Like most doctors, I am a clinician first and foremost. In my view, the establishment of GP commissioning is an opportunity for primary and secondary care clinicians to align their efforts to deliver integrated care.
This will be good for the profession and, more importantly, good for our patients. In most mature healthcare systems that perform well (like the health maintenance organisations Kaiser Permanente and Mayo Clinic in the US), all the clinicians work to achieve common goals. The result is greater efficiency in financial and clinical terms.
In its latest guidance to hospital consultants, the BMA stresses that its involvement in the new commissioning arrangements will be crucial. Its experience in what is current and important in its specialities needs to be brought to the table. Consultants also have clinical and research evidence vital to services development.
Key principles
There are two key principles in the White Paper: putting patients first ('no decision about me without me') and improving healthcare outcomes. But delivering these will be impossible without primary care and secondary care clinicians speaking the same language and delivering services where the staff, who are involved at each step of the patient pathway, understand each others' roles.
So much for the rhetoric: how can we make this happen? We need to examine:
- What we achieve in primary and community care and how can that be achieved better and more efficiently.
- What do we buy and how do we buy services, including patient pathways determined with secondary care colleagues.
- How we manage the health of our populations to prevent ill health and to stop at-risk patients going into hospital when this is avoidable.
Once GP commissioners have thought all this through, we can start to talk to our hospital colleagues in a collegiate and collaborative way.
At my practice in the West Midlands, the GPs have started to implement this in a small way.
We have created consultant outreach services. My practice has run an extended primary care diabetes service through a PMS-plus contract for more than 11 years. Under this, a consultant holds regular community clinics, all care developments are shared between primary and secondary care and savings are reinvested in developing the service.
This has allowed new and innovative ways of delivery, such as consultations using 'conversation maps', for example dialogue between diabetes patients and their healthcare professionals.
We have developed a community elderly care service with a consultant geriatrician and psycho-geriatrician, an elderly care co-ordinator and a GPSI. Hospital admissions are down and there have been prescribing savings.
The incentive for our hospital colleagues is delivering a joined-up service with well up-dated patient records and care co-ordination done efficiently and well. Our care co-ordinator's assessments are accepted by three local authorities.
There is a sessional community orthopaedic service provided by a consultant. Using local guidelines, GPs provide the consultant with detailed information about patients' symptoms. This results in a high conversion-to-surgery rate for patients seen who are subsequently referred to hospital.
The feedback is: 'This is a great clinic to do; I get to see the right patients.' The financial incentive is that the NHS trust's resources are not being squandered on patients who are inappropriately referred.
The incentives for GPs are from initiatives like better professional satisfaction and improved patient outcomes and satisfaction plus a good result financially.
Designing pathways
With GP consortia buying decisions, achieving the two key principles depends on designing pathways with specialists. For example, with hip or knee surgery, it should become possible for pathways to include pre-assessment and rehabilitation to prevent readmissions and improve patient satisfaction.
The benefits will be better looked-after patients, greater professional satisfaction and financial savings that can be shared between primary and secondary sectors to improve services and get innovation going. There will also be constructive dialogue about the best practice services to achieve common aims and joint consortia/hospital decision-making on how to use funding.
Using health informatics to stratify population risk, my practice has co-developed tailored interventions for better patient management with healthcare company Aetna Health Services UK. This has enabled us to identify people at risk early, set up programmes for better disease management and reduce hospital admissions.
Developing teams
In the disease areas concerned the early indications are a 40 per cent fall in admissions. The money saved will be redirected to develop community teams. As a practice, we have changed the way we work by being more accessible, and offering a collaborative approach to dealing with ill health and prevention.
GP consortia will need to overcome many disincentives. These include payment by results, fossilised hospital outpatients services for specialties where patients can be readily seen in the community and immature commissioning dialogues that do not motivate providers to help develop integrated services.
GP commissioning is an opportunity to develop a model in which providers are encouraged and funded but also held to account in a constructive but challenging way.
It is time for primary and secondary care clinicians to 'capture the moment' and work together to do the best for our patients.
If we can successfully collaborate, the coming NHS reorganisation could be just what is needed to deliver better and cost-effective healthcare in these times of austerity.
- Dr Pall is a GP in Sandwell, West Midlands, chairman of Pathfinder Healthcare Developments CIC and a member of the NHS Alliance's clinical commissioning federation
