Successive governments have attempted to engage primary care in commissioning in recognition of the sector’s vital role in demand management.
Initiatives have focused through three areas: excellence in chronic disease management, responsive and effective management of urgent care and management of elective referral.
While some patients would think twice about contacting their GP on Sunday afternoon about a blister from yesterday’s new shoes, they are less reluctant to contact the anonymous “out of hours” services
Excellence in chronic disease management is critical for good outcomes for patients. Variable primary care capacity and capability contributes to health inequalities and impacts on secondary care usage. To pay real attention to the active management of chronic disease is to take seriously the notion that “an unplanned admission is a system failure”.
The annual health check attempted to make a difference in chronic disease management and the radical new GP contract of 2004 prioritised it through financial incentives. The approach rewarded good practices for doing the right thing and put real money in the pockets of those who needed a tangible incentive. The enduring power of Aneurin Bevan’s “stuff their mouths with gold” approach was that many practices delivered extraordinary turnaround within a year of the money being right.
The contract has since attracted a lot of criticism but it did deliver wholesale system change within a year - which is more than can be claimed for most policy initiatives. While it cost in core wages, it has contributed to controlling broader system costs through shifting the focus of care into medical management in primary care rather than undermanaged disease and acute episodes. It has also improved patient care.
In introducing concessions to 24 hour responsibility, it reduced the personal investment of GPs in ensuring patients were seen in hours and that out of hours requests were “reasonable”. While some patients would think twice about contacting their GP on Sunday afternoon about a blister from yesterday’s new shoes, they are less reluctant to contact the anonymous “out of hours” services. By focusing on speed of access to any professional rather than timely review by a GP, the contract perversely made it more difficult for patients to book to see their own GP and drove people to choose A&E instead. The role of the GP in core urgent care was compromised. The incentives for GPs were limited and outweighed by the lifestyle benefits of opting out of 24 hour care.
It is in elective care where the position has been most confused. The core contract made no explicit arrangements for either quality or use in relation to elective care. Rather the system of local enhanced services provided a means by which PCTs could make additional payments to practices interested in delivering specific additional services.
This has been fraught with problems. The income is marginal to the practice so attracts a consideration of whether it is “worth” bothering. The transactional nature of contracting has also led to many services previously considered a core part of holistic care being described as “enhanced”. PCTs are now expected to pay extra for GPs to remove stitches or monitor blood in patients on methotrexate. Patients are confused if their GP decides not to offer that service. This fragments care, creates unnecessary overheads in small additional payments and does nothing for relationships either between PCT and practice or practice and patient.
Demand management in elective care has now been shifted into the domain of practice based commissioning rather than basic good primary care practice. It is managed through reviewing usage and becomes the focus for debate on baselines and benchmarking, which diverts attention from doing something about usage. Proposals to redesign services thus fall within territory which is seen to be about substitution of care and therefore requires additional funding in the practice, even where the burden of work is more likely to be falling on community services or alternative providers. Given the difficulties in closing capacity in hospitals, a PCT can face the prospect of paying three times for the same service, which makes the option of doing nothing rather attractive.
None of us should underestimate the contribution the UK model of primary care has made to the NHS. It provides a foundation for long term relationships encouraging continuity of care and the holistic overview of a patient. The GP as “case manager” makes a huge contribution to efficiency by triaging access to other services. The fundamental importance of this role requires us as commissioners to target investment to practices with highly skilled, motivated people, operating in teams from premises with the right capacity. They must align to the strategy of the PCT and want to work with us to improve health and secure best value for public money.
All parties considering NHS policy should think about the benefits of investing in PCT commissioning of primary care versus GP commissioning of secondary care as the best route to demand management at lowest overhead cost. We should also learn from the last decade: practices respond best to core investment in their core business of delivering holistic and effective care to registered populations. We may do better to invest more in that than in asking them to spend time in meetings pondering other people’s service use.