Monday, May 23, 2011

Re-Assura-nce ?

O.k. I know I’ve not been around much lately—or indeed at all, for months. I know there’s a lot to say right now, and not having a voice with which to say it has been a huge frustration, but sometimes words just elude me. So I’m grateful for an email from a friend that gave me a prod to try again.

I fear it’s polemic time, but since I imagine so many of you have drifted quietly away in the long silence perhaps I won’t end up boring too many people. I should also point out that the email came over two weeks ago, so I fear this is not the best place to come for an answer to any queries you may have. Certainly it’s unlikely to be the speediest :-(

So on to the email. My friend was talking with a consultant who revealed the following;

“Apparently the PCT are refusing to fund all 3 monthly hospital reviews, and have been for some time (ie before Coalition took over) The hospital are still arguing about this, to get the PCT to accept those patients they put on pathways exempted from the GP's…”

I have to say the same is true, in some form, in our own PCT and likely in almost every PCT in the country. The reasons for this are many and complicated and though driven by finance are not purely dictated by the bottom line. What we have to bear in mind is our fractured, battered, beloved but struggling NHS has been through six decades of continual change. This change has been technical and clinical every bit as much as financial.

So, how dare a PCT dictate to a consultant when and how a patient should be reviewed? Well the first motivation right now will undoubtedly be financial. Each encounter of a patient with any hospital or “hospital-supplied” service since at least the early 1990s has carried a price tag. So the initial encounter at outpatients generates a bill. There is then a tension between hospital and PCT, both of whom have a primary statutory duty to deliver a balanced budget which overrides any other duty they may have. So more hospital outpatient reviews means more money for the hospital, and a bigger drain on PCT resources.

In the time I’ve been in family practice the level of care and expertise available in the community has gone through a quiet revolution. Pretty much everyone, including our consultant colleagues still see general practice as a sleepy medical backwater of two surgeries a day and a round of golf in between. Anyone who has had any regular dealings with their GP surgery over the past decade or more will know that things aren’t like that anymore. At least they will if they take a quick look around. First, it’s likely that their surgery has a number of doctors rather than just the one or two that was the norm in the first few decades of the NHS. Next, as well as the normal surgery appointments there are likely to be dedicated clinics for a number of conditions including diabetes, heart disease, asthma and COPD as well as “lists” for minor operations ( a rarity in 1990 and near universal by 2000) wart treatment, travel clinics, counseling, physio, and in some of the more adventurous, even “alternative” therapies like acupuncture, chiropractic and a host of others. (True in remoter and more deprived areas not all of this will be so, but even there the GP is still likely to be offering a range of services that thirty years or more ago would have been the preserve of the hospital).

All of this activity is also funded by the PCT. So if the PCT can agree diabetes reviews as an exemplar, in practices, for a fixed price well below that of the hospital, and if the practice is geared up to provide a service at least as good as that of the hospital for the vast majority of punters, why would they opt to have these patients reviewed in hospital or hospital led outpatients? Particularly when the service commissioned from General Practice is a “block contract” paid per capita and not per encounter. But there’s great deal more to this than mere finance. Any regular user of hospital services will tell you that they seldom get to see the same doctor two clinics running, because of the way hospital careers and training are organized, and because the minimum realistic interval between appointments is many months. In practice a GP will generally take a lead role in a given clinical area and will be rather more available. When patients are stabilized and well managed yearly or six monthly reviews will generally be the norm and these could be delivered in either setting, but in Practices the team doing the reviewing will de facto be smaller and longer in post, and so likely more consistent, delivering better continuity and with a greater hollistic knowledge of the patient. And when things are more complex practices can generally respond if needed in a day or two and review in a week or two, where the only option available to the consultant would be admission or “urgent” outpatients which—in this locality at any rate, could be anywhere upwards of 4 to 6 weeks.

This is not to deny that there are some, rather iller and more complex patients who genuinely need more frequent hospital care, and for them the existing system is undoubtedly flawed, to the unending frustration of Consultants and GPs alike.

There was another point raised in the email, “(h)is other interesting information was that here the GP's refer to a private company called Assura as well as the NHS. He pointed out that many of the local GP's have significant shares in Assura and therefore a clear conflict of interest…”

Here’s where things start to get complicated and not a little murky. Before I start I must declare an interest in that our locality has services provided by Assura in which every practice in our consortium are partners.

Assura was started some years ago as a commercial supplier of outpatient style services to GPs run by GPs. They have grown down the years and to the best of my knowledge now continue this model and also help practices with premises development in a model similar to PFI. They tend to develop local services as stand alone ventures—franchises if you like, in joint ownership with GPs, and often engage some of those same GPs who have developed particular expertise, alongside Consultants and other practitioners as appropriate, to provide the service. Their services can range form Physio to Dermatology to Orthopaedics to name but a few. I believe they have also been involved in tendering to offer out of hours GP services as well but cannot be sure if they presently run any.

True they are a “private provider”. So are many others currently offering care and services under the NHS umbrella. And true they provide services in partnership with local GPs, and invite referrals from those same GPs. However, to be able to provide such services they are obliged to tender in an open market to the PCT who commission the service, in competition with other providers, NHS and Private Sector, and stringent attention is paid in that tendering process to cost benefits and to potential “conflicts of interest”. So much so that it can take anything upwards of 18 months to 3 years for tender to gain official sanction.

This is the shape of our modern NHS and current reforms look set to oblige commissioners to look not just to NHS-allied organizations like Assura, but also to the wider marketplace, opening the door for strictly commercial private sector providers who will not have either the tradition of engagement with the NHS nor the public service ethos that alliance with GPs who are grounded in the existing systems carry in their “DNA”. One of the consequences of these new arrangements in our locality has been an increase speed of access to specialist opinions for patients who would otherwise have had to pay personally to see a consultant privately. Under these arrangements the PCT is paying the franchise and the patient is seen as an NHS patient. I wonder if this has some bearing on my friends’ consultant’s concerns over conflict of interest?