Debate over the health bill has centred on proposals to hand over responsibility to GP-focused clinical commissioning groups. Far less attention has been paid to primary medical care provision, and yet providing care to patients motivates most GPs much more than commissioning.
Although general practice in the UK has developed further and faster than in many other countries, the King's Fund's 2011 inquiry into quality in general practice showed that standards of care are variable and the scale at which practices operate is often too small.1 Excellent practices operate in close proximity to those offering care of an unacceptable standard, and this cannot and should not be tolerated in an NHS that aspires to deliver high-quality care to all.
Responsibility for commissioning primary medical care in the reformed NHS will rest with the NHS Commissioning Board. The board will also have a role in supporting good practices to become better, and sharing lessons from practices already delivering high standards of care. The bill introduces a duty on CCGs to improve the quality of primary care provision – and they are unlikely to succeed as commissioners unless they do.
The strengths of British general practice when it works well are accessibility to patients and continuity of care. These strengths derive from the established model of relatively small practices serving registered populations and the personal relationship built between GPs and patients over time. The challenge in future is to harness these strengths while encouraging practices to collaborate in federations.
Federations offer the opportunity to tackle variation in the quality of general practice while also creating a platform for delivering more care in the community. Linking singlehanded and small practices with their neighbours will help break down professional isolation and enable expertise to be shared through peer support and review.
Eliminating duplication
Equally important is the potential of federations to enable more services to be provided out of hospital. Innovative practices are already showing what can be done by investing in premises and equipment that enables appropriate diagnostic, outpatient and minor surgical procedures to be done in the community. Some forms of urgent care can also be delivered in this way with the right funding and support.
To make a reality of these ideas requires CCGs to commission new models of care. It also depends on practices – both individually and in federations – working closely with other providers to develop integrated care.
An early priority for CCGs should be to engage with constituent practices and other partners to inform commissioning decisions and to ensure that these decisions are future proof.
As they do so, it is essential that wasteful duplication is avoided at a time when NHS funding is going to be constrained for at least five years. Simply adding services in surgeries without making necessary changes in how care is provided in other settings would be the worst of all possible worlds.
Commissioners must agree with the providers of community services and hospital care how to migrate to new models of care, including managing exit from existing services where necessary.
The argument for integrated care has been endorsed by the Future Forum and accepted by the Government, and now is the time to make it happen. While there is no inherent contradiction between integration and competition, CCGs will need to show leadership in navigating the emerging rules of the healthcare market and not falling foul of the economic regulator. Constructive dialogue between GPs as providers and commissioners, and all other providers of care must be the way forward.
This dialogue should extend to social care as well as healthcare, in view of the critical contribution made by social care to the needs of older people and those with complex needs. A new model of integrated care that delivers more services closer to home is contingent on much closer alignment between health and social care teams in the community and general practices.
Professor Chris Ham is chief executive of the King's Fund
Reference
1 King's Fund. kingsfund.org.uk/document.rm?id=9040
