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