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1st October 2013 

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News and Comment from Roy Lilley
I was chatting with a very senior GP.  Not the usual; 'nothing can change' type.  This was a thoughtful, working, policy savvy man whose experience and intuition I trust.

 

He said the muddle the LaLite reforms have created means we have lost a main chance to reorganise primary care. 

 

He is right; giving GPs the opportunity to commission healthcare has reinforced the pre-eminence of the practice.  CCGs are little more than clubs for the proprietors of the very units of healthcare delivery that are the barriers to real, step-change.

 

Around 90% of all NHS contacts take place in Primary Care.   This one fact, alone, is important because there is a policy push for GP practices to do more.  Ninety per cent of those who use primary care will be diagnosed and treated without being referred to secondary care.  It is for that reason GP practices can't do any more; they are choc-a-bloc with the day job that they are designed for.

 

However, the trends are clear; primary care must do more heavy lifting but will need steroids to do it. The practice unit will have to go the way of the corner-shop.  Today's chaotic care, where patients are bounced between primary and secondary care, social services and the support agencies has to end.  The interfaces are wasteful and the results haphazard.

 

Business would look at its supply-chain, end-2-end.  We have to look at ours.  From Band-Aid to bedside and back again. 

 

If healthcare delivery is to change we have to change the way GPs are organised.  Patients with long-term conditions are clogging up secondary care.  They shouldn't get anywhere near the front door of the hospital.  A much higher level of integration and consolidation is required. 

 

Integrated care pathways can only be delivered by Integrated Practice Units; actual and virtual services side-by-side. We have to think about IPUs treating disease and the related conditions, complications, and the wider circumstances that commonly occur with them.  Think about kidney and eye disorders for patients with diabetes, or palliative care for those with metastatic cancers.

 

IPUs could provide treatment and assume responsibility for the whole family by providing education and counselling, encouraging treatment, compliance and prevention.  Being part of the family to support behavioural changes such as smoking cessation or weight loss.  IPUs are not a medical model.  They are a community model.

 

This is a radical change that may mean the GP is no longer preeminent and no longer owns the business.  The services might be owned by community cooperatives, local authorities, the private sector or social enterprises of staff and patients.  They might even be owned by secondary care.  It will mean social services will no longer be part of local government.  They will become players in this new approach with a much greater say, focussed on admission avoidance.

 

Students of international healthcare models will know this is very like the Virginia Mason, Seattle model.  It works there because primary care in the US is poor.  It works there for the same reasons it will work here, it is an in-yer-face logical solution where primary care is poor or can't cope.

 

We measure primary care inputs but apart from clunky QoF, don't really have any idea of outcomes.  If we don't systematically track, compare and measure outcomes, safety and satisfaction we might as well stand in a bandage factory tearing up ten pound notes. 

 

All that matters for patients is return to function.  If we have no measures for that we might as well employ witch-doctors.  Patients want the 'Get-Go'; Get in, Get diagnosed, Get fixed up, Get out, Get on with their lives and never Go back.  Shouldn't we find out if we do it?

 

The defining factor of post credit crunch healthcare is cost.  The absence of accurate primary care outcome costing is perplexing.   Costs keep going up and there is no real idea what to do.  If care pathways are interdependent so, too, should the funding and costing methods, encouraging shared budgets, risks and discouraging cost shifting and encouraging team efforts.

 

Redistributing care might mean diabetics are seen by a diabetes team and never see a GP.  We don't lack the technology for entire care pathways to be conducted on-line.  We lack the will.

 

The future of primary care will not be defined by the costs we absorb or the investment we make in it.  It will be defined by the value we can extract from it.

 

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