Vets give us the best example of successful integrated care
Dr Gavin Jamie describes what he learned at the vet surgery
I was excited recently to visit a healthcare centre which seemed to tick most of the boxes that are currently in vogue for NHS commissioning. Primary care was provided in conjunction with a network of branch sites, the majority of blood tests are analysed on site - despite the centre being smaller than the building where I currently practice - and ultrasound and X-ray machines were just a few steps from the consultation room with CT scanning planned for the future. A suite of well equipped theatres allowed those general practitioners with particular interests to carry out operations and there was even an on-site grooming parlour.
My practice’s patients, as you have probably guessed, are not eligible for treatment at this health centre because it is not open to human patients. My visit was part of a live BBC Wiltshire show from a local veterinary hospital, finding out about how things worked behind the scenes.
There are some very obvious differences between veterinary and human medicine, particularly around end of life care which touches on deep moral issues, but there is much else that is simply down to different traditions and business models.
The thing that made the biggest impression on me was the flexibility available to the practice
The time it takes to become initially qualified is similar for both doctors and vets, but vets’ postgraduate training is much less rigidly structured. Specialisation was visible in the practice with staff taking the roles of surgeons or general practitioners but the borders are much more fluid.
There was a lot that looked familiar. Consultation rooms led off the waiting room (with separate cat and dog areas) while in the treatment room there were racks of bandages, green needles, venflons and IV fluids. The canine recovery ward had bleeping machines, clipboards and comforting blankets, although there were more bars on the cubicle doors than might be considered normal in the NHS. And the dogs, starved for their operations, put on their most endearing looks in the hope of a snack.
In the theatre suite an ultrasound scan was taking place with a family gathered around the table alongside the vet. Several operating rooms led off this central room as well as a dental room. The theatres had facilities for general anaesthesia and positive pressure ventilation. In a room at the far end, beyond the yellow radiation warnings, was the digital X-ray equipment. Diagnostic imaging is swift and the images will be reviewed by the same person who clinically examined the patient.
Another room allows the majority of blood tests to be conducted on site. Blood samples tend to be smaller than we might use in humans, at least for the domestic animals, and can be analysed for basic haematology or biochemistry in machines no larger than a laser printer. This is a much broader range of tests than are typically available even in those surgeries already offering cholesterol or c-reactive protein tests. Anything that could not be done on site was picked up by a daily courier.
This practice is run by a number of partners who are all working vets with other employed vets and staff in a structure very similar to many larger GP practices. Veterinary medicine is of course completely private with animal owners either directly paying or taking out an insurance policy. I am no advocate of privatised general practice but the gap between the veterinary model and my increasingly ’item of service’-based contract is probably narrower than we might like to think. A rough headcount suggested that they had fewer administrative staff than my surgery did - billing may be simpler to administer than the QOF and enhanced services in the GP contract.
A comprehensive NHS has meant that private human medicine currently caters for the luxury end of the market. I associate it with polished pot plants and trendy modern art. The veterinary hospital in contrast was as clinical and efficient as any modern NHS facility. The pictures on the wall were largely of healthy patients.
The thing that made the biggest impression on me was the flexibility available to the practice and how they used it. The distinction between primary and secondary care is much weaker than in the NHS. Funding does not arrive in specific pots and the vets themselves train and invest flexibly to meet patient needs. The capital costs of radiology or pathology equipment are small enough to put them in the community with the limiting factor being the skills of the operator. I was quite capable of a basic reading of an X-ray as a junior doctor, but have not done so for over 15 years.
After this visit I have started to get an impression of what integrated care could look like far more clearly than I have gained by listening to any of the vanguard advocates. The changes to achieve integration will need to be huge but one possible model could be much closer than we think.
Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website. You can follow him on Twitter @qofdatabase