“Equity and Excellence: Liberating the NHS”: can GPCC really work and what are the consequences for General Practice?

1. “Equity and Excellence: Liberating the NHS”: can GPCC really work and what are the consequences for General Practice? Mark Pickard & John Field

2. 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

3. 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

4. 1984 NHS structure (Conservative)

5. 1990’s Community Care Act – Health authorities to manage their own budgets (Fund holding)1991 – 1st of 57 NHS Trusts established

6. 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

7. PCG’s (Labour) 1997-2002 • Fundholding replaced by PCG’s • York, Harrogate, Scarborough • Red Book replaced by PMS and nGMS contracts

8. 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

9. PCT’s and foundation trusts

10. 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

11. The NHS Political football

13. The White Paper 2010 • To devolve power from central govt to ‘patients & doctors’ to reduce bureaucracy, costs and targets to improve health outcomes

14. 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

15. 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

16. The Future !!

17. 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!!)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Can this work? • No choice – it is happening!! • The key isefficiencyand integration • From California to Torbay

26. 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.

27. 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

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

29. 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.

30. 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.

31. 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

32. 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

33. 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.

34. Torbay (Hitchen, 2005) • Patient survey • Choice of hospital low on agenda • Local hospital and good care most important

35. Can this work in York?

36. 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.

37. 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??

38. 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.

39. 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?

40. 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.

41. 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.

42. 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?

43. The GP Hotel?

44. 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.

45. The GP role • Potential for conflict of interest • Would need to put in a firewall between roles of commissioning and provider.

46. 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.

47. 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

48. 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

49. The risks to GP’s

50. 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!!!