By Dr John Ribchester, 28 February 2014
I am sorry to say that I have read BMA deputy chairman Dr Kailash Chand's critique of the King's Fund's report on commissioning and funding general practice with increasing concern and frustration, writes Kent GP Dr John Ribchester.
Dr Ribchester: 'The King’s Fund’s report advocates changing the commissioning landscape to enable family care networks.'
If are representative of the BMA, then I fear that the organisation will be following the ornithomimosaurs (ostrich dinosaurs) into extinction. As a lifelong exponent and supporter of general practice I would like to address his main concerns and explain why I support the tone and content of the report.
Dr Chand states that ‘primary care does not need another reorganisation’. The last major change to the GP contract was in 2004, with small scale changes commencing from this April. The change from PCTs to CCGs which came into force last April was of course a change in commissioning rather than something that had much effect on GPs as providers.
Admittedly, some GPs increased or developed a role in commissioning, but for most it was business as usual. It is surely widely accepted that continuing with GPs doing much the same as ever in an unchanging NHS is not a sustainable option either clinically or financially. A population of increasing size and age and a time of financial austerity is enough of a stimulus to require significant changes.
Recommendations within to reorganise general practices into large groups which can genuinely perform population healthcare planning and better community healthcare provision seem very logical. The sharing of expertise between the practices, economies of scale in managing fewer, larger practices and the ability to genuinely integrate with secondary care, community care, mental health services and social services can only occur once general practices are larger, whether this be through federations or mergers.
Dr Chand states that we should be focusing on tackling the serious workload and financial challenges faced by GP practices. I completely agree with this statement, but the point is this. Surely general practice would be in a better position to face these challenges once arranged into larger groups.
There is already a trend for CCGs to obtain smaller numbers of larger contracts from larger providers. This means that the small general practice does indeed face a financial challenge by being poorly equipped to attract an AQP or community contract.
I disagree that the model of GP family care networks is totally inappropriate and costly in rural areas. It is certainly true that, given the varying population, density and demographics across the country, one model will not be appropriate for all locations.
One would certainly not advocate siting a large provider unit in a rural area. However, the concept of practices collaborating in some way and sharing clinical and management expertise is equally applicable regardless of location.
I think my largest objection is to the statement that ‘there is a complete lack of evidence for the alternative of moving care closer to home’. There is a growing body of evidence nationally and internationally that this can produce a better experience at less cost.
The King’s Fund’s report itself studies four models and draws from experience of many others. Although not mentioned by name, Whitstable Medical Practice also provided evidence. Our model of community integrated healthcare has been evolving for a number of years.
Currently, 19 GPs look after a locality of 34,000 patients in collaboration with over 20 consultants and other healthcare professionals. Work streams have been developed to innovate in the care of long-term conditions, urgent care and community elective services. The result has been an enhanced patient experience, closer to home, with shorter waits and one-stop care where possible.
This has been delivered at less cost to the system and also to the greater satisfaction of the doctors, nurses and other healthcare professionals involved in delivering the model. Other super partnerships and federations report similar findings.
The evidence is out there and it is growing. One reason that there are not more innovators is that they are trying to develop new and better systems in a bureaucratic environment which is at best unhelpful and at worst oppositional. The King’s Fund’s report advocates changing the commissioning landscape to enable family care networks - otherwise known as community integrated healthcare. This is a concept which has been talked about for many years. Surely there could not be a better time to facilitate progress.
I agree with the statement that conflict of interests for GPs as commissioners and providers needs to be addressed. The report advocates managing this effectively which seems a better alternative than allowing it to block progress, which is all too often the case at present.
Transparency, honesty and scrutiny are the key to success. I find myself agreeing with Dr Chand’s statement that ‘to implement needlessly disruptive policies that focus more on structures than outcomes needs rejecting’.
However, this is not what the report is advocating. Instead it states that the GP contract should focus on outcomes and not inputs.
Finally, Dr Chand makes the point that new investment is required in general practice. I agree that we appear continuously to be asked to do more with less resource, something we all feel pressurised by. However, it is possible that the King’s Fund’s recommendations provide one answer to this. If more clinical activity is occurring in the family care networks then more finance will flow into them.
Economies of scale in running practices and also in providing shorter patient journeys with less duplication, hand-offs and omissions should all have the potential to produce savings which could in turn increase the amount of resource in a new version of general practice which has a leadership role in family care networks.
As the King’s Fund’s report states, simply doing more of the same will not be sufficient and therefore there is a strong argument for a better approach based on innovative ways of providing services.
This debate is advancing in our locality, and others that I have visited. Potential ornithomimosaurs please take note.
* Dr John Ribchester is a Kent GP.
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