Apollo Medical Web Log

Passive Drinking

Many of you will be familiar with the phrase "getting your retaliation in first".  Well it happened to Sir Liam Donaldson, Chief Medical Officer for England, last weekend over his measured proposals to increase the price of alcohol to a minimum of 50p per unit to reduce deaths and hospital admissions and accrue a benefit of £1billion over ten years.  Forty-eight hours before, presenting the SMO's Annual Report, Sir Liam was comprehensively "duffed up" by Government and Conservative politicians, including the Prime Minister, in terms of "sensible drinkers should not have to pay for the excessive drinking of the minority", and 'taxes should be targetted at high alcohol drinks favoured by binge drinkers". 

Sir Liam refers to the second-hand effects of alcohol consumption as "passive drinking" but more complex than those for "passive smoking" and, as he says, the ban on smoking in public places which came into force in July 2007 was recommended in his 2002 Annual Report. 

What are the chances of a second victory for Sir Liam in the next 5 years?

Challenging the Citadel - Breaking the hospitals' grip on the NHS

In between teenage taxi duties,   half term gave us an opportunity to re-read Dr Howard Stoate MP and  Bryan Jones’s policy paper, published by the Fabian Society in 2006.  Dr Stoate has been a GP since 1982 and is a member of the House of Commons Select Committee. The authors refer to the dominance in all public and political discussions of hospitals and their future and the obstacles that this creates to changing healthcare delivery.They point out the incompatibility of the OHOCOS White Paper vision of a public health, prevention-focussed and primary care led NHS [endorsed by the Darzi Review] and the onward march of all hospitals to foundation status with its “flexibilities and freedoms”. With the autonomy to do so, foundation hospitals will inevitably resist any removal of beds, staffing, resources and specialties and their reprovision in the community.

The authors support the integrated care models  such as Kaiser Permanente and point out that the lack of structural/organisational barriers between the sectors promotes that integration.They would like to see single Care Trusts in place of Acute Foundation Trusts [give or take a structural change, this may indeed happen if the newly formed Community Health social enterprises form partnerships with Foundation Trusts].

Two years in advance of Darzi, the authors are strong advocates of what they are happy to call “polyclinics” which are seen as primary care facilities in which secondary specialists, GPs and Nurse practitioners, work together in teams alongside other family practitioners and therapists providing more cost effective alternative care to the local hospital. 10 % of acute nurses would be redeployed to work in the community on health prevention and disease management.

Perhaps the most striking recommendation is for every school to have a school nurse to champion the health agenda [in 2005, there were only 2,400 school nurses for the 25,300 schools in England]. Though the Government has this week in the strategy “Healthy Lives, Brighter Futures” promised to strengthen the child health workforce, the focus would appear to be on paediatric care.The paper lives up to its title and though it may be too late in this Parliament to influence Government it may strike a chord with others.

Many more than 5 a day

Scrolling through the Health Profile for England 2008 we came across some interesting comparative data on healthy eating, adult obesity and their links to other lifestyle factors. For example, people in Greece eat, on average, 423 kilos of fruit and vegetables a year (over 110 kilos more than any other EU country). The next 4 countries are all Southern Europe/Mediterranean Coastal. The EU average is 233 kilos and England  is 207 kilos (just below Slovenia and above Germany). 

However, adult obesity tells a different story.  People in England and Greece are comparable(23% and 22%), significantly higher than either France (9%) or Germany (14%).  Further, more people in Greece smoke (37% as against 25%) and children have less healthy teeth (2.2 decays rather 0.7).

We all know the dangers of selective use of statistics but in spite of what the data appears to say, our enthusiasm for 5 a day remains undimmed given England’s miserable performance on this measure.  Perhaps many more GPs should join the healthy living centres in making local fruit and vegetable box schemes available in their patient areas??

Individual Budgets and their Impact (continued)

Last week we considered two aspects of implementing personal budgets in the NHS, learning from the experience of the DH sponsored pilots and how to support and allow patients to use their budgets. 

This week we consider who might be eligible and how packages might be designed.

Eligibility

Experience from the evaluation of individual budgets for social care pilot projects suggests that service users in mental health and adults with a long term physical or learning disability are most likely to benefit and older people less so.  It is important to recognise that holding a budget is an opportunity and not an imposition and may not suit everyone.  There is a consensus that emergency and urgent care and elective procedures would not be appropriate for personal budgets.

Designing Care and Support Packages

The right to hold and use a budget is assumed to be incorporated into the design, planning and delivery of a package (health, social, psychological and recreational) which enables an individual with long-term and continuing needs to be relatively independent rather than passively dependent on services delivered to him or her.  Spot purchasing of services may occur eg. to obtain a service for which there would otherwise be a wait but will be exceptional.  A formal and funded care plan and package, regularly reviewed and updated, will provide a framework within which the co-ordinating professional - possibly a district nurse or community matron, the patient and family carers, can work together on equal terms.

The Individual Budget evaluation report concluded:

"Culture is the key to successful implementation - major shifts in staff and organisation culture, roles and responsibilities are required, backed with extensive training".

 

Individual Budgets and their Impact

The Health Bill, published by the DH last week, introduces pilot schemes for patients holding individual budgets and making direct payments for support and care from a provider of choice. This was first mooted in the NHS Plan 2000, repeated in OHOCOS in 2006, and promised in the Next Stage review by Lord Darzi.  He commented that:

“We need to learn how to support and allow eligible service users to design their care and support packages”.

We must assume that Lord Darzi chose his words carefully so we can use them to comment on the potential impact of individual budgets under four headings:

• need to learn
• how to support and allow

Further information on these two points below and in next week's blog we will report on:

•  eligible service users

• design  of care and support packages

Need to Learn

In spite of the strong political drive behind this initiative, the pilots must consider and provide effective solutions to issues of commissioning, funding, staffing and service design, not least the fundamental changes in relationships between professionals and cared for people in planning and service delivery. The assumed benefits of personal health budgets are:

• improved personal control and empowerment encourages self and shared care

• greater choice and responsiveness to needs are promoted

• patients actively involved in designing care packages improve cost effectiveness and reduce waste

• integration of health and social care is improved

• reduced emergency admissions and lengths of stay in hospital

How to support and allow

There are concerns from professionals that patients may spend money "unwisely” or on the ”wrong” services.This may reflect their own uncertainty in changing roles but also underlines that personal budget holders will need support in making the choices available to them and professionals will need training in helping to influence those choices without disempowering the patient.  Equally the menu of choice may be restricted and not include high cost medicines or complementary therapies.  Patients may need support from independent advocates/brokers in making their choices of care or care provider.

Log into our blog next week for part 2 of this topic!

Using technology to transform the patient experience of Primary Care

The Kings Fund report "Technology in the NHS" [2008] reviews the adoption of technologies and their impact on the patient experience in maintaining health, receiving care and managing a condition.The technologies include E Health [such as electronic communications and records],Telecare [continuous monitoring and risk management to enable independent living],Telemedicine [interactive audiovisual medical care through links between hospitals and GP surgeries, for example] and Telehealth monitoring[remote exchange of physiological data between a patient at home and clinicians in primary care to assist diagnosis and self care].

The report cites the Office of Communication's study of health, socio-economic and technology scenarios [2008] and develops the Age of Abundance scenario in 2018 which assumes a widespread availability, use and acceptance of technology to support clinician-patient relationships and those with carers and families. Examples in primary care could include home hubs, hand held devices, medical bracelets and smart medication.The future scenario is based on sustained economic growth and increasing health care funding [conditions not certain in the immediate future]. However the Darzi final report - 'High Quality Care for All' [2008] envisages a start being made through the SHA's statutory duty to promote innovation.

Clinical Judgement and Cash....

GPs and NHS Managers must dread making newspaper headlines and being ticked off by the BMA at the same time. Back in October, a modest initiative from Oxfordshire PCT suffered this double whammy. Faced with a rising and unexplained rate of referrals from GPs to secondary care, the PCT, as the funder and commissioner of the whole system, encouraged GP practices to look at their referral practices, apply some triage and find scope for reducing referrals.  A sum of £20,000 was available to each practice adopting [80 out of 82 practices] and implementing the scheme.The PCT estimated that full take up of the funding would cost £ 1.2m a year but the savings on the reduced rate of referrals could be £6m a year. Eminently sensible you might think but not to Dr Laurence Buckman of the BMA who described the policy as “money being given to me to not behave appropriately”. This message was echoed  by several newspapers in outraged tones as if clinical judgments were being compromised by cash - talk of “lining pockets” etc.

This story illustrates how difficult it is to change services and manage demand - both central objectives of this [and probably any] Government’s strategy for shifting care from secondary to primary settings. It is difficult enough engaging clinicians to support the strategy without an evidence base and this scheme makes a start. The reality is that the additional staff and system costs involved in setting up and sustaining the process would more than absorb the money offered to practices.  Perhaps the real issue is, how much of the £6m savings will be reinvested in primary care?

This is the last piece of 2008 so best wishes for Christmas and the New Year to all our readers.  Let’s get some discussion going in 2009. 

PBC - Where to next?

Two years ago, Apollo published a pamphlet on the likely consequences of Practice-based Commissioning. We focussed on the opportunities that PBC could bring in helping GPs and others to shape local care provision and, through collaboration between practices, to bid for and deliver a broader range of services. We outlined how we could give business, organisational and commercial support to these initiatives.  As we approach 2009, a major report on PBC from the King’s Fund, which carries the strap line question - “re-invigorate, replace or abandon?” bears our experience that whilst community-based services and our involvement in providing them through joint ventures has grown, PBC has not been as influential as we predicted.

DH concedes this in the Darzi review in committing to "re-define and reinvigorate” PBC and last week introduced the PBC Framework consultancy resource.

The King’s Fund report concludes that commissioning responsibilities should be defined and funded at three or more levels within a PCT area:

• At GP practice/primary health care team level, there should be real budgets [not retained at the PCT] for people with long term conditions, self-care and the advent of personalised budgets and plans, for example.

• At PBC cluster level, devolved budgets to organise a defined range of primary and community services with clusters being set up as private sector companies or social enterprises with the capacity and capability to perform this complex role effectively [with some scope for cluster companies to come together to organise shifts of care outside hospitals for larger populations].

• At PCT level, more strategic commissioning for public health, health inequalities, acute sector reconfigurations and care that crosses patient pathways such as urgent care and mental health.The PCT could only play this role through Local Strategic Partnerships with other public service commissioners and the provider community.

By realigning clinical, organisational and financial risks and responsibilities at each level of commissioning [and erecting appropriate Chinese walls between commissioning and providing firms], there would be greater clarity for all stakeholders, including Apollo, who want to support GPs in provider joint ventures.

Pharmacy White Paper and GP Dispensing

 A letter from a singlehanded dispensing GP in Suffolk, Dr Paul Thomas, throws an interesting light on the debate on the Pharmacy White Paper and the role of doctors in dispensing.  The White Paper "articulates a vision of pharmacy practice that supports healthy living and better care, expands access to clinical services and provides more support for people with long term conditions".

The Dispensing Doctors Association (DDA) representing 6,000 doctors in the UK in 1,300 practices are broadly supportive of these aims but fear that any change to the existing control of entry regulations would threaten the viability of GP dispensing and potentially reduce patient choice and lead to the loss of integrated medical and pharmaceutical services, and possible surgery closures, in rural areas.  Consequently, the DDA favour the no change option (which means rejecting the option that PCTs should commission dispsensing services).

Dr Thomas echoes these fears but wonders why rather than restricting doctor dispensing this should be an available choice for all patients rather than maintaining  pharmacies' "lucrative monopoly in state funded dispensing" created by Lloyd George nearly 100 years ago.

If there were to be change (which, in spite of the DDA seems likely) and Dr Thomas' proposal was taken up), PCTs could commission dispensing services through a competitive dialogue with pharmacies (both independent and corporate) and GPs (single practices and consortia) that maintained the advantages of current provision (especially in rural areas) but encouraged the increasing role of pharmacies in primary care provision.

Managing Change in Primary Care

The following 'Ten Commandments' (Kanter, Stein and Jick, 1992), are cited in a report "Bringing beneficial Change to St Elsewheres Medical Centre" by Xytal - about a 4 partner GP practice in Yeovil, with our comments in brackets: 

1. Analyse the organisation and its need for change (distinguish between strategic, tactical and operational changes).

2. Create a shared vision and common direction (need to articulate where a practice wants to be in five years in terms of structure, staffing, services, skill mix etc. Probably best achieved through a whole team process rather than the GP partners alone and evidence-based in terms of population needs, involvement of patients and carers, for example).

3. Separate from the past (not least because an attachment to the past can stifle innovation and fresh thinking.  Of course, there are and should be continuities - a practice's reputation and standing are major assets - but successful change management is about responding to [and sometimes anticipating] the business and professional environment that GP practices face).

4. Create a sense of urgency (ie. it is no time for ostriches - change takes time so we had better get on with it).

5. Support a strong leader (who must be a clinician but may or may not be the Senior Partner.  We know of practices where the Clinical Director [and change leader] is a nurse and a partner in the practice).

6. Line up political sponsorship (from the local NHS, practice based commissioning consortia,professional bodies who, without micro-managing practices, want confidence that practices know where they are going and have realistic plans for getting there).

7. Craft an implementation plan (if the change strategy is too high level it could disappear into the mists.  A plan should make changes to how practices operate, skill mix and working practices.  For example, the move to Personal Care Plans [and possibly individual budgets] for  people with chronic diseases/long term conditions will challenge how practitioners relate to patients).

8. Develop enabling structures (this applies to both corporate structures - the pros and cons of remaining a partnership or forming a limited company or setting up a joint venture with other practices and/or a private sector partner - structure is a function of purpose.  Within a practice team, the strategy and plan may require changes in roles and new skills and competences.  For example, Practice Managers need to identify opportunities for new business as well as ensuring that existing contract requirements are met).

9. Communicate, involve people and be honest (this complements the actions flowing from the other "Commandments".  The "honesty" point is about managing expectations about progress, timescales, affordability etc.  As well as being sensitive to how changes may bring resistance because people see threats to their jobs and interests,it is vital to maintain a forward pulse and well grounded optimism about the achievability of the vision).

10. Reinforce and institutionalise change (there is nothing more unsettling than living in a permanent revolution in which there is no certainty and clarity.  It would be self-indulgent of leaders who may be more comfortable with ambiguity to ignore the need to consolidate and make changes, practical and grounded).