Lean thinking

While there is evidence supporting a case management approach to the care of patients in the greatest need of healthcare, this has been less convincing than some seem to believe. Also, the creation of structures that are separate from general practice is both counter-intuitive and seems to run contrary to lean principles.

Community matrons usually have different accountabilities and variable relationships with the general practices whose patients they help to manage. This runs the risk of diluting responsibility and increases the number of 'handoffs', where care passes from one person to another, rather than concentrating on the care of patients by the primary healthcare teams of individual practices.

It also does nothing for developing the skills of teams or addressing the needs of the wider group of patients who may soon fall into the category of very high-intensity users.

It would surely be preferable to encourage primary healthcare teams in general practice to adopt the best features of this approach, ensuring better continuity and the local focus that both patients and professionals prefer?

The emphasis should therefore be on helping to promote the comprehensive care that is one of the hallmarks of good general practice through supporting integrated primary healthcare teams rather than fragmenting care and complicating its managerial arrangements.

New contractual possibilities (the General Medical Services contract and practice-based commissioning among others) plus the enhanced focus on commissioning by primary care trusts should offer ways to facilitate this and work on mechanisms to oversee such developments.

John Toby, GP and consultant on primary healthcare