“Equity and Excellence: Liberating the NHS”: can GPCC really work and what

are the consequences for General Practice?

Mark Pickard & John Field

Aims & Objectives

• The NHS history• The White Paper• The GP Consortia• Can this work? From California to Torbay• Can this work in York?• The handover• The benefits and risks for General Practice

The NHS political History

• 1948 – Bevan (Labour)• Hospitals, Doctors, Nurses, Pharmacists all under 1

umbrella

• 1952 – Prescription charges (Conservative)• 1962 – Enoch Powell (Conservative)

• NHS split into Hospitals, Local Health authorities and GP

1984 NHS structure (Conservative)

1990’s Community Care Act – Health authorities to manage their own budgets (Fund holding)1991 – 1st of 57 NHS Trusts established

GP Fundholding (Conservative 1990’s)

• Budgets given to individual practices• Opportunity to use alternative providers

• eg. Opthalmology Scarborough• eg. DN’s team at Priory Medical

• GP’s involved in management decisions and financial planning

• Political decision to change

PCG’s (Labour) 1997-2002

• Fundholding replaced by PCG’s• York, Harrogate, Scarborough

• Red Book replaced by PMS and nGMS contracts

The NHS (Labour)

• 2000 – The NHS Plan• Increased funding and reform to eliminate geographical

inequalities, improve standards and increase patient choice.

• 2002 – PCT’s launched (Amalgamated PCG’s)• 80% of NHS budget, contracting of services• Payment by results (PBR)/tariffs• 4 hour A&E target

• 2004 – Foundation trusts launched• Run by local managers, staff and members of the public• More operational and financial freedom

PCT’s and foundation trusts

The NHS

• 2006 – At least 4 provider choice• 2008 – Free choice, any provider

• 18 week waiting list target

• 2009 – Care Quality Commission launched• To regulate health, mental health and social care• Need CQC approval/inspection to set up a service

• 2010 – THE WHITE PAPER “Equity and Excellence” (Con Dem Coalition)

• Lansley shadow health minister for 7 yrs• Not in manifesto & not discussed during campaign

The NHS Political football

The White Paper 2010

• To devolve power from central govt to ‘patients & doctors’ to reduce bureaucracy, costs and targets to improve health outcomes

The White Paper 2010

• Discard the PCT’s and SHA’s• Put in place a commissioning board• Oversee GP consortia (?300-500)• Commission services from a number of

providers to be more streamlined & aligned with patients needs

The White Paper 2010

• Putting patients & the public 1st

• Discard targets (Target driven/Labour)• Improve Quality (Outcome driven/coalition)

• NICE, develop standard tariffs

• Reform QoF• Joining up of Health and Social care• Regulation

• Quality care commission, Monitor

The Future !!

GP Consortia (Size?)• A GP led commissioning group• Sufficient geographic focus to agree and monitor

locally based contracts.• Big enough to take on risk

• Impact of a £200,000 ICU stay on 50,000 patient consortia to one of 300,000??

• Hold 80% NHS budget• Hard budget

• Need to be financially balanced• Make a saving & keep the money• But make a loss (ehmm!!)

GP consortia (size?)

• Government suggested 100,000 patients• RCGP suggested 500,000 patients

• Pool risk and create economies of scale

• North Yorkshire and York PCT = 800,000• Vale of York GPCC transition team

• York, Selby, Easingwold, Terrington, Kirbymoorside, Pocklington• 326,000 patients

GP Consortia

• Can commission from external organisations, including local authorities, private and voluntary sector bodies. (Choice!)

• Shadow PCT 2011-2012• Take over 2013.• Responsible for OOH commissioning• 86% consortia ‘Pathfinders’

• ….i.e have written the letter

Money, Money, Money

• NHS budget £110 billion• NY & York PCT £1.3 bn• Nationally the reforms will cost £1.4 bn

(redundancy of 40% PCT & SHA staff leaving)• Hope to recoup this within 2 yrs on salary

savings and then save £1.7 bn per yr.• 45% less money available for management

envelope for GPCC compared to what PCT received

QIPP(Quality, Innovation, Productivity, Prevention)

• NY & York PCT 2010• £250 million Primary Care• £900 million Secondary care

• How the GPCC can save money• Commission MSK services• Levels of care (1 to 5)• Unscheduled care• Referral reviews• Prescribing reviews• Care pathways

The NHS Trusts (Hospitals)

• All NHS trusts will become Foundation Trusts• Cap on earnings from private sector abolished

• Surgical PLC (lets make some money!!)

• Private sector to compete for services• Ramsey/Bupa/Virgin Healthcare

Differing opinions

• “What do you call a government that embarks on the biggest upheaval of the NHS in its 63 yr history, at breakneck speed & while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be : MAD

• BMJ 2010; 342

Differing opinions

• “If Mr Lansley’s vision is right and if GPs are guided by patient centred values when they provide & commission care for patients, then we will have health service to be truly proud of. This is the challenge for general practice

• BMJ 2010; 341

Can this work?

• No choice – it is happening!!• The key is efficiency and integration• From California to Torbay

Kaiser Permanente

• Healthcare insurance company in USA• Founded 1945• 8.2 million patients, (NHS 45m)• Similar demographic population/ costs to NHS• Primary and secondary care physicians are

share holders.

Kaiser Permanente (Feachem et al, 2002)

• Compared KP and NHS• Costs very similar• KP had a 1/3 less use of acute hospital beds• 80% patients seen in secondary care in 2/52

with KP vs. 13/52 with NHS

Hospital bed utilisation in the NHS, Kaiser and US Medicare (Ham et al, 2003)

Group Number of bed days per admission

NHS Kaiser Medicare (US)

Stroke 27.08 4.26 6.53

COPD 9.87 3.79 5.37

Bronchitis or Asthma 11.73 3.09 4.41

Coronary bypass 13.27 9.60 9.98

Acute MI 9.39 4.35 5.46

Heart Failure 12.42 3.70 5.37

Angina 5.88 2.21 2.56

Hip replacement 12.60 4.54 5.46

Knee replacement 11.32 4.17 4.40

Hip Fracture 26.88 4.89 6.47

UTI 15.19 3.80 5.32

K.P. (Ham et al, 2003)

•Adjusted for age, KP again had a 1/3 less acute bed days compared to NHS•Due to lower admission rate but in particular due to shorter stays.

How achieved by Kaiser Permanente

• Integrated seamless primary, secondary care & social care

• Easy access to radiology, physio, OT, social care

• K.P. allows greater input by primary care physician to prevent admission and shorten any hospital admission.

Kaiser Permanente (Ham et al, 2003)

• If saving in bed days extrapolated to NHS pop.• 40 million bed days saved• £10 billion• 17% of NHS budget in 2003

Torbay (Hitchen, 2005)

• Embraced integrated primary and secondary care• One stop shop for Elderly in the community• One number for GP’s to use as physio, OT, social

workers and DN’s under 1 roof.• Used less emergency bed days than rest of SW• Also decrease in acute bed days• 750 bed days in 89-90• 520 bed days in 08-09

Torbay (Hitchen, 2005)

• Community discharge coordinator• Decreased referrals to hospital discharge

team by 56%• Collaboration/integration is the key• Competition over emphasised (particularly in

elderly population)• Competition may have a role in elective

surgery or diagnostics but not elderly care.

Torbay (Hitchen, 2005)

• Patient survey• Choice of hospital low on agenda• Local hospital and good care most important

Can this work in York?

York

• York has excellent primary care and consultant body at York hospital

• Many good links already in place with secondary care

• Improve efficiency and collaboration further.

York – Acute medicine• Recent work by Acute physicians on AMU to

improve acute care• Improving through put of patients.– TTO and medication preparation on admission so

does not delay discharge.– Utilisation of short stay ward for predicted 1 to 2 day

admissions.– Consultant review at or shortly after admission.– Specialist nurse to coordinate discharge and social

care.– BUT LEVELS OF CARE STEPPING DOWN TO??

York – Acute medicine

• DVT management has moved from medicine to A&E

• Fragmin given to patients with suspected DVT• USS arranged (same or next day)• If confirmed anticoagulation clinic take over

Mx• Extrapolate to primary care? Practice nurse

fragmin administration and open access GP USS slots to book same/next day.

Elderly care/Dementia care

• Increase community support• One stop OT/physio/DN/social care• Develop step down units to free acute beds

prior to possible home rehabilitation?

York - Radiology

• Increase GP access to radiology• May prevent admission?• ?Same day USS for DVT• ?Same day USS for biliary colic/acute cholecystitis• ?Targeted MRI for knees and only refer if

arthroscopy indicated (Open access arthroscopy)• ? CT abdomen for non specific abdominal pain.

York - Surgery

• Reduce acute urinary retention admission• DN/PN/GP to pass catheter and check U&E’s.• Thus avoiding initial admission • Refer for TWOC +/- TURP• Prevent re-admission for wound care/stoma

problems by employing community tissue viability nurse.

Surgery - Bariatric

• Should this service be offered?• Should this be debated again?• Negotiate with YH for open procedures• Bradford syndicate – 0% mortality over past 2

years for laparoscopic Roux-en-Y bariatric surgery.

• Is this an opportunity to discuss provider choice?

The GP Hotel?

The GP Health Village!

• Pharmacy and primary care in same place• The GP Hotel?

• Step down beds for rehabilitation• Long term Nursing beds (?CUE beds)• One stop OT/physio/DN/social care team• On site OGD/flexible sigmoidoscopy suite• Gym

– Health visitors in mornings– Physio rehab afternoons– Paying members evenings to promote healthy living.

The GP role

• Potential for conflict of interest• Would need to put in a firewall between roles

of commissioning and provider.

The GP superhero

• Elderly patient found by carers in morning after fall• Urgent direct access radiology CT head arranged

by GP – no acute bleed• Arrangements made for short stay in GP hotel,

avoiding acute admission.• Physio/OT/social input/assessment• If safe discharged home/ if not arrangements

made for appropriate NH placement.

The VoY GPCC

• Representatives from each practice/practices in each area reporting to GP consortia board.

• Potential to un-couple administration services across North Yorkshire

• Finance and Human resources to cover all North Yorkshire consortia to avoid duplication.

• This would create strong purchasing base

The GP consortium (The handover)

• A difficult time• Decreasing morale of the PCT• Need to bring on board PCT staff• Essential to understand existing PCT

tariffs/contracts before 2013 in order to commission services efficiently.

• Establish efficient/integrated care pathways

The risks to GP’s

The Risks to GP’s

• Long term– Blame shifted from Government to GP’s

(Education, FSA)– No Bail out for failing consortia– Doors opening for NHS privatisation!!!

Lets end on the positives!!!

• If managed well GP’s could have massive potential to improve patient care

• Stop NHS being a political football• Supports quality standards developed by NICE• Needs informed and understanding GP’s,

good local hospital(s) and services with efficient access – York is potentially ideally positioned

In summary

• More emphasis on integrated primary and secondary care.

• Develop efficient care pathways• Develop local unit/GP hotel• Less emphasis on competition.

Any Questions?