The DoH’s pending announcement on practice-based commissioning (PBC) figures is expected to say that almost all, if not all GPs in England, are now signed up to the scheme.
There’s more than a little dispute about what exactly being ‘signed up’ constitutes, but it should mean that most GPs are now considering which services they should be redesigning or considering offering themselves.
Traditional concerns of cost, quality and value for money will all automatically be considered, but there is also the issue of loyalty to existing local services.
A precedent for such altruism has been set by 11 government ministers who were ‘outed’ in recent weeks for opposing hospital closures brought on by their own party’s policies, deciding that local loyalties superseded their masters’ orders. GPs may face a similar dilemma with PBC if service plans run the risk of destabilising established local hospitals.
The conundrum was brought into focus last week by reports in the national media that GPs in County Durham had set up an orthopaedic service at a local private hospital in competition to the local NHS general hospital.
Dr Stuart Findlay, one of the GPs involved, said that in this instance they tried to use the facilities at Bishop Auckland General Hospital to run the service, but were unable to negotiate a similar deal.
A spokesman for the hospital told GP that it had ‘never been formally approached’ to host the service.
Whatever the reality of that situation, Bishop Auckland is one of a number of hospitals struggling to hit financial and care targets and GPs may now be in a position to help or hinder this through PBC.
There will be a number of GPs who are now designing services, which could be operated by a variety of possible providers — including an existing NHS hospital, a new private provider or even the GPs themselves.
Effects of new schemes
The latest round of DoH guidance, which came out towards the end of last year, advises PCTs and GPs to consider the knock-on effects of new schemes.
It says: ‘PCTs are responsible for leading the implementation of national policy at local level. This includes advising, co-ordinating and informing practice-based commissioners of the wider implications of their proposed services redesign (such as the impact on local hospitals) while respecting clinical and management decisions taken by practice teams on behalf of their patients.
‘Where PBC plans affect secondary care, practices should seek the involvement of consultants and wider secondary care clinical teams.’
However, while the two paragraphs above ask commissioners to think about the impact of new schemes, the overall tone of the 40-page guidance is clear, with six mentions of ‘value for money’, 10 mentions of ‘choice’ and 12 mentions of ‘cost’.
Dr David Jenner, PBC lead at the NHS Alliance, said that GPs should always consider the impact of new schemes on their NHS hospitals.
‘What GPs have to do is tread a fine line between competing with and destabilising their local hospital and maybe an A & E department,’ he said.
‘I have a thing called the heart attack test. If I have a heart attack, will what I am doing in my practice affect the care I will get from my hospital? You need to monitor that.’
But does that mean that GPs should actively seek to set out schemes that will help other NHS providers in their area?
Dr Jenner said that if GPs value local NHS services the biggest gains are when primary and secondary care services worked in tandem anyway.
‘At the moment Payment by Results has set primary care against secondary care. But, if we stop beating up secondary care and it stops creaming off primary care, that’s when we’ll see the biggest gains.’
GPC negotiator Dr Richard Vautrey said that he expected most GPs would prefer to work with local hospitals anyway but in the long term it may well be important that they choose to.
‘There will be changes of provision taking place but a lot of work is best done with existing secondary care,’ he said.
‘GPs need to have in mind the longer term of their service and that will involve building up local hospitals that may have been run down in the past. All sorts of models will arise very few GPs who will want to be involved with outside providers.’
He added that this would not prevent the private sector finding a niche for provision but said that ‘the generality of care’ could stay with existing providers.
No obligations for GPs
However, Dr Tim Kimber, a PBC lead in West Sussex, said that GPs have no obligation to support local hospitals because they might end up supporting failing services.
‘I think it would be a very sweeping statement to say that GPs have a moral obligation to support an NHS hospital at a time when government policy is designed to produce a plurality of providers,’ he said.
‘As in all things, there are good hospitals and bad hospitals, and if your local hospital isn’t doing what you want it to do, you might very well look to a provider who will. Remember also that the latest PBC guidance encourages GPs to become providers and change care pathways, all of which potentially destabilises acute trusts. Forward thinking trusts will be working with their GP colleagues to change care pathways and find new niches for themselves in the modern health economy.’
Ultimately, there are good arguments either way for whether hospital stability should be a concern for GPs, but as the 11 Labour ministers found, local interests can sometimes supersede the most well-supported of national policies.
GPs worry about destabilising hospitals with new PBC schemes?
Dr Rebecca Torry, Bermondsey, south-east London
‘Of course we need to worry about relations with our colleagues in secondary care. If we don’t work together with them it is to everybody’s detriment.’
Dr Amanda Harry, Plymouth, Devon
‘We’re caught on the fence in general practice. On the one hand we want to keep the NHS but on the other do what is best for our patients. In the short term that may mean a private provider but long term I’m not sure.’
Dr Phil Yates, Bristol
‘Loyalty has to be a two-way process. My priority has to be my patients - not my local NHS hospital. My own view is that primary care is seeing very little loyalty in the way that acute trusts are up-coding and billing under Payment By Results.’
Dr Hwa-Lon Liu, Horsham, West Sussex
‘PBC should be done with the help of hospitals. I run an ENT clinic with the help of the local hospital and it would be difficult to run a service without it. Stability at the hospital is important.’
Dr Anita Sharma, Oldham, Lancashire
‘I do not think being involved with PBC will destabilise hospital services — we are complementary to them. It will free the time of consultants to concentrate on more specialist areas of their choice.’
Dr Jonathan Holliday, Eton, Berkshire
‘We absolutely have to be concerned about destabilising hospitals. Our experience of Choose and Book here has told us that as long as the local hospital is alright, patients want to go to the local hospital.’