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Make or buy?

Our protagonist wonders how he can apply the wisdom of primary care tsar Dr David Colin-Thome without upsetting the acute trust

Our protagonist wonders how he can apply the wisdom of primary care tsar Dr David Colin-Thome without upsetting the acute trust

The story so far

Dr Peter Weaving is a GP in north Cumbria whose role as a locality lead for Cumbria PCT leaves him sandwiched between clinicians and managers as they try to make a go of PBC implementation...

We should ask ourselves whether to ‘make or buy' when we consider the management of an individual patient, says Dr David Colin-Thome, national director of primary care, in last month's Practical Commissioning.

Can I solve this patient's problems myself, within the practice, a neighbouring practice or the community, or do I need to buy it in from secondary care?

In my locality we have had numerous schemes proposing to divert patients away from orthopaedic, ophthalmology and surgical outpatient clinics – all aiming to provide more appropriate and cost-effective patient care.

Now let's look at my financial spreadsheet. An A&E attendance costs about £100, a specialist consultation about £150; but an elderly person admitted to hospital costs several thousand pounds.

Last year the biggest financial hit, not to say overspend, for my practices was ‘non-elective excess bed-days' – finance department speak for ‘you are admitting too many emergency cases to hospital and not getting them out fast enough'. Well, let's turn it around! We need just four changes:

• Better chronic disease management to keep people with COPD, heart failure and diabetes as well as possible. Did you know there is an evidence base for phoning people with bad chests to tell them there's a cold snap coming so wrap up warm?

• Better support services in the community to manage exacerbations, deteriorations and the unexpected in patients with chronic diseases. Our community services arm has implemented a rapid response nursing team. They will now pop round to Mr Miggins, who has fallen over again, and assess the cut on his nose and his Glasgow coma scale and determine that Steri-strips and a cup of tea are more appropriate than blue flashing lights and a CT.

• A bit of GP tolerance of risk and uncertainty at the front end of your hospital – I foresee a marketing problem with this one so we'll call it a primary care assessment service, or PCAS. Since the out-of-hours service is the prime handler of risk, with a contact-to-admission rate half that of the A&E department, and as they have no four-hour limit pressurising them to admit, we shall ask them to provide the service co-located in our A&E department.

• Finally, since our intelligence tells us the only practice on the patch that made a saving on its activity budget last year was the one with access to a community hospital for step-up and step-down care, we shall commission a community ward within the acute trust.

Cut to the reality of implementation.

I am sitting opposite the deputy chief executive of the acute trust.

‘So, Peter, these 20 beds earn the trust about £3m a year but you want to take charge of them and pay me just £300,000 to staff them. Why would I agree to that?'

Swallow hard.

‘Er, because I want to make not buy?'

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