Forcing PCTs – and GP commissioners as their heirs – to separate commissioning of community services from provision is the wrong direction of travel, says Dr Donal Hynes, but this has given GPs a new opportunity to develop community services everyone wants, says Dr Joe McGilligan
The Transforming Community Services process was launched by the Department of Health in January 2009 and stated that PCTs must divest themselves of community services by 1 April 2011. We need to ask ourselves how this change helps the NHS become fit for its future purpose.
The challenge facing the NHS is to improve outcomes while enhancing the patient experience and remaining within budget.
But this challenge takes place against a backdrop of a growing elderly population as well as intensifying financial constraints. This – plus the ever-increasing sophistication and cost of treatments – makes one conclusion very clear. The NHS cannot survive without fundamental change.
That change is the responsibility of everyone. We have to move patients from being the passive recipient of reactive care to becoming a responsible partner in their own healthcare, which is a daunting challenge. Similarly, the change required of healthcare providers, especially us clinicians, is huge. The traditional approach where we provide discrete episodes of care is no longer appropriate.
We now need to be closely involved in the maintenance of health with the individual and to move away from being a paternalistic provider – all in the context of the person’s own community.
The movement of care out of hospitals into communities is fundamental to that direction of travel. The changes brought about through Transforming Community Services have simply not met this need.
Separation of commissioning from provision is an important principle in the world of business. But it may not be the best way to deliver a new model of healthcare that no longer provides discrete episodes of care at a certain tariff but is concerned with an ongoing relationship over a longer period.
To be effective, GP consortia – as the heirs of PCTs – will need to enhance community services hugely. Every aspect of care should be provided in the patient’s community – upstream and proactive.
But the insistence on strict separation of commissioning from provision is at odds with that vision. It acts as a barrier to care being provided in a wholly integrated partnership with patients.
GPs will have to decide whether the provision of upstream care is a cost-effective way ofpreventing high-cost care later.
Are the consortia providing care to avoid commissioning more expensive care? Are they commissioning proactive care? Or is the separation not relevant any more?
Now look at the timescale.
Most GPs recognise the vital importance of community-based services. They see their future success as dependent on the excellence of their upstream involvement in health maintenance. Community services will be pivotal to their success.
But the timescale means PCTs must divest themselves of their community services by the current financial year. And GP consortia are simply not yet advanced enough to take on the employment of this huge number of critical healthcare providers. So the general option has been to see them subsumed by acute trusts.
Is that a problem?
Yes. Acute foundation trusts are business-based providers of units of care where discrete episodes generate the income
that ensures their survival. These trusts will presumably be aware that upstream models of care will not enhance their prospects of survival.
So the current insistence on separation of commissioning from provision without facilitating integration with primary care, and on a hectic timescale, is wrong.
We need greater coherence in our strategy. Our population will demand it.
Dr Donal Hynes is a GP in Bridgwater, Somerset, and co-vice chair of the NHS Alliance
Now that we know we will be responsible for commissioning community services we will need to get a much better handle on what’s being delivered. At the moment we have no idea. If we know what contracts are in place we’ll know what to expect and how best to plan for it.
Those working in the community do a very important job and we need to get involved and support them because we all – GPs included – work in the community. We should all be part of one primary care team.
I do see where the critics of Transforming Community Services are coming from. But here in Surrey, we saw it as an opportunity to do exactly that – bring everyone working in the community together as one team.
Our local groups – as part of ESyDoc LLP, a practice-based commissioning partnership – have put in a request to become a social enterprise. We want to develop services in conjunction with the acute trust, rather than working against each other, to develop services that everyone wants.
ESyDoc will be the commissioning body for the social enterprise, and we have a provider arm, ESyHealth, which is going to work with the commissioning arm, to provide the community services.
I believe the model can be replicated elsewhere. It can be done if you can break down the boundaries and silo working.
I thoroughly believe there’s only one NHS – one organisation that needs to be managed appropriately. We have one pot of money and we need to use it more inventively.
Community services are important to GPs, but because the PCT paid the bills we had no influence. As GPs gain the responsibility for community services we will have much more influence and no longer have to leave it to PCTs to dictate how they are going to be provided.
This is our opportunity to commission the right services and put people who do the job in control of their own destinies.
Community services have always been provider driven, rather than commissioning driven. But the policy offers an opportunity to change this and demand what we need from providers.
It’s true that Transforming Community Services has meant things have changed quickly – and the decision to transfer provision to acute trusts is far from ideal. But this has been talked about for years – it’s not something new.
People always work to a deadline, no matter how far in advance they are told to do something, and PCTs waited until the last minute before acting and then made quick and sometimes rash decisions.
But decisions made now don’t have to be stuck to and I don’t think those made by PCTs now should be set in stone. There should be the means once GP commissioners have responsibility to revisit them and put any mistakes right.
The reforms announced in the NHS white paper mean we will need early adopters to find out what the potential problems are and how to solve them or prevent them. We don’t want to wait until the deadline to make everyone change, because we need early adopters to find out what will work and what won’t. If we do find issues it means not everyone will make the same mistakes.
Talks on community services started two years ago, so the timescale has been feasible. Unfortunately it’s one of those things that has never really been a priority on anyone’s agenda, and because of all the other changes in politics people put it on the back burner. But GPs shouldn’t hide away from it; we should have a bit more courage. Communities are always a soft target when it comes to cuts. But the community is where most work happens, so we need to ensure it is properly protected.
Dr Joe McGilligan is a GP in Redhill, Surrey, and chair of ESyDoc, a consortium of 20 practices covering 117,000 patients
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