During a recent visit to South Devon and Torbay the now-former health secretary, Andrew Lansley, was clear. ‘GPs have been asking for this for many years,’ he said. ‘It’s now over to you.’
Mr Lansley was right. Both GP fund-holding and practice-based commissioning were early – and somewhat clumsy – attempts at trying to achieve greater clinical involvement.
We have tinkered before, but we have never had this level of responsibility.
Things are different now and, 10 years on from practice-based commissioning, GPs are in the ascendant.
Whatever your view on the reforms (and the pragmatist in me says you usually have to take the rough with the smooth to achieve change), I welcome the opportunities Messrs Lansley and Hunt are giving to GPs like me. It is, I think, undeniable that we will have real influence over how services are delivered in our acute and community hospitals and clinics, making changes that really affect patient outcomes.
But there remains, for me, a lingering question. We may control the vast majority of the NHS budget, but do we have all the levers to achieve the change we want to see locally?
For me, patient experience is the key. To make this a reality we need to see the system as a whole and reduce the gaps between organisations. There is a gap that we cannot bridge at present, though, and that new ‘no man’s land’ is in primary care.
We know that primary care provision has always had a softer focus in the NHS. Only a few weeks ago, in the pages of Pulse, we saw speculation that LES funding could be about to fall further.
While it may not be LES funding that is the answer, there needs to be some system of investment to encourage GP providers to initiate or improve services. Personal influence may not be enough and, just as we use CQUIN payments for acute providers, other levers are needed.
Back in the days of practice-based commissioning, many GPs were genuinely enthused about innovation, backing schemes that even today we have failed to roll out across the NHS.
But, many failed business cases later, enthusiasm turned to gloom as colleagues speculated that the underlying problem was that it was safer, politically, to give money to NHS-run hospitals rather than use it, in tabloid parlance, ‘to line GPs’ pockets’.
A whole-system approach
It is not popular to invest public money in primary care and this has resulted in the system evolving ‘organically’ – or, if you listen to the critics, with no real planning to speak of. It may meet patients’ immediate needs, but such an approach will never allow the preventive or self-care agenda to be truly explored. Neither will it allow us to deal adequately with complex elderly patients so that they avoid trips to A&E and unplanned admissions. Add to this the need for more generalists in the NHS and it seems the pressure on GPs is likely to increase – not fall away.
If we don’t take a whole-system approach, primary care is in danger of being left behind in the race to join up services. There has been little work on mapping capacity in primary care, for instance, and over the years there has been a patchy but significant shift of work from secondary care. During this time there has been no overall primary care service redesign and no new contracting arrangements.
If primary care is to work well, there needs to be capacity for training, time to reflect to allow innovation and a culture of sharing learning. Of course, all this takes time; but it also takes will and authority.
While we in the CCG have the will and the time (although at times I wonder if I should move into the office), we don’t have the authority. Primary care commissioning rests with the NHS Commissioning Board local area team (LAT). This is where the role of the LAT director is key.
I understand the arguments around the need to separate primary care commissioning from the other forms of commissioning. But I really hope that our LAT director is someone who understands the dynamic I have spoken of above.
My great fear, and one that I know is shared by many colleagues up and down the country, is the great ‘what if?’. What if the LAT director doesn’t get the relationship between primary care and the rest of the system? What if they see their task as only to monitor performance? What then?
Unless LATs grasp the opportunity to look at the whole system, including primary care, we may have to accept that our vision of seamless care will not be truly achieved.
We can make real changes to care pathways, community hospitals and work closely with our social care colleagues to join up services.
But, unless CCGs and LATs are as one in their approach, we may be missing a trick. Are we really all in this together?
Dr Sam Barrell is clinical accountable officer for South Devon and Torbay CCG and a GP in Brixham