Clinical commissioning groups (CCGs) will be under pressure to demonstrate the positive impact of clinician power.
The temptation will be to focus on measures that produce rapid savings or improvement at the expense of less immediately obvious or appealing areas where the benefits may be greater in the long term.
Quick wins are important and in the first year or two of their existence CCGs can be forgiven for worrying about the short-term factors likely to affect financial balance.
But big wins demand a longer view and it will be these that determine whether or not CCGs invest wisely in the health of their populations. It will also be the big wins that determine the future prospects of CCGs and stop them from limping from one financial year-end to the next.
Develop local tariffs
Use your commissioning power to develop local tariffs with acute providers that keep people out of hospital and shorten stays. Handing so much money and commissioning power to GP-led groups can only make sense if they consider whether national tariffs for acute work are appropriate to their community's needs. If not, renegotiate.
Commissioners will have to consider the risk of undermining the viability of a local acute services provider. The debate will have to take place with secondary care colleagues. It may be that some of the work the national tariff pays for in acute care is renegotiated to be purchased from community or primary care.
Use clinician-to-clinician contact to cut through bureaucratic nonsense, cultural inertia and vested interest. If existing arrangements do not work, make new ones.
Invest in community services for end-of-life care. Increasing the availability of nursing and other support in the community can help reduce the high number and cost of emergency admissions involving people nearing death. This is good for patient, family and NHS finances.
Specific measures can include investing in clinical nurse specialists working in the community to respond to individual crises and incentivising GPs to make full use of end-of-life care registers.
Such registers can ensure that any professional or service called to a dying person's home is aware of their needs and preferences - thereby preventing unwanted or unnecessary admission or treatment.
Encourage patient self-management. Treating people with long-term conditions consumes 70% of the primary and acute care budget in England. Commissioners could draw on existing NHS initiatives, such as the Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) programme, to encourage more patients to manage their care.
Look at patient and carer education, telecare and telehealth services and psychological interventions.
Ensure regular reviews of placements and services for people with learning disabilities. They often go years without a full review to consider if the placement is still appropriate. Teams involving local authority staff should be assessing individuals regularly. Investment in quality community services could reduce current high levels of attendance at A&E by people with learning disabilities and improve diagnosis of other health problems.
Commission a home oxygen assessment service. It is estimated that between 25 and 43% of oxygen therapy prescribed for home use is of no clinical benefit or is unused. Effective assessment and follow-up by doctors, nurses or physiotherapists specialising in respiratory care could make a big cut in the £120 million cost of home oxygen therapy.
Encourage and support GP telephone triage. There is evidence that increased use of the telephone could reduce A&E visits, improve GP productivity and improve patient access. The practices guarantee patients calling in the morning that they will speak to a doctor that day. The GP calls the patient back and, after a conversation averaging three minutes, either offers an appointment that day or resolves the concern over the phone. The analysis suggested a 20% fall in A&E visits and lower did not attend rates.
Get to grips with the new medicine service (NMS) and targeted medicines use reviews (MURs). Pharmacists can play a vital part in helping people adjust to new medicines and to use medicines appropriately. This can reduce both the waste of prescribed medication and the number of A&E visits or emergency admissions linked to medication.
Prescribed medication accounts for around 12% of the NHS budget - with costs rising by around 10% each year. There is plenty of evidence of the benefits from MURs and the NMS provides sensible guidelines to help commissioners to help patients make the best use of the drugs they are prescribed.
Commission more services from pharmacies. There is massive scope for expanding the range of services commissioned from pharmacists - with no overheads or start-up costs for the CCG. The DoH is supporting healthy living pharmacy pilots. Pharmacies are commissioned to provide at least two enhanced services - increasing access, moving care closer to home and releasing precious GP and practice nurse time.
Challenge poor financing
The theoretical underpinning of much of the reforms is that clinicians should be shaping healthcare services and provision. With clinicians at their core, CCGs should have the expertise and the ethical purpose to challenge referral or prescribing practices that appear to use public money inefficiently. There is often a sound demographic or clinical reason why a practice might be an outlier on a particular measure, but where there is not, challenge is important.
Develop telephone and email consultations. This could potentially improve both access and primary care productivity. Finding more efficient ways to stay in touch with patients without compromising safety can reap potentially huge cost benefits, free up clinical time and reduce inconvenience and anxiety for patients.
- Julian Patterson is director of marketing and communications at Primary Care Commissioning