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The Future of Primary
Care

A personal perspective
Chris Locke
Chief Executive, Nottinghamshire
Local Medical Committee Ltd.
Context
 Before the ‘Patient-led NHS’ we had the
  ‘Primary Care-led NHS’, but both concepts
  are still both largely aspirational;
 While 90 % of NHS patient contacts are
  with GP practices, when it comes to
  resources, it is still a ‘Secondary-care
  dominated NHS’.
‘Our Health, Our Care, Our Say’
   ‘Our Health, Our Care, Our Say’ put emphasis
    on care closer to home
   It empowered GPs to develop new patient
    pathways to offer more convenient and cost
    effective care for patients under PBC
   It envisaged a large shift of activity from
    secondary to primary care – patients would only
    go to hospital in future when all primary care
    options are exhausted.
Payment by Results
   PBR intended to bring down costs of secondary
    care
   ‘Money follows the patient’ but Trusts compete
    on quality/convenience not price
   Reference costs ensure activity costs kept under
    control
   Not having a tariff for primary care means PCTs
    free to commission more from GPs.
Practice based commissioning
Has this happened ? No. PBC has ‘stalled’.
Well documented reasons include:
 Poor activity data
 Failure of PCT/PBC Cluster relationships
 Failure to properly fund clinical time
 Failure to ‘unbundle’ tariffs
 Failure of GPs to establish effective new
  alternative provider organisations.
Practice based commissioning
Less well documented reasons:
 System inertia
 Lack of commissioning expertise
 Reluctance of PCTs to destabilise Trusts
 PCTs’ failure to identify and help develop
  new provider organisations
What about community services?
 ‘Commissioning a patient-led NHS’
  suggested they’d be put out to tender
 DH backtracked, spoke of ‘market testing’,
  equivocal about idea of community FTs,
  flirted with idea of social enterprises
 Now comfortable with ALMOs aspiring to
  become FTs, but GPs and private sector
  still have designs on some services
What about GP services?
   Much questioning of whether small business
    model is still fit for purpose
   Concerns about access used by govt. as excuse
    to introduce more competition
   ‘Our NHS, Our Future’ bringing one GP-led walk
    in centre to every PCT and 150 new APMS
    practices across the country (inc. three in
    Nottingham City) whether needed or not !
Competition
   Government wants plurality of providers, sees
    NHS as a ‘franchise’
   Procurement biased towards large companies
   As their monopoly eroded GPs have been forced
    to look at new business models
   GP consortia successful in tenders only because
    companies don’t have ‘relevant’ experience
New business models
New collaborative business models include:
 GP-led companies
 Multi practice partnerships or Federations
 Umbrella mutuals or social enterprises
 Co-located or ‘virtual’ practice
  associations
 Joint ventures between GPs and private
  sector (eg Virgin, Assura, Boots)
Potential Benefits
Potential benefits of collaboration include:
 Improved performance/quality through more
  efficient management, mutual support and peer
  pressure
 Reduced costs, due to economies of scale
 Increased range of services, due to pooling of
  resources and skills, and increased opportunities
  to expand due to sharing of business risks
Further new ideas
   ‘In sickness and in health’ (NHS Alliance)
    postulates case for integrated care
   They argue logical end point of services
    redesigned around patient is to create a primary
    care-led integrated care organisation (ICO)
   It will provide care close to home, through new
    breed of Consultant community specialists, and
    commission all other services, inc. redesigned
    unplanned/out of hours care
Integrated Care
 Integrated care will bring improved access
  across all strata of NHS
 Models based on “values rather than
  structures”
 Virtual health centres rather than polyclinics
 Hospitals deal with acute care only
 ICOs supported by patient empowerment,
  public health focus, and new Academy of
  Clinical Leadership.
Primary Care 2020?
 Universal standards of care in pluralistic
  franchised NHS (under independent board)
 Patient has free choice of providers (and
  budget for some forms of care)
 Element of private insurance/co-payment
 Health Maintenance Organisations
  commission services from Foundation
  Trusts, ICOs, Private companies and GP
  led MPPs/Federations/Social Enterprises.
Thought for the day

  “The average GP practice costs £150 per
  patient per year. That is less than the
  average cost for a single outpatient
  appointment in most specialties.”

  “In sickness and in health: achieving an integrated
  NHS”. (NHS Alliance April 2008.)

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The future of primary care

  • 1. The Future of Primary Care A personal perspective Chris Locke Chief Executive, Nottinghamshire Local Medical Committee Ltd.
  • 2. Context  Before the ‘Patient-led NHS’ we had the ‘Primary Care-led NHS’, but both concepts are still both largely aspirational;  While 90 % of NHS patient contacts are with GP practices, when it comes to resources, it is still a ‘Secondary-care dominated NHS’.
  • 3. ‘Our Health, Our Care, Our Say’  ‘Our Health, Our Care, Our Say’ put emphasis on care closer to home  It empowered GPs to develop new patient pathways to offer more convenient and cost effective care for patients under PBC  It envisaged a large shift of activity from secondary to primary care – patients would only go to hospital in future when all primary care options are exhausted.
  • 4. Payment by Results  PBR intended to bring down costs of secondary care  ‘Money follows the patient’ but Trusts compete on quality/convenience not price  Reference costs ensure activity costs kept under control  Not having a tariff for primary care means PCTs free to commission more from GPs.
  • 5. Practice based commissioning Has this happened ? No. PBC has ‘stalled’. Well documented reasons include:  Poor activity data  Failure of PCT/PBC Cluster relationships  Failure to properly fund clinical time  Failure to ‘unbundle’ tariffs  Failure of GPs to establish effective new alternative provider organisations.
  • 6. Practice based commissioning Less well documented reasons:  System inertia  Lack of commissioning expertise  Reluctance of PCTs to destabilise Trusts  PCTs’ failure to identify and help develop new provider organisations
  • 7. What about community services?  ‘Commissioning a patient-led NHS’ suggested they’d be put out to tender  DH backtracked, spoke of ‘market testing’, equivocal about idea of community FTs, flirted with idea of social enterprises  Now comfortable with ALMOs aspiring to become FTs, but GPs and private sector still have designs on some services
  • 8. What about GP services?  Much questioning of whether small business model is still fit for purpose  Concerns about access used by govt. as excuse to introduce more competition  ‘Our NHS, Our Future’ bringing one GP-led walk in centre to every PCT and 150 new APMS practices across the country (inc. three in Nottingham City) whether needed or not !
  • 9. Competition  Government wants plurality of providers, sees NHS as a ‘franchise’  Procurement biased towards large companies  As their monopoly eroded GPs have been forced to look at new business models  GP consortia successful in tenders only because companies don’t have ‘relevant’ experience
  • 10. New business models New collaborative business models include:  GP-led companies  Multi practice partnerships or Federations  Umbrella mutuals or social enterprises  Co-located or ‘virtual’ practice associations  Joint ventures between GPs and private sector (eg Virgin, Assura, Boots)
  • 11. Potential Benefits Potential benefits of collaboration include:  Improved performance/quality through more efficient management, mutual support and peer pressure  Reduced costs, due to economies of scale  Increased range of services, due to pooling of resources and skills, and increased opportunities to expand due to sharing of business risks
  • 12. Further new ideas  ‘In sickness and in health’ (NHS Alliance) postulates case for integrated care  They argue logical end point of services redesigned around patient is to create a primary care-led integrated care organisation (ICO)  It will provide care close to home, through new breed of Consultant community specialists, and commission all other services, inc. redesigned unplanned/out of hours care
  • 13. Integrated Care  Integrated care will bring improved access across all strata of NHS  Models based on “values rather than structures”  Virtual health centres rather than polyclinics  Hospitals deal with acute care only  ICOs supported by patient empowerment, public health focus, and new Academy of Clinical Leadership.
  • 14. Primary Care 2020?  Universal standards of care in pluralistic franchised NHS (under independent board)  Patient has free choice of providers (and budget for some forms of care)  Element of private insurance/co-payment  Health Maintenance Organisations commission services from Foundation Trusts, ICOs, Private companies and GP led MPPs/Federations/Social Enterprises.
  • 15. Thought for the day “The average GP practice costs £150 per patient per year. That is less than the average cost for a single outpatient appointment in most specialties.” “In sickness and in health: achieving an integrated NHS”. (NHS Alliance April 2008.)