Choice, change and community service

Choice, change and community service

For the past few years, government health reforms have placed great emphasis on the need to shift health service provision out of hospitals and into the community, nearer to patients’ homes. In July, the Darzi Review provided a framework to accelerate this process. The subsequent publication of ‘Our vision for Primary and Community Care’, a subset of the NHS Next Stages Review, details how this will be implemented. Is it another example of where reform meets rhetoric? Pf reports.

This summer, the Department of Health followed up the publication of its NHS Next Stage Review by unveiling new plans for the development of primary and community care. The publication of ‘Our Vision for Primary and Community Care’ forms a central component of Lord Darzi’s Next Stage proposals, and further extends the rationale that providing ‘choice’ to patients is critical to delivering healthier outcomes.

The DH proposals are part of a wider commitment to ensure high-quality care for all that experience primary and community care. In a modern and evolving society where health inequality remains rife and economic pressures vary from postcode to postcode, the DH’s challenge is laudable yet ambitious. In the information age, where the speed of therapeutic advancements is matched only by rising expectation, achieving health equality within the tight financial constraints of the NHS budget will be no easy task. ‘Our Vision for Primary and Community Care’ lays down a framework to help realise the government’s lofty ambitions for primary and community care.

Its conclusions are divided into four broad themes:
• People shaping services
• Promoting healthy lives
• Continuously improving quality
• Leading local change.

People shaping services

The measures outlined in the report vow to promote ‘personal and responsive services that listen to and act on patient views’. To this end, the DH is developing its GP patient survey to allow patients a greater say in whether their practices are providing a good patient experience – are they fast, efficient, convenient and high-quality? Furthermore, patients will be given a greater choice of GP practice, and better information to help them make that choice. Performance and quality information will be made available online through the NHS Choices website, and will enable patients to compare GP and community healthcare services, as well as give their own feedback. In tandem, GPs will be offered better rewards for providing responsive, accessible and high-quality services.

Special provision has been made for patients with long-term conditions. By 2010, 15 million people with long-term conditions will be offered their own personalised care plan. “Named lead professionals will help ensure that plans are tailored to support the needs of those with the most complex care needs,” the report promises. In addition, a ‘Patient’s Prospectus’ will help support individuals who want to take greater control of how they manage their long-term conditions – with plans to pilot a scheme to provide individualised personal budgets.

Promoting healthy lives

According to the proposals, the NHS will work with local government, the third sector and the independent sector to promote health and wellbeing in local communities. A ‘suite of indicators’ will be developed to help PCTs, local authorities and PBC Groups to measure and incentivise improvements. Crucially, the government proposes a range of primary and community care services to help support people in staying healthy. These include:
• Health visitors in the new Child Health Promotion Programme
• Community nurses to help older people remain healthy
• Piloting integrated access to musculoskeletal, psychological and other services to help people return to work more quickly
• A range of healthy living services to help people give up smoking, control alcohol abuse and improve diet and exercise.

These initiatives provide an undoubted opportunity for pharmaceutical companies, where appropriate, to partner with PCTs and local authorities to support implementation. Once again, from a commercial point of view, understanding the health needs of local communities and working in collaboration with PBC groups to improve health outcomes will reap dividends.

To support these initiatives, the report promises to improve the Quality and Outcomes Framework to provide better incentives for maintaining good health as well as good care.

Greater emphasis on commissioning better services again provides opportunity for pharma companies to collaborate with the NHS

Continuously improving quality

‘Our vision for primary and community care’ proposes the introduction of a programme of professional development to strengthen clinical leadership and skills for community nurses, health visitors and allied health professionals. This will, it claims, also release more time for direct patient care. In addition, the DH will pilot information tools to compare clinical quality, clinical productivity and patient experience in community health services. This effort is designed to align with the themes outlined in the NHS Next Stage Review, which promised High Quality Health for All. To support the aims, new tariffs will be developed to improve the commissioning and delivery of services, and to encourage more healthcare to be provided in community settings – a central motif of NHS reform over the past decade. Another mainstay of recent reform rhetoric has been a focus on improving health outcomes. To this effect, the new proposals say the DH will work with professional and patient groups, and with NICE to create ‘an independent, transparent process for developing and reviewing the indicators in the Quality and Outcomes Framework… and focus resources on health outcomes and quality.’

Leading local change

The final theme of the proposals promises to support PCTs and clinicians in making local decisions on how to develop more integrated primary and community care services. At the heart of this, the ongoing development of practice-based commissioning remains critical. According to the plans, PBC groups will be entitled to improved information and management, and financial support – for which PCTs will be held to account through the world-class commissioning assurance system.

“PCTs, as the local leaders of the NHS and strategic commissioners of health and healthcare for their population, will give increasing power and responsibility to high-performing, multi-professional PBC groups that achieve better health outcomes for local patients in a transparent and accountable way,” the report notes. Significantly, it will pilot new ways of allowing primary, community and hospital clinicians and social care organisations to provide more integrated services for patients, including the formation of new integrated care organisations. This greater emphasis on commissioning better services again provides opportunity for pharmaceutical companies to collaborate with the NHS.

The response

Reaction to the publication of the report has been positive, though the size of the challenge ahead cannot be underestimated. The respected charity and health thinktank, the King’s Fund, welcomed the emphasis of the report, but criticised its failure to address out of hours care. “Patients place enormous value on the care they receive from family doctors and community staff, but a step change in these services is needed – not least because the reforms to the rest of the health system rely crucially upon them,” said Niall Dickson, Chief Executive of the King’s Fund. “This strategy lays down an important challenge to the professionals involved – the future lies in changing the nature of services so that they are geared more to helping keep patients as healthy as possible, rather than just treating their illnesses. However, out of hours care has not been addressed in the review. This is a major omission given the poor way it has been handled in recent years. Patients should not have to wait for another ‘once in a generation review’ to see this tackled.”

The King’s Fund also criticised current progress with PBC and said that this initiative would be pivotal to the prospective success of many of the report’s key objectives. “Current evidence shows a lack of progress with practice-based commissioning and a lack of overall GP involvement in the scheme,” said Dr Nick Goodwin, Senior Fellow at the King’s Fund. “The evidence suggests GPs are more interested in providing services rather than commissioning them and some PCTs are less supportive of PBC. Whilst the strategy to hold PCTs to account for the quality of their support, our research has found that PCTs themselves need more capacity to provide such a role effectively. In particular, the quality of data on which to give GP commissioners real budgets is in some cases so poor this would not actually be possible. Better articulation of the practice-based commissioner’s dual role as a commissioner and provider is essential to manage inherent conflicts of interest. Until PBC really gets off the ground, the jury is still out on whether it can achieve all its objectives.”

Once again, for the drug industry, the opportunity to offer support to PCTs struggling with a lack of capacity is clear. As previously reported in Pf, the industry certainly has much to offer in the areas of service redesign, while its own expertise in handling data and developing health outcomes models could provide real value for the NHS.

Finally, the King’s Fund also urges caution with Integrated Care Pilots, and fears that they may end up reducing, rather than increasing, patient choice. “The principle of better care integration between primary, community and social care implies a welcome move to a better continuity of care, a more personalised service and more efficient care coordination for patients. However, there is a tension between integrating care across community, primary and secondary services on the one hand, whilst on the other, promising patients in the draft constitution the right of greater choice not only over treatment but over providers. If integrated care organisations are also commissioners of care, there is a potential conflict of interest which could reduce patient choice rather than increase it. The government’s plans to test the benefits of integrated care through pilots must be accompanied by robust evaluation of its risks as well as its benefits.”

The DH is to publish a series of newsletters to set out some of the key policies and programmes underpinning the vision for primary and community care .The first issue was published this month and is available for download at www.dh.gov.uk along with a full copy of the report ‘Our Vision for Primary and Community Care’.

The BMA, however, was less enthusiastic about the proposals, slating what it described as ‘petty swipes’ at family doctors and citing GPs’ lack of trust in the government’s ability to run the NHS. “While many of the ambitions within the government’s Vision for Primary and Community Care are welcome, previously announced proposals will undermine the positive in this report,” it said. “Unfortunately, the government’s recent behaviour towards GPs has destroyed any trust they had in the government’s ability to run the NHS. GPs are a key part of the health workforce and rather than take petty swipes at family doctors, as Ben Bradshaw (Minister of Health) has done, the government would be much better off working with us than against us. We want to see General Practice be the best it can be for patients. While we welcome the good notions in this report, we are still to be convinced that previous announcements, and by that I mean the polyclinic agenda, will do anything other than damage general practice and continuity of care for patients. Choice of a GP is a good thing for patients, but unnecessary and potentially destructive competition ends up wasting NHS resources. We know every PCT has to build a ‘GP-led health centre’ or ‘polyclinic’ if they want any new money to invest in primary care. GPs and the one and a quarter million patients who signed our petition want to know why that money can’t be used to improve existing practices. Lack of investment is the reason why patients in some areas have trouble registering with new surgeries. A practice may be full to bursting but when they ask the local PCT for money to expand, they are told there is none. We hope the £250 million extra investment promised by Darzi, which is very welcome, is spent wisely.”

Clearly emotions run high among health professionals as the substantial wave of health reform intensifies. Undoubtedly there are opportunities for pharma to support implementation of these reforms and, in the process, help the NHS deliver its targets for the good of patients. Community service could be the way forward for pharma.