GPs and senior managers in a deprived locality tested GP commissioning with successful outcomes. Roger Levesley describes the project
Sceptics have already found 101 reasons for The New NHS white paper not to work. But our experience in Doncaster suggests that primary care groups comprising GPs and managers can work together and improve the health of their local population.
A group of senior managers and GPs from Doncaster health authority agreed in the autumn of 1994 to test out a locality model of management in which the GPs would have the power to make and implement decisions for the benefit of their locality. They would need their own resources and the freedom to contract with a range of trusts independently of the HA. The Primary Care 2000 total purchasing pilot was formally established in mid-1995 and went 'live' on 1 April 1996. Ten practices were involved (eight solo doctors, one practice with two doctors, and one with three). The GPs were supported by 3.5 whole-time managers. It has since become a national pilot along with 70 other sites.
This project was based in a deprived locality with no GP fundholders, and a high proportion of single-handed GPs covering a population of 30,000 people to the north and west of Doncaster. An important feature was the provision of dedicated management support to minimise the time commitment and 'hassle factor' for the GPs involved. The fund allocated to the GPs, approximately pounds15.6m for 1997-98, covers hospital and community health services, prescribing and practice staff. The GPs, through monthly board meetings and sub-groups, make all the clinical decisions and manage the total fund.
The baseline allocation for the group was calculated from historical referral patterns but the HA has also calculated a needs-based allocation, which the group will adopt over a number of years.
The group has the resources to contract directly with all its major trusts to provide high quality healthcare as locally as possible. There has been a dramatic improvement in the interface between primary and secondary care. When the project started, links between GPs and hospital consultants were almost non-existent. Now hospital doctors attend the project board meetings regularly. And the local trusts speak to the group before changing services. Discharge summaries, previously the source of great concern to many GPs, are now issued more promptly.
Results from the project include the introduction of community psychiatric nurses attached to general practices, a better service for paediatric emergencies and shorter waiting times for eye and orthopaedic services.
Board meetings have become a developmental environment and this has been helped by the attendance of clinicians from the local trusts, which has often been seen as the first opportunity for face-to-face dialogue. Many of the service changes have arisen or have been supported through this mechanism.
The group employs a full-time pharmacist as part of a district-wide initiative to advise GPs on prescribing matters. The GPs value the pharmacist's support, and the group is heading for a sizeable underspend for the second year running.
The group has produced a five-year health plan for the locality with the help of the public health consultant, who attends board meetings. The plan focuses on heart disease and cancers, mental health, sexual and drug abuse and improving the environment. The group now has a clear view of where it needs to focus its resources.
Further developments include piloting an integrated pathway of care for chronic stable angina patients with the local acute trust and a new model for treating drug abusers in primary care with the local priority services trust.
The York Health Economics Consortium has evaluated the first years of the project and concluded that it has been successful in commissioning health services for the population and has improved communication with hospitals. But the evaluation points out that there are potential additional costs in providing management support to total purchasing pilots and the future primary care groups.
The project has also proved that it is possible to pull together a group of GPs (with no previous fundholding experience) to commission services for their area. Holding a total budget for hospital and community health services, prescribing and practice staff encourages a responsible attitude from the GPs, as there is no way that they can 'pass the buck'. GPs also see the size of the budget (approximately pounds15.6m for 1997-98) as an important factor, providing the leverage for change.
The development of primary care groups is a central plank of the government's reforms. The Primary Care 2000 model already encompasses many of the features set out in the white paper. The GPs who, apart from one former fundholder, had no previous experience of management, have made remarkable progress over the past two years. They have shown they can manage a budget for total healthcare for their locality by working with colleagues in the local trusts. Perhaps of even greater significance is their ability to plan for long-term health improvements in their locality.