Our local health care system is hospital-centric.
I suspect most of the NHS is.
There is a huge amount of work being undertaken in the community, but what I mean is that the current funding streams encourage increased investment in secondary (hospital) care and not in community based care. Our local system has some of the highest rates of admission to hospital from A&E for less than 24 hours in the country. When we have looked at this we are told that one of the reasons is that there are not community based alternatives to admission. It has been suggested that we should invest in these community services in order to reduce the admission (and potentially attendance) rate. The problem is that the money we need to do this is tied up in the hospital contract, which is based on Payment By Results (PBR – essentially a Pay As You Go contract where the hospital gets paid for the activity undertaken). When we suggest that we should reduce the hospital contract (in order to invest in the community services), we are told that we cannot do that because the hospital need the money to keep dealing with all the people they are seeing and admitting because of the lack of community alternatives. You see the problem – a cyclical argument.
This is a problem because we (the CCG) have a fixed financial envelope which we are under considerable pressure to live within. Most parts of the system are on fixed, block contracts, and one part of the system (the hospital) is on PBR. This appears to drive certain behaviours. Let’s use an analogy to make the point. With regard to your personal income and expenditure, how do you budget? You most likely look at your income, and then work out what you can afford to spend on your house, car, groceries, holidays etc. You know how much money you have and this dictates what you can afford. You also choose how to prioritise this, so if you want to spend your money on holidays, you might have to have a cheaper car, and vice-versa. This is how General Practice works – you know how much money is coming in, and you work out how to spend it – how many GPs can you afford, how many nurses, receptionists and so on. If income goes down, or remains flat while demand increases and expenses rise, then you have hard decisions to make – less take home pay for the partners, or less services for the patients? I would ask you to pause here and note that GP partners are genuinely subject to fluctuations in their pay year to year. In recent years I believe that some GPs have been in deficit (we hear about hospitals in deficit, but not General Practice), and this can mean GPs receiving less money, or working harder for no or minimal increase in funding,
There is another way you could budget. You could decide what kind of lifestyle you want – which car, house, brand of cereal and type of holiday. Then work out how much it would cost, and then set out to earn that. I suspect not many of us do that. I would, however, suggest that this is how hospitals can behave. They can work out how much they feel they need to run the hospital, then ensure they deliver the level of activity required to bring in the income. There are many ways you can potentially do this ranging from entirely appropriate efficiencies to other things I would question: lower thresholds for operative procedures, waiting list initiatives pulling more people through the system, admitting people from A&E for assessment before discharging home, increased consultant to consultant referrals.
I would suggest that the tariff based PBR system can drive these behaviours, and is not conducive to system-wide collaborative efforts to reduce costs. It is a particular problem when you remember the fixed financial envelope the commissioners have.
What we need are system-wide ‘control totals’ that bring all parties together to decide how best to spend the limited resources we have. Rather than having individual organisations aiming to increase their slice of the pie, we need to put patients first and appropriately budget as a system.
Some places are doing this. Accountable Care Organisations are all about this and STPs should be doing this. It requires hard work and for some people a real change in thinking. It is, however, essential that we do this. The financial situation we find ourselves in locally is going to be worse for 2017-2018, and if we can’t work together to solve the issues we face, then we are in trouble.
We need to move away from systems where the NHS world seems to revolve around hospitals. We need to emphasis the importance of out of hospital care so that all understand that the majority of healthcare in the NHS takes place in settings other than A&E or a hospital bed. We seem to have a fixation in the UK that we should fight to maintain the viability of all hospital services, regardless of the impact this may have in other parts of the system – you will probably be aware of campaigns against closure of hospitals and hospital departments, but can you recall many campaigns against closure of General Practices? As a colleague of mine once said “MPs don’t lose their seats over General Practice closures.”
When we try to move the money from hospital care to community care, these are the barriers we come up against, but we need to do it. We need to be able to demonstrate that closing a ward in order to keep people closer to home and provide care in a different way is a good news story. This absolutely requires investment in General Practice and other community based services and disinvestment in hospitals.
The NHS England “Next Steps on the NHS Five Year Forward View” does talk about increased investment in Primary Care and Mental Health as well as a focus on “Integrating Care Locally”. This direction of travel sits comfortably with me and I sincerely hope will support us to commission in this way. Above all I hope that we can all move towards systems that enjoy increased collaboration and that can move away from the hospital-centric systems that currently exist and enter the new world of seamless care that people need.
Dr Jonathan is a GP at Swanlow Practice in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.
Follow Jonathan on Twitter @DrJonGriffiths