Primary Care Based Commissioning
The Answer lies in Outpatients
• Herts “Investing In Your Health” plan assumes there is a transfer of activity from Secondary to Primary Care. Similar plans exist in other Health Authority areas.
• Payment by Results needs G.P.s to validate the data.
• Choice and Choose & Book are with us.
• New Estates Strategy is under way. This will attempt to develop services such as polyclinics and Diagnostic and Treatment Centres.
• Need to reduce casualty use.
What G.P.s see for PBC now:
The current plan for PBC excludes outpatient services and casualty attendances, and only includes elective operations. Since G.P.s cannot book operations without the first outpatient attendance, the current PBC model has limited appeal for G.P.s, quite apart from little concrete evidence of a management allowance to run with it. PBC seems weaker than Fundholding in its approach and has more limitations than that scheme. There seems little in it for practices and their patients.
The Technical Guidance on PBC is so brief that it is neither technical nor guidance, so it seems PCTs can develop their own models.
Over the last few months government policy has become more overt. The Shipman Report may have outed the Government on its unwritten policy that bigger practices are better. Jo Whitehead, of the Department of Health, outlined the policy at Practice Based Commissioning Conference Hammersmith on 10th March The G.P. "list" would go, there would be walk-in centres and G.P.s would be in large practices of at least 10 doctors. This is already in play; in 2004 the number of single-handed practices collapsed, by more the fall throughout the previous decade, from 2,578 to 1,918. The overall number of G.P. practices fell by 291, the largest fall since 1994. The new vision is:
There will be three levels of Primary Care:
• Tier 1 – non registered access (i.e. walk-in centres)
• Tier 2 – registered access for LTC/serious episodes of care
Diagnostics and treatments: typically 10+ GPs?
• Tier 3 – Access to a specialist, diagnostics, outpatient attendance, pathology, and day-case surgery.
Whilst the medical press has been cross about the implied demise of small practices, they have missed the huge opportunity offered by Tier 2, and particularly Tier 3 where outpatients is now to be part of Primary Care.
Idea to Discuss:
All local G.P.s form an APMS company to run CURRENT outpatient services.
Why take this route in PBC? Because other methods to reconfigure health services failed in the past. We heard all the wonderful things that “PBC” could do back in the Fundholding era. We seem to be in a time warp. Commissioning and contracting produced little change to the structures of the Health Service then, so why should it now? Fundholding shifted the power for a short while, but the mechanism to shift resources and restructure services failed. One could argue that Fundholding had not had enough time to bed in. However the same forces of resistance that caused the demise of Fundholding would be applied to PBC and Payment by Results as a whole. PBC would fail if we simply followed a commissioning model on its own. One of the reasons that Fundholding was abolished was due to the tensions of the purchaser/provider divide within a fixed budget economy.
G.P.s owning and managing outpatients, through a new APMS, would fit with Government policy, and be more likely to create change than relying on practice budget setting and contracting processes alone. If it is sensible and economic to move the physical location of these services to new centres, then we would do so over time.
The outpatient service is grossly inefficient. Although there are more doctors, nurses and clerical staff, outpatients cannot even cope with the throughput of an average general practice. Patients and G.P.s are not very happy. Both seem to get little out of it, especially from follow up attendances. I have no evidence for that assertion as yet….references appreciated!
• The role of outpatients is help G.P.s manage patients. It is almost part of the education process for G.P.s. It is not a system for consultants to develop their own lists.
• Outpatients are a training tool for hospital staff and G.P.s, but are poor at this role.
• The follow-up ratio has remained constant since 1948: three to one.
• The number of new patients seen by consultants has fallen every year since 1948.
• Lack of access to outpatients and diagnostic facilities FUELS the use of A & E departments.
• Outpatients are aeons behind in the use of I.T. G.P. input would help the LSP/NPfIT make an impact.
Primary Care needs to wrest the management and budget of outpatients from the local Trust, so that we can really reconfigure services. As an APMS there would be a real incentive keep costs down.
Waiting until we develop new facilities would be almost capital-based planning. Changing buildings is one thing; we need to change systems first; this would be quicker but harder work. DacDoc showed that local G.P.s can run companies to manage local services.
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