The Real Deal
By William Little
With the dust at last starting to settle in the debate on primary care-led
healthcare, confusion remains over how the reforms will work in practice.
When NHS Confederation chief executive Dr Gill Morgan told a confused Commons health select committee hearing last month that 'we are now clear that provision will stay with primary care trusts', MPs breathed a sigh of relief. Someone had at last managed to make sense of the bewildering array of letters and notices coming from the government about the future of PCT commissioning and provision.
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More information
Most patients unable to access GUM in 48 hours
Health Service Journal, Helen Mooney
Published: 15/09/2005 , Volume II5, No. 5973 Page 8
“Less than half of all patients are able to access genito-urinary medicine clinics within 48 hours, according to figures published last week by the Health Protection Agency. The HPA's bi-annual GUM waiting times report highlights a deteriorating picture of access to sexual health services in many parts of the country, with only 40 per cent of patients nationally accessing services within the recommended time.”
Mapping the Issues - Transmitted Diseases in the United Kingdom 2005
Health Protection Agency (2005)
“This 2005 annual surveillance report for the United Kingdom describes a worrying situation with undiminished and high levels of transmission of HIV and other sexually transmitted infections among men who have sex with men, a steady increase in the number of HIV-infected black Africans in the UK, limited but compelling evidence that heterosexual transmission of HIV within the UK is slowly rising, and continuing high transmission of other STIs, especially chlamydia among young people. The report summarises current surveillance information on HIV and STIs, as well as some of the behaviours underlying transmission, and shows the distribution of the problem across different areas of the country.”
How to make local partnerships work
Health Service Journal, Linda Pollard and Peter Noble
Published: 03/11/2005 Volume 115 No. 5980 Pages 28, 29
“….a report on a summit that brought together regional agencies with a combined spend of £6.3m. In summer 2004, a small think tank of senior officers from the regional government office, West Yorkshire strategic health authority and Leeds University considered how, by working together in new ways, organisations could tackle problems more effectively in partnership, and with a real local impact. In West Yorkshire , chief officers across a range of public and private organisations have been involving key decision makers more directly in the partnership process to secure greater sustainable development of health and wealth for local people .”
Best supporting role
NHS Magazine ( 25/11/05 )
“… in the capital, the South London HIV Partnership is a collaboration between the Terrence Higgins Trust (THT), Positive Place and 10 PCTs and local authority service commissioners, offering a variety of HIV services through a single contact point, the THT helpline.”
Review of Transfer of Undertakings Protection of Employment, Regulations 1981
Department of Trade and Industry (2001)
“This document sets out detailed background information and analysis in support of the proposals contained in the Government’s consultation document on reform of the Transfer of Undertakings (Protection of Employment) Regulations 1981 (as amended) commonly known as the TUPE Regulations.”
Practice Based Commissioning Conference
13 th December 2005 Immarsat, London , EC1Y
“Driving up momentum and working towards full implementation ….With an accelerated timetable for full implementation, the universal roll-out of Practice Based Commissioning (PBC) is now a high priority on the primary care agenda. Against a rapidly ticking clock, enthusiasm and energies must be actively harnessed to grapple with the challenges of implementing a fully devolved commissioning system. Pressured to deliver rapid and effective results, local innovation, solutions and experiences must be shared for national success.
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10th November 2005
On 10 November HSJ published articles by Judith Smith of Birmingham University and Richard Smith of the King’s Fund on the future market in primary care. Here we publish longer versions of those articles as well as giving access to the papers that support them.
What is the future for primary care?
With a white paper on the horizon and proposals for the reorganisation of primary care trusts rushed through during the late summer, the government’s radical reforming zeal is set to engulf primary care. If root and branch change is on the way this seems to signify that, in the government’s mind at least, primary care as it currently stands is ‘broken’ and in need of major repair.
Primary care teams might be forgiven some surprise at this suggestion. After all, primary care is one of the most popular bits of the NHS among patients. Moreover, general practice has just implemented a sophisticated new quality improvement scheme with the startling achievement that the average practice team has met more than 90 per cent of the myriad quality indicators required of them.
Yes, there are weaknesses, most notably around access to routine GP visits. First, patients complained that they had to wait too long. Now, with advanced access appointments in short supply, patients are rightly upset that their wait is too short.
But these limitations aside, one might be forgiven for thinking that the fundamentals of primary care are in pretty good shape. The reformers, therefore, should be mindful to ensure that the medicine is not worse than the disease.
Of course, there is no room for complacency. Primary care can and must be improved, not least because the reforms to the rest of health system rely crucially on the primary care sector. In the new world of NHS markets and ever-tougher waiting time targets, primary care must deliver a wide range of services capable of decisively shifting care out of the hospital sector. In addition, practice teams must prove able to commission care with more sophistication than has so far been achieved by PCTs.
Primary care faces three main challenges if it is to successfully take on the role that is being created for it. First, is the issue of the variable quality of primary care. While many primary care teams offer comprehensive and excellent services, they sometimes do so cheek-by-jowl with practices offering only the bare minimum. This is particularly true in major cities such as London , even though it is nearly a quarter of a century since the Acheson report set out a comprehensive plan to tackle this problem.
The second challenge is to develop effective commissioning. So far, commissioning has proved to be the dog that has not barked. With a few honourable exceptions, PCTs have failed to address the domination of NHS trusts over the planning and delivery of care. PCTs have been largely unsuccessful in engaging their front-line professionals in the commissioning process. They now have little over a year in which to whip up enthusiasm, corral all of their practices into practice-based commissioning and develop the skills, techniques and information that will be essential to effective commissioning.
Unfortunately, the climate for this development in many areas is not terribly helpful. Getting practices to take a share of an underlying PCT budgetary deficit may prove a stretch for even the most persuasive of PCTs.
The final challenge is that of clinical integration, particularly with regard to the management of patients with long-term conditions. Overseas commentators sometimes remark on the ‘iron curtain’ that separates primary care professionals from specialist colleagues and competitive pressures introduced as part of the NHS market may serve to exacerbate this lack of integration.
So if these are the challenges, how might they be addressed? The first strategy could be to increase the contestability of primary care. In theory, of course, general practice is the most contestable part of the NHS; patients should be able to change their GP at will. In reality, of course, general practice has been largely protected from any real competition for patients. In some areas, this reflects a chronic shortage of doctors. In others, it appears something akin to a cartel where patients seeking to change practices without changing their address encounter a strange reluctance to accept them on the list.
Nor have many PCTs been very proactive in introducing more competition. Personal medical services (PMS) pilots have enabled PCTs to introduce new types of primary care provider since 1997, yet few have pursued this course energetically. Perhaps, it is now time to open the primary care market place to any willing provider able to meet agreed quality standards. Indeed, one might go further and end the preferred provider status of existing independent contractors, allowing PCTs to test the market periodically. After all, what other service provider can expect to keep a contract regardless of whether there is a better alternative waiting in the wings?
Some real competition among practices could help to redress the balance between the supplier and the consumer leading, one might expect, to more patient-sensitive services and access arrangements.
The second strategy could be to put some stronger incentives behind practice based commissioning. It is not terribly clear where practices’ responsibilities for an ‘indicative budget’ end and the PCT’s begin. Moreover, the benefits of practice based commissioning may not look terribly compelling when seen from the perspective of a practice: uncertain management support, savings that must be off-set against overspends three years into the future, and restrictions over what any savings might be spent on.
If practice-based commissioning is to have bite, it must involve the transfer of real financial risk to the practice. In return, practices must feel that they receive a proper reward for the effort to manage care that will be required. There is no reason for that reward not to include higher personal incomes for those involved, providing that their commissioning is successful and effectively regulated.
Of course, the converse should also be true; those practice commissioners that do not deliver what they have promised should feel it in the pocket. This degree of rigour will not suit all practices and certainly not right away. However, it could be the direction of travel and the more ambitious and competent practice commissioners should be facilitated to go down this route without delay.
Many practices will group together for commissioning purposes and will need to invest in high quality management. Spending money on the management of practice based commissioning is not, of itself, shameful, although this is sometimes implied.
Primary care needs to move away from its ‘cottage industry’ roots. The much admired managed care organisations in the US spend far more on management than we do in the UK . What is more important than the amount of money spent on management is the return on that investment in terms of better health and patient satisfaction. PCTs need to benchmark the performance of their practice based commissioners and use this information in setting challenging, but achievable, accountability agreements.
The next strategy is to re-examine public accountability in primary care. The rights of patients as consumers are not a satisfactory substitute for the right to be engaged in the design, delivery and monitoring of services. As commissioning powers are delegated to practice level and as ever more services are provided from primary care, new forms of accountability need to be introduced. The divestment of community health services by PCTs offers an opportunity to develop new ‘mutual’ organisations, with a formal stake offered to staff and to patients. After all, there is arguably a far more compelling case for foundation-style principles in primary care, where patients have long-term relationships with the team and continuous contact, than there is for hospitals.
The last strategy that might be adopted is that of promoting integrated care through the development of community-based, multi-specialty organisations. Such organisations could be ‘virtual’, based on collaborative agreements between hospitals and primary care about innovative ways of dividing their labour along the care pathway (and facilitated by the ‘unbundling’ of fees payable under payment by results).
However, there is no reason why they could not be real organisations where specialists and generalists work jointly to manage care within a global budget. Already, some PMS ‘plus’ have begun to explore this territory. More should follow now that practice based commissioning and payment by results are combining to offer powerful incentives for proactive care management.
Importantly, many of the reforms can be achieved within the structure of general practice as we know it or by building on its foundations. Indeed, they are perhaps not as radical as they may at first seem, bringing reality into line with the rhetoric that has long surrounded primary care.
But while we consider what needs to change, we should also be clear what should be left well alone. Our system of patient registration is the bedrock of continuous and comprehensive primary care. Tinkering with this would be fraught with difficulty; for example, who would take ultimate responsibility for chronic disease management if patients could register simultaneously at two practices. Abandoning patient registration altogether in favour of a highly competitive market fuelled by fees-for-service rather than capitation would be to lose the population focus that has been a much-envied characteristic of our system.
Of course, the healthcare outside hospitals white paper is a good opportunity to reflect on primary care’s areas for improvement. However, any reforming zeal should be tempered by an understanding that primary care is not fundamentally broken and we have much to be proud of.
Dr. Richard Lewis is Fellow in Health Policy at the King’s Fund. The King’s Fund’ new programme of work that will examine three critical aspects of the new NHS market - regulation, commissioning and primary care, and incentives. The series has been launched with an overview paper - NHS Market Futures: Exploring the impact of health service reforms [PDF] or visit the website.
To market, to market: what future for primary care?
NHS primary care is widely envied by international policy makers for its ability to offer cost-effective care whilst assuring good health outcomes. It is particularly valued for its strong gate-keeping function and its ability to offer continuity of care to patients registered with local practices, and a new GP contract that enables PCTs to agree specific levels of service to be delivered by practices according to a national quality framework.
It can however be argued that NHS primary care has become a little complacent in its position close to the top of world rankings, and that it is in fact in need of further change, particularly in relation to two factors. Firstly, it is clear from research evidence and from the recent Your Health, Your Care, Your Say consultation that many patients want a more responsive primary care service that offers improved access to care in a greater variety of locations based in the community. Secondly, the rising tide of chronic disease calls for new models of care for people living with complex long-term conditions – models of care for which traditional general practice is often not well-suited.
The opening up of a market in primary care is being mooted as a way of snapping primary care out of its current complacency. Through tendering for new forms of service provision, PCTs might place contracts with existing practices and with new private and voluntary sector organizations, providing competition and evoking a wider range of services delivered in new and different ways. Examples include primary care centres that open for longer hours and at weekends, community-based diagnostic and specialist care for long-term conditions, services tailored to the needs of groups such as teenagers and commuters, and practices offering email and phone consultations in addition to traditional face-to-face appointments.
Primary care has in fact always been a market of sorts, with independent GPs, dentists, pharmacists and optometrists working according to contracts held by the NHS. In the recent past, a new range of contract options has been made available to PCTs, and in some places, a more active primary care market is already in operation. For example, some PCTs have tendered for new forms of general medical services where practices have become vacant, or where marginalized groups are unable to access care within traditional general practice. A major policy and management question to be posed during the current white paper consultation is: why have few PCTs used these contract flexibilities and why has there been little challenge to existing models of care?
Commissioners need to get braver in how they approach contracting for primary care, being prepared to challenge local providers and use their funding power to exert more responsive and better integrated services. As well as needing an injection of courage, they need to develop a wider range of incentives to use in negotiations with practices and other providers. This might mean using current contract flexibilities more imaginatively, extending the GP contract to cover a more exacting range of non-clinical indicators of quality, and developing specific payments for new services. Policy-makers and commissioners will need to ensure that providers from all sectors are able to have a level playing-field in respect of staff terms and conditions, premises development funding, access to clinical governance, and involvement in PCT planning activity.
The opening up of a market in primary care offers significant opportunities to further improve NHS primary care. For patients, the possibility of a wider range of services delivered in a way that fits with people’s lifestyles, work and other commitments, and some exciting new models of integrated care based in the community for people with complex conditions. For providers, the opportunity to use skill-mix differently, extend existing services (and increase income), and use resources released from secondary care via practice-based commissioning to extend local service provision. For commissioners, it offers the chance to do some radical redesign of care outside hospitals, in turn enabling shifts of care across the wider health system.
There are however some very real risks associated with a more active market. A wider range of providers could mean fragmentation and duplication of care for patients unless secure and effective information flows can be assured. Similarly, the co-ordination of patients’ care could suffer unless commissioners are able to purchase effective pathways of care and incentivise strong partnership working across organizational boundaries –something that has been hard to achieve even within a relatively managed system. A further risk is that of an unholy scrap as providers compete for the scarce GPs, community nurses and allied health professionals in the NHS.
If the opportunities of the primary care market are to be realized and the risks averted, there is an overriding need for strong and explicit commissioning of primary care. This requires skills in market analysis, development and regulation, and effective governance of the local system and its resources. Only then will the weaknesses in the current system be addressed, and care made more responsive and better integrated for the needs of patients in the 21 st century NHS.
NHS primary care may not be very broken but it sure needs a degree of fixing if it is to be properly responsive to patients. Uncomfortable times lie ahead for those working in primary care – the benefits of the new GP contract (little out of hours work, rare weekend opening for practices) may prove to be short-lived if the market is opened up.
Judith Smith is senior lecturer at the Health Services Management Centre at the University of Birmingham . On 10 November, HSMC publishes a thinkpiece report ‘To market, to market: what future for primary care?’. Copies available from www.hsmc.bham.ac.uk/news/whatsnew.htm
