylum seekers, non-English speakers, people with learning disabilities and patients in nursing and residential homes; neonatal examinations; and area-wide home visiting schemes.
The Department of Health has also identified specific LESs - eg Saturday morning surgeries.
To identify the current scope of LESs, a survey was sent out to all PCTs at the end of last year, in collaboration with the NHS Information Authority and my PCT. It has yielded detailed information from a representative sample of 96 PCTs.
From this, LESs can be categorised into five major groups, ranging from improved access to more comprehensive patient care. -32 Enhanced access While there is an improved access DES, some PCTs have developed LESs to target specific groups.
Homelessness is included under NES, but 13 per cent of the PCTs surveyed had an LES for asylum seekers, 6 per cent for teenagers/young people and 5 per cent for people with a learning disability.
Other examples included healthcare for travellers, ethnic minorities and patients with HIV/AIDS.
One PCT has developed a second-line or backup primary care access service to ensure that practices meet the 24/48-hour target. Two are encouraging 'flexible working outside normal hours' and several are considering commissioning Saturday morning surgeries.
Three PCTs have developed minor ailments services based in a pharmacy and two others have an enhanced access service involving healthcare assistants. The new pharmacy contract will encourage a further extension of such services.
Some services already delivered as essential or additional services, or as a DES, have become LESs by developing more stringent delivery criteria.
Thirteen per cent respondents had developed an LES for pneumococcal immunisations for 'at-risk' groups not covered by the DES and 6 per cent for MMR/mumps immunisation for teenagers/ students. The most common LES, commissioned by over a third of respondents, was a smoking cessation service to supplement services provided under the new GP contract.
Secondary to primary enhancement
A variety of LESs encouraged a shift of activity from secondary to primary care. Four global commissioning incentive schemes rewarded practices for managing their referral patterns to predetermined criteria. In other examples, providers of an LES for counselling or musculoskeletal medicine were given the option of delivering the services themselves or subcontracting the work to a third party.
Community-based care is encouraged by some PCTs using LESs for intermediate care, nursing homes and community hospitals. One PCT commissioned a number of clinically specific LESs, eg deep vein thrombosis diagnosis and management in the community.
Some respondents had also commissioned specific technical activities normally undertaken in secondary care, eg 19 per cent had developed a phlebotomy service; others were funding it within a basket of procedures that would otherwise be provided by secondary care.
A few PCTs have used LESs to encourage more comprehensive patient care. Examples include diabetic care, diagnosis and management of heart failure and COPD, care of peri-menopausal patients and prostate cancer follow-up. Many also have a link to a practitioner with a special interest, eg dermatology, epilepsy or ophthalmology.
LESs for services traditionally unavailable in primary care included vasectomy, endometrial sampling, sigmoidoscopy and homeopathy.
Three other PCTs are using LESs to support service enhancements by allowing time to be funded for training.
How are LESs likely to develop? Many were established as a way of continuing existing GP services. The danger is that this maintains the status quo rather than improving standards.
Some PCTs are now recognising that this needs addressing. Similarly, opting for an LES where there is already an NES may sometimes be justified on clinical grounds. But because an LES does not have to meet national specifications, it may result in a cheaper, lower-quality service.
A recent survey of drug misuse services by the user group Network found twice as many PCTs had selected an LES over a NES and that these generally had stringent training requirements.
Many PCTs are using LESs to improve access.
But some of these referral management schemes actually restrict patient choice. For example, one LES sought to restrict access to orthopaedics or neurology, but did not provide an alternative other than a headache clinic or triage service.
Conversely, some PCTs are attempting to extend patient choice by using alternative providers. This is likely to be an increasing trend as DoH policy now seems to be that general practices should not have preferred provider status for LESs.
On the face of it, PCTs with the biggest financial problems have the most to gain from LESs designed to reduce demand for secondary care. But these PCTs are also more likely to suffer from a lack of planning capacity and difficulties engaging with primary care clinicians. One option is to seek local enhanced 'solutions' to problems rather than commissioning particular 'services'.
By being less prescriptive, PCTs could lessen their own workload, encourage innovation and open up the market to new providers. With this in mind, my PCT has rewritten the governance criteria for LESs to cover both service planning and delivery.
PCTs have received significant extra resources for enhanced services, as well as the option to use a wider range of providers. LESs have enormous potential to improve patient care by capitalising on these opportunities.
Nick Summerton is a GP and PCT medical director.
Find out more
National Health Service (General Medical Services Contracts) Regulations 2004: Primary Medical Services (Directed Enhanced Services) Directions 2004 www. dh. gov. uk
'WE ARE LOOKING FOR A BETTER BALANCE OF RESOURCES'
Early intervention and health promotion has been a focus for Adar, Arun and Worthing PCT, along with the management of people with long-term conditions. LESs are 'about enhancing resources and skills in primary care to prevent unnecessary admissions', says deputy chief executive Bob Deans.
'We are looking for a better balance of resources between secondary and primary care.' With 32 practices, one of the aims has been to try to kindle a spirit of co-operation. 'We have said to GPs, if you can't provide the service, how can you work with others to do it, ' he said. There has also been joint-working with secondary care. For example, a prostate cancer monitoring service has involved collaboration between GPs and the acute hospital to give earlier monitoring in primary care.
The PCT is also exploring bringing in other providers, such as community pharmacists. 'We haven't actively encouraged private sector providers because We have had the co-operation locally, ' adds Mr Dean. 'But the potential is always going to be there.'
'WE HOPE THAT IT WILL BE A LIFE-CHANGING PROGRAMME'
Locating a pulmonary rehabilitation service next to an abandoned tobacco factory is an irony not wasted on Bristol GP Dr Mike Rossdale (pictured below).
As a GP with a special interest in chronic obstructive pulmonary disease, he has long held an ambition to set up a community-based service.
Thanks to funding for local enhanced services, this ambition is about to be realised.
'COPD is a particular problem in this area, ' he explains. 'Fifty per cent of people smoke and there is deprivation.' Pulmonary rehabilitation has been shown to be effective in the management of COPD, and in reducing hospital admissions.
But it is usually delivered in a hospital setting, which may not be accessible to those who need it most.
Under the new programme, patients with severe to moderate COPD from GP practices with the highest number of hospital admissions will be offered an eight-week exercise and advice programme.
This will be delivered from two neighbourhood sports centres by a team including Dr Rossdale, three senior physiotherapists employed by the PCT and a respiratory nurse.
By creating a patient nework and linking in with charities such as Sport England, 'we hope that it will be a life-changing programme that shows people that even if you are breathless you can do exercise, ' he says.
'We hope eventually to extend it to all GP practices across the patch.' Enhanced services are a bit of a hot topic here at the moment, ' he adds.
Bristol South and West PCT is one of an estimated 80 PCTs reported to have underspent money for enhanced services this year, leading to accusations in the GP press that it is using money meant for primary care to bail out its acute hospitals.
But Dr Rossdale stresses that he has found the PCT 'incredibly supportive, not just with funding, but with practical support'.
'They have been fantastic and brilliant.' Bristol South and West is also among a handful of PCTs highlighted in a national survey (see main article) as being leading-edge in exploring the opportunities presented by LESs.
PCT assistant director of primary care Trevor Beswick says the underspend -£300,000 out of a total of£2.3m for enhanced services - is because these services take time to set up.
'We haven't just been able to turn the tap on.' The PCT 'is trying to find ways of carrying forward the money not spent this year to next year', he says.
The prime focus in the development of LESs has been the management of long-term conditions, he says. 'If we get that right it should reduce unplanned emergency admissions.' He adds that another advantage of LESs is that it is enabling them to provide services on a PCT-wide basis.
Initiatives have included employing four community phlebotomists to provide a blood testing service for house-bound patients.
This is freeing up GP and nursing time, including 'creating more capacity for district nurses to provide a high level of service to patients with heart failure', which is being developed as another LES.
'We are STILL WORKING ON THE FRINGES OF WHAT WE COULD ACHIEVE'
One of the main drivers for Wyre Forest PCT when planning LESs has been 'admission prevention and reducing demand on secondary care', says assistant director of primary care Daniel King.
Previously 'the financial position of the PCT would have taken precedence over the development of services', says Mr King. But enhanced services have changed all that.
New services developed as LESs include laryngoscopy and phlebotomy. The PCT is now consulting on proposals for next year, including heart failure monitoring; and counselling for people over 65.
Local GP and General Practioners Association chair Dr Richard Horton said much of it was work GPs were doing already, which is why the PCT's acute admissions rates are 'about 20 per cent of the national average'. The money has increased, he says, but 'It is not megabucks'. This coupled with constraints on GPs' time, means 'We are still working on the fringes of what we could achieve'.
'WHY NOT TAKE IT FURTHER AND GET MORE MONEY FOR IT?'
Doncaster East PCT is using LESs to tackle some of its more pressing health problems such as high rates of chronic obstructive pulmonary disease and high teenage pregnancy rates. Service improvement manager Andrea Owens says staff are working mainly with the PCT-wide school nursing team to provide health promotion and advice for young people, including use of a mobile van service.
Local GP Dr Alison Fisher says her practice initially bid for a healthy lifestyle LES, but is now bidding to do COPD, diabetes and learning disabilities. 'Our initial thinking was that we had too much to do, but we were pretty much trying to do the work anyway and so we thought why not take it further and get more money for it?' she says.
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