Published: 04/08/2005, Volume II5, No. 5967 Page 14 15
The white paper on healthcare outside hospitals, due for publication at the turn of the year, will be accompanied by a major public consultation on its proposals. Over the next four weeks, HSJ will be anticipating the government's vision of modern healthcare in a community setting.
Here, Mary-Louise Harding opens the series by looking at what will happen when choice, contestability and foundation trusts are unleashed on primary care.
According to the Audit Commission, 14 per cent of GP practices in England have closed lists, and one in 10 people have been forced to register at a particular surgery because they had no alternative where they lived.
That figure is thought to be a vast underestimate, as many primary care trusts, particularly in London, did not respond to the Audit Commission's survey in September 2003. And even where patients do have a choice, they are not always able to choose a service to suit their needs, whether that is defined by lifestyle, environment or illness.
The idea that people need to be given a choice at the point at which most experience the NHS - in primary care services - has been well trailed.
The new general medical services contract was designed to give traditional family doctors the incentives to improve services. This also applies to all the contract's hybrid sons and daughters, such as the specialist primary medical contract, that allows GPs to focus on a specialist area or group; and, more recently, the alternative primary medical services contract, which allows any organisation to bid to run a primary care service.
More importantly, the contracts were configured to give PCTs a range of ways they could plug provision gaps and hold services to account.
However, it is clear that the government believes some PCTs have failed to address fundamental gaps in provision. Even before the consultation paper is completed, the Department of Health's commercial team has grabbed the APMS reins to ensure that the worst catered-for areas get new services such as walk-in centres and extended surgery hours.
A national tender will go out in the autumn inviting organisations - including both foundation trusts and private sector providers - to bid for services in six of the most needy PCT areas. A further 15 PCTs will get similar treatment in a 'second wave' next year (news, page 6, 28 July).
In the first of a series of papers for think tank the Social Market Foundation, the co-author of the NHS plan, Professor Paul Corrigan, who was special adviser to health secretaries Alan Milburn and John Reid, bluntly argues that PCTs have failed in part of their statutory duty and that it is time to unleash patient power in primary care.
'It is terrifically important we now focus on engendering people's confidence in primary care, ' he says.
'It matters much, much more to patients' daily lives. If we are going to build systems of reform to improve the quality of care and the quality of patient experience, then we need at the same time and in the same way to tackle the issue of quantity as a part of quality improvement. The empowered patient will improve the quality of their experience, but only if there is a genuine increase in the amount of capacity within localities to allow choice and preference to have an impact, ' he says.
Professor Corrigan's paper calls for a white paper that speeds the opening up of primary care to a range of providers offering services to suit different patient needs, such as young people, who he says currently have very little contact with primary care because services do not cater to their needs.
He would like to apply foundation trust principles to family health.
This would mean patients, either through a local government representative or directly, demand services of PCTs, which would be statutorily required to cater to their demands.
NHS chief executive Sir Nigel Crisp clearly set out the government's store in March when he said in Creating a Patient-led NHS, 'choice and diversity are as important in primary care as in hospital services'.
'The NHS needs to have enough capacity so a patient's existing choice is not constrained... and the NHS needs to develop new choices for patients who want an alternative to traditional models.' With the direction of travel so clear, how will the new white paper remove barriers or increase incentives?
National clinical director for primary care Dr David Colin-Thomé says the process is about a wish to 'genuinely consult with the public on what they want from primary care services'.
'It is essential we provide services to meet growing need, such as in long-term conditions. How we deliver and how much power patients and the public have is crucial and will need to be set out, ' he says.
He adds that people will demand information, and he anticipates a lot of reform to focus on how frontline clinicians interact with patients.
Those with long-term conditions, if they are to be empowered to make choices on the type of care they need, will require consultations to be more of 'a meeting of two professionals', he says.
Despite extensive work on improving services for people with long-term conditions, most agree that services still need a much more integral redesign to suit changing health needs.
Dr Tim Wilson - an Oxfordshire GP and, as a former member of the DoH strategy unit, a co-author of 2004's NHS improvement plan - argues that it is probably time to wave goodbye to the family practice.
'The DoH needs to be very careful about allowing traditional general practice to be fragmented, but personally I do not see why it has to be one family practice - it could be broken up for different age groups, ' he says. 'Given patients and GPs are now much more mobile, arguments around family practices providing continuity are not really valid any more. The model of general practice that we have does a disservice in particular to teenagers, and more targeted models of care for people with long-term conditions, ' he says.
This brings us to the thorny issue of registration. Most GPs are vehement in their defence of patient registration with a single practice.
This ensures, they argue, that one provider is ultimately responsible for that patient's care, regardless of if they then access other providers.
While politicians and civil servants are careful to give a nod to this traditional model, their comments on it are usually followed by doubts about its continuing viability.
West Yorkshire strategic health authority chief executive Mike Farrar says that while he is a 'believer' in registration, people must have the 'freedom to move around services'.
'Patients need to know about available care and they could be supported in managing their longterm condition by community nurses, expert patient groups, acute outreach or a voluntary sector organisation such as Mind.
'If you add those to the mix it does give people greater choice. And some services might be delivered by individual primary care providers, but they could also be dedicated people contracted in by the practice, ' he says.
Health secretary Patricia Hewitt recently spoke about the importance of involving 'residents in the development of local services' and thereby 'the regeneration of their own communities'.
Professor Corrigan - a chief architect of the foundation trust model - has spoken of his interest in developing community ownership models in primary care, and Mr Farrar says he would like to see exploration of a 'variety of ownership and governance models in primary care'.
'The [APMS] contract allows community ownership of primary care practices, so the community governance model is very interesting. The direction of travel is pretty clear - the government clearly sees putting power in the hands of patients as a real driver of quality, ' he says.
The idea of expanding direct payments to health, where patients are given their own 'notional' budgets, is also likely to come under the microscope - especially as PCTs and social services departments find their boundaries more closely defined.
County Durham and Tees Valley SHA chief executive Ken Jarrold says giving people with long-term conditions their own budgets to manage 'their own day-care' would be a sensible development for the white paper and would tick the empowerment box.
It is clear that choice, contestability and different models of ownership are on the horizon for primary care. Just how radical those are will depend in part on what people ask for when the consultation begins in September. .
OUT WITH OUTPATIENTS: TREATMENT IN THE COMMUNITY
In addition to considering tailoring primary care services to cater for different needs, the Department of Health wants to see up to 15 million outpatient consultations shifted to community settings.
According to Creating a Patient-led NHS, fewer than 1 million currently take place outside hospitals.
Primary care czar Dr David Colin-Thomé says this is a great opportunity for primary care to break down the walls of an unnecessarily rigid system. He says 10 million outpatient appointments could be carried out in community settings as diagnostics move out into the community, either by GPs or by hospital staff such as respiratory nurses working in primary care settings.
The accelerated rollout of practice-based commissioning should - in theory - jump-start GPs' role in service redesign.
The spectre of a more demanding public, a sharpened focus from the Healthcare Commission on whether they are responding appropriately to demand, and liberated foundation trusts may also encourage them to rise to the challenge.
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