Alisdair Stirling asked our panel of GP commissioning experts what GP-led commissioning is doing for hard-to-reach groups and what impact the new coalition Government's plans will have
What can GP-led commissioning achieve for hard-to-reach groups of patients?
JA GP commissioners have the influence and accountability to commission services that are truly representative of the type of patients they see on a daily basis.
In local areas where there may be a higher concentration of ethnic minority communities, for example, they can commission services that are more culturally appropriate and sensitive to the needs of particular individuals or groups.
Culturally appropriate mental health services, for example, can directly link with primary care with access to community-based clinics or outreach services.
GP commissioning can also incentivise service providers to commit more specialist and sustained input into delivering appropriate services across different registered populations – such as the asylum- seeker services in Calderdale or Huddersfield.
BF GP commissioning groups have a responsibility for the health of the whole of their population, which puts commissioning for hard-to-reach groups on the agenda from the word go.
To some extent it's a question of social justice. Often these groups have more health needs than the rest of the practice population and are more demanding of healthcare so we have to go that bit further to help them.
This can be the difficult part because it entails us reorganising ourselves and we're not always geared up for that in primary care. The whole system has to be adapted for what is often a small part of the population.
But if GP commissioners talk to the right community agencies and ask them to reach out on their behalf, they can take the first steps.
PB Personally, I don't think we have got to the hard-to-reach groups yet. In Cambridge, we have commissioned 20 expert patient programmes and supported the employment of health coaches for our deprived practices to use to support their patients for lifestyle change in smoking, obesity, exercise and so on – but these are just drops in the ocean.
What are the main reasons for the successes GP-led commissioning has had in reaching hard-to-reach groups?
MD GP commissioning has great potential in this area because of its granularity. A lot of GPs know their localities very well and are in a very good position to know what's needed because of their knowledge of the whole community.
It´s a bit like with out-of-hours care where we hope GPs take on commissioning responsibility. It would be good for them to take on such responsibility for hard-to-reach groups too.
It's commissioning for the totality, so you have the power to interconnect all the elements.
JA One of the reasons GP-led commissioning has delivered redesigns so effectively is that it can create effective local clinical partnerships.
For example it can involve local community leaders, or professionals such as community pharmacists who can deliver needs assessment and service redesign activities to ensure that medicines management is addressed.
How could the system be improved so that GP-led commissioning can benefit hard-to-reach groups more?
JA Patient consultation and board representation would improve the community accountability of the local NHS and embrace the different hard-to-reach groups.
Increasing the outreach options for service providers or creating formal partnerships with the voluntary sector or local authority would improve GP commissioners' ability to access greater numbers and population diversity.
BF I think in general, PBC hasn't been as good at this as we could be because we've tended to have a very GP-centric view. We're not as interested as we could be in responding to what people tell us.
However, one idea for improving things is that we start to work towards community development. We could use outreach workers to tell us what patients' real needs are.
This is what we're exploring in the NHS Alliance´s new publication Whose NHS is it Anyway? Sharing the Power with Patients and the Public. We could also make more use of LINks – local involvement networks, getting them to feed back from local people to the PCT.
On the whole, it's not that difficult. It's possible to get the data. The difficulty is in responding. There are disincentives to primary care getting involved.
A lot of hard-to-reach groups are not registered and getting paid for treating them isn't easy. You need a GP commissioner who is willing to take it on in spite of these difficulties.
PB The main role for GP-led commissioning will be to try to save current excess spend in the acute sector and redirect it into community and primary care services with a focus on prevention and self-management.
I doubt whether this will have any real impact on health inequalities. As we all know it depends much more on financial and educational factors. Unfortunately, good health as an outcome is not a good enough incentive for deprived patients.
We can make services more accessible through GP-led commissioning but whether patients wish to take it up is another matter. The inverse-care law is still a fact of life. There are two ways to look at life: look after today and tomorrow will look after itself – or live for today because tomorrow may never come. The strength of the GP is that they realise there's more to health than medicine.
Is there anything in the new Government's plans for the health service that you think will give GP commissioners more power to help hard-to-reach groups of patients?
JK It is going to be more important to get the right quality and amount of contracted health care practitioners in those areas through primary care contracts. This is what PMS/APMS was designed to do, and should be the focus of PCT commissioning. GP commissioning can then support those healthcare practitioners once they are in place.
JA The proposals to give GP commissioners hard budgets will incentivise GPs to think about how to manage hard-to-reach and hard-to-engage groups. People with long-term conditions, for example, often need the kind of integrated health and social care services that are not traditionally provided in our local health economies.
Enabling GPs and social care commissioners to develop close partnerships and to implement personal health and social care budgets could really empower people to make better informed decisions about how they use local resources and services.
BF The new Government says it wants commissioning to be more local, which is a good sign.
There's also something in the big society idea – thinking about how to work with communities – that is hopeful too. I think giving all GPs budgets will also be helpful but only if the governance of GP commissioning groups encourages it. The governance has to say: ‘This is what commissioning looks like. It involves making contact with the groups that are hard to reach and also those who are hard to hear – as well as the rest of the patients on your list.'
MD The Government is very committed to outcomes and to equality of outcomes for all. Ergo, care for hard-to-reach groups should be improved.
The way it will happen is through the GP commissioning groups and this is how it will differ from the days of fundholding, when a small minority of practices actually rejected patients because they were too expensive to treat. If you've got a budget for all the people in the locality, as consortiums will have, you don't start picking and choosing.
I also hope that the budgets will take account of levels of deprivation and build in some money for tackling the harder-to-reach patients so as to make sure there is more of a level playing field.
Alisdair Stirling is a freelance journalist
Commissioning for deprived areas: 'GPs' strength is that they know their localities and understand what the community needs' Commissioning for deprived areas: 'GPs' strength is that they know their localities and understand what the community needs' Experts
