Read the full interview with Professor Chris Ham on GP contracts
GPs and integrated care
GPs really understand why integrated care is important, why there is fragmentation between GPs and hospitals and GPs and social care that get in the way and most of the GPs here at the Kings Fund would say ‘well done' to the organisation for getting involved with the Nuffield Trust in pushing for integrated care.
In clinical commissioning groups, they themselves will be able to push integration on the ground perhaps better than PCTs were able to. They will be able to do that, round frail elderly care for example, and a lot of that will be for people with specific conditions like COPD and diabetes which makes up so much of the work of a GP practice.
If a GP can call more easily on the support of community matrons, social care staff and have good access to specialist hospital teams to help them manage the demand of the ageing population with chronic disease that can only be a good thing. It is certainly something that they have argued in support of for a long time and integrated care should help them.
That said there are a lot of barriers to integrating care which doesn't make it easy for GPs or others to achieve a level of integration they we need.
Competition
There are risks, if we don't get the role of Monitor right and its too gung-ho in opening up the market to competition then there will be more fragmentation but I have been really encouraged by what I have heard [Monitor chief executive] David Bennett say in speeches over the last few months when he has said that he doesn't want Monitor to stop integrated care where it will bring benefits around the needs of older people and those with chronic conditions.
Payment systems
We need to be much smarter about payment systems to encourage integrated care than we have been. Payment by results for example does not work because it pays for widgets rather than continuity of care. We must to be much smarter about regulation through Monitor and the CQC. Why doesn't CQC regulate across a system of care in a borough or a county looking at how patients are moved between care in their homes, communities and different parts of the system rather than what it does at the moment which is looking at how a particular hospital or commissioning group is doing. So we need smart regulation to support integrated care, we need the right kind of incentives and above all we need to get those frontline clinicians: GPs, hospital specialists, social workers to talk to each other around the needs of patients.
Centralisation
We are at a point of significant danger for the NHS as a system because we are in transition and we don't yet have CCGs in a form that allows them to take on their full budgetary and commissioning responsibilities. So for the time-being at least we have [NHS chief executive] David Nicholson, as is entirely proper, at a national level exercising leadership which will look like a lot of central control but I don't think that until CCGs can take on their full responsibilities there is any alternative otherwise money will get out of kilter , waiting times and other key indicators will get worse and that would clearly be bad for the patients, for the government because it would be held accountable for it and any sensible management strategy during the transition will be holding things together from the centre until you are really confident CCGs can take on their full responsibilities. But if that continues beyond that point then the fears of the GP community will be realised and it will require the judgement of Solomon to decide when we are in the position that CCGs can be given much more autonomy to do what's right for their patients and populations.
