Will shift to primary care work?
Derek Wanless, in his landmark 2002 report on NHS finances, concluded the current, hospital-centred model would soon become 'inefficient and unaffordable'.
By Emma Wilkinson
In last week's White Paper, the Government unveiled its solution pledging to shift at least 5 per cent of hospital resources into primary care.
The strategy relies on a series of innovations which have already seen action in the NHS, including GPs with special interests, community matrons and a new breed of high-tech community hospitals.
Primary care experts insist the White Paper offers real opportunities for GPs, with the potential for new career paths and an influx of specialist equipment and resources.
But they warn it carries risks too, particularly in trying to meet unrealistic Government expectations for cheaper care and fewer hospital admissions.
Professor Chris Salisbury, professor of primary health care at the University of Bristol, recently published an evaluation of a GPSI dermatology service which threw its cost-effectiveness into doubt.
Professor Salisbury said: 'There are lots of good reasons to move things out of hospitals and into primary care and in many ways I'm in favour but we should be cautious in assuming it's cheaper.'
He added: 'We found it was more expensive. It is partly economies of scale, partly GPs give people more time and partly GPs are more expensive. You have got to be clear what the purpose is is it for money or better patient care?'
Professor Martin Roland, director of the National Primary Care Research and Development Centre, was equally sceptical, warning it was 'incorrect' to assume transferring services to primary care would save money. He said: 'If your priority is patient access you will provide a service in smaller units closer to home, but if your priority is cost-effectiveness you provide a service in large central units.
'One of the real issues around the White Paper is, can we afford to give patients what they want?'
The Government has proposed 20 to 30 demonstration sites over the next year to trial 'transferred care'. The pilots will cover conditions such as dermatology, ENT and gynaecology and many will make use of GPSIs.
GPs who have been involved in such schemes believe they can be successful but only with sufficient support from PCTs.
Dr Neil Crowley, a GP in Ealing, west London, had to quit his GPSI dermatology service last year after his trust refused him admin support.
He said: 'There's a huge advantage to having an adequately resourced GPSI service. It's local, my waiting times were three weeks compared with three months for the hospital. It is feasible if there are enough GPSIs who are adequately supported.'
Dr Crowley insisted his service had been highly cost-effective and had saved the local hospital trust many thousands.
Professor Roland agreed primary care could give value for money, but asked whether it was realistic for the NHS to 'disinvest' in hospitals.
Professor Roland's work is among a raft of studies questioning another of the White Paper's key assumptions that primary care services will cut admissions to hospital.
A study only this week found chronic disease management schemes could not be relied on to cut admissions.
Dr Donal Hynes, who as PEC chair at Somerset Coast PCT has developed a clinical assessment unit to reduce hospital admissions (see right), questioned Government strategy.
He said: 'Just having community matrons on their own won't make a huge difference. As a GP you realise people will get ill regardless of how much care there is around them.'
Dr Jon Glasby, head of health and social care at the Health Services Management Centre, University of Birmingham, wondered whether there was enough joined-up thinking in the White Paper to have a real impact on admissions.
Dr Glasby, who has just completed a three-year evaluation of intermediate care, said: 'We keep moving to the next thing before we solve the problem. Intermediate care and community matrons are practically the same thing but in many areas they've not been set up like that.'
But Dr Glasby welcomed another key element of the White Paper proposals the 'new generation' of community hospitals or treatment centres provided they weren't used as dumping grounds for patients.
'Community hospitals have the potential to be part of the solution. If you actually rehabilitate people you probably are fulfilling the White Paper ideas.'
Those ideas provide entrepreneurial GPs with a potentially exciting challenge but one with the attendant pressures of expectation.
Case study 1 PCTs hailed as GPSI trailblazers
PCTs in north Bradford have been trailblazers for the GPSI scheme and now have 30 working in 10 clinical areas as diverse as paediatrics and peridontics.
Bradford's GPSI service is now used for at least 60 per cent of all GP referrals and was hailed in the White Paper as an example of best practice.
Dr Ian Rutter, chief executive of North Bradford PCT and a GP in the city, said: 'The GPs are based in practices, treatment centres and community hospital sites.
'It's popular with patients because they do not have to go to hospital and has helped with [doctor] recruitment.'
Case study 2 Assessment unit to back up matrons
Somerset Coast PCT is to open a new clinical assessment unit in the next few weeks, designed to support community matrons in keeping patients out of hospital.
The 12-bed unit will be staffed by medical nurse practitioners and aims to admit, assess and discharge patients within 24 hours.
Dr Donal Hynes , PEC chair at the trust and a GP in Bridgwater, said the centre would work with community matrons to reduce admissions. 'It will take a huge workload away from the acute hospital. It will be an awful lot cheaper,' he said.