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Why GPs are going to work more closely with specialists

Whether GPs like it or not, barriers between primary and secondary care are coming down.

By Nigel Praities

Whether GPs like it or not, barriers between primary and secondary care are coming down.

The NHS is often described as a vast state monolith by those who peer in from the outside. From within though, it is a disparate variety of groups with often competing interests, not least among them GPs and hospital doctors.

The two groups have had an occasionally fraught relationship over the years. When consultants and GP leaders get together for a crunch meeting on the NICE skin cancer guidelines later this week, you could be forgiven for suggesting St John's Ambulance brigade be on standby outside.

So what are GPs and specialists to make of the Government's new integrated care plans, which aim to bring down the barriers between primary and secondary care?

Mr Jonathan Osborne, vice-chair of the BMA Welsh Council and an ENT consultant at Glan Clwyd Hospital, sums up what many see as today's reality.

He warns: ‘Some GPs don't even know who their hospital consultants are.'

That could all change under proposals to move towards a system of integrated care organisations, or ICOs, many of which might ‘vertically integrate' primary and secondary care.

The Government is testing out the plans with a £4m experiment, which will see 16 pilot projects running for the next two years and GPs often taking the lead on projects bringing them much closer to their consultant colleagues.

Take, for example, the trial chosen in Norfolk, which will see specialists and GPs work together to reduce hospital admissions and increase the range of services in the community.

Or a scheme at Bishop Auckland General Hospital, where GPs will be placed at the front-end of A&E and will run general practice wards.

Another scheme in Sunderland for patients with long-term conditions will see GPs at one practice becoming employees of the local acute trust, with direct access to diagnostics and specialists coming to the surgery to conduct clinics.

In Cumbria forming a federation of 21 practices has aspirations to eventually merge with other healthcare services and form one all-encompassing organisation.

Integrated care might sound radical but it is not new.

Rewind to 1997 when a Government paper promised to remove the NHS internal market and move towards local doctors working together to improve patient care.

The ‘New NHS: modern, dependable' paper proclaimed: 'Individual patients, who too often have been passed from pillar to post between competing agencies, will get access to an integrated system of care that is quick and reliable.'

But critics say in the more than a decade that has followed the Department of Health has undermined this promise, by introducing every more complicated reforms that have acted as barriers to co-operation.

The drive to increase competition and drive down waiting times, and the payment by results system, have, they say, fragmented professional relations.

Professor Chris Ham, professor of health policy and management at the University of Birmingham, says the Government has failed to provide incentives to get clinicians working together.

‘Payment by results has incentivised increasing hospital activity, whereas with long-term conditions you want to avoid this. PBC could provide incentives to manage conditions and provide care closer to home, but it has not engaged enough GPs.'

The US care organisation, Kaiser Permanente, formed in Oakland, California, is often regarded as the poster boy for how the NHS, which it predates by three years, could work.

Providing medical services for roughly the population of a small country – 8.2 million people – it has no separate commissioning and providing arms. Doctors work in partnership with responsibility for the entire budget and provision of clinical services.

One analysis in the BMJ in 2002 compared this approach with the NHS. They found the US model provided much better access to primary care services and two-thirds less use of acute hospitals.

The authors concluded: ‘Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition and greater investment in IT.'

Professor Ham credits the shared goals and clinically-led nature of Kaiser Permanente with its success.

‘Within that organisation you are able to do all the right things for patients, you have incentives to keep them healthy, prevent illness, provide care in a primary care setting and avoid use of hospitals.

‘If you are within those integrated systems use of a hospital becomes a cost centre, whereas in ours hospitals are a profit centre and we have it all the wrong way round,' he says.

So could this model come to the UK? In fact it already has.

Luton is a world away from the Californian sun, but its PCT – one of several NHS Kaiser Beacon sites in the UK – has shown its model can improve patient care.

The pilot in Brixham, an area serving around 23,000 people, proactively identified vulnerable older people and provided intermediate care services in the community with a single point of contact.

Over two and a half years, it increased the number of patients with care plans from 67% to 97% and the number assessed within 28 days of referral by 72% to 83%.

The approach has proved seductive to the Department of Health, with the Darzi review promising to make integrated care once again a goal for the NHS.

The latest plans have been welcomed by evangelists, who believe they may become a model for exciting new models of commissioning.

Dr Michael Dixon, chair of the NHS Alliance and a GP in Cullompton, Devon, said PBC hubs could eventually develop into federations to commission and provide care.

‘In a sense they become a health maintenance organisation, but one at the good end. It is not a corporate organisation and one that serves the whole population and doesn't cherry-pick patients,' he says.

Dr Oliver Bernath, a former consultant neurologist and managing director of the company Integrated Health Partners, says the NHS currently behaves like a giant balloon.

‘Everyone squeezes it a little bit and when another problem pops up somewhere else, they say "That is not my problem anymore."

Dr Bernath is working with GPs and PCTs to design integrated care programmes for patients and has recently launched its first scheme with NHS Surrey.

The scheme will see GPs from six practices take accountability for the entire healthcare budget for their area, working with hospitals, social and community services.

Dr Bernath says one of his biggest issues has been convincing specialists the new scheme is not a threat to their profits.

‘The local hospital is always initially hostile, thinking you want to take activity and income away. But after you break the ice, they can see benefits for patients,' he says.

But rather than integrated care being a threat to hospitals, there are some who believe it could become a threat to primary care.

Dr Dixon warns: ‘The great danger is that we become more secondary-care centric and they feed the beast of hospitals.'

Dr Nick Goodwin, a senior fellow at the King's Fund, fears the pilots could lead to monopolies under which care stagnates.

‘If you back to a non-competitive monolithic type organisation then the worry is it will not do the best for patients and will go back to concentrating on the institution and the physicians within it.

‘It is quite clear that competition and integration are not good bed-fellows.'

In the swathe of policy statements and new initiatives, it is hard to see how the integrated care experiment will affect patient care.

But it is clear GPs are likely to find themselves pitched into working much more closely with their specialist colleagues, whether they like it or not.

How integrated care can work for COPD

GPs in Norfolk have managed to overcome professional tensions to establish an integrated care service for COPD that may be rolled out across Norfolk.

GPSI clinics are run in Tetford Healthy Living Centre, in conjunction with specialist nurses from West Suffolk Hospital.

This means patients are managed by the same team if they require oxygen assessment at home, pulmonary rehabilitation in the community or admission to hospital for an exacerbation.

Dr Daryl Freeman, a GPSI in Norfolk, said they had to overcome ‘real problems' with secondary care colleagues when setting up the service, but now the main issue was convincing NHS managers of the usefulness of the service.

‘The clinicians are working very well together, the depressing thing is getting the managers to meet and talk and say we can take this forward,' she said.


What is integrated care?

Integrated care is defined as when health and social care services work together to ‘ensure individuals get the right treatment and care that they need'.

In practice, it often means getting primary and secondary care to work more closely together, or joining up care between general practice and social services.

Why is the Government focusing on this now?

Integrated care has been a DH buzz-word for over a decade, but until recently this has largely been lip-service. Impressive results from US managed care organisations have convinced the Government to launch pilot schemes here.

What are the pilot schemes?

The sixteen pilot schemes range from providing care for older people, to services for substance misuse. In many cases, traditional barriers between primary and secondary care are removed, in some cases with GPs becoming employees of trusts or running community wards in hospital.

How will they affect me?

The pilots will be evaluated after two years, with the DH expecting a ‘robust contribution' to the evidence base around integrated care. Successful ideas are likely to be used in policy.

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