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Our Health, Our Care, Our Say, the new White Paper on care outside hospitals heralds a radical shake up for Primary Care and acute hospitals

Our Health, Our Care, Our Say, the new White Paper on care outside hospitals heralds a radical shake up for Primary Care and acute hospitals.

One specific goal is to shift 5 per cent of total acute hospital spending into community services by 2016. In an NHS budget of nearly £70bn a year, where acute services swallow a large share of cash, this is a substantial amount.

In Peckham, South London, during the 1930s, a community-based polyclinic-come-cottage hospital was piloted. It was carefully designed and purpose built, and valued by the local population.

Over the decades that followed, big acute hospitals dominated health planning and the Peckham experiment came to an end.

During the 1980s, some of the thinking from Peckham was behind a decision to build a new community care centre in Lambeth. The then Lambeth Health Authority got together with visionary local GPs and community groups, and consulted on what services people wanted in their community following the closure of the old Lambeth Hospital.

After consultations, architects were able to compete to design and build the new facility. It opened in the mid-1980s, running a range of day programmes led by local GPs and offering 22 inpatient beds.

Since then it has won many design and care awards and continues to be the only centre of its kind in London. The idea was to treat people locally and prevent expensive admissions to St Thomas' Hospital, or facilitate earlier discharge.

At the height of GP fundholding in the 1990s, a group of doctors purchased the cottage hospital in Epsom, Surrey, which was facing closure.

Using private, and some public, monies they created a state-of-the-art diagnostic centre and day surgery unit, coupled with modern outpatient facilities.

Over time they shifted huge amounts of work out of acute hospitals; waiting times for their patients for many elective procedures were minimal.

Patients, of course, were more than happy to have these services on the doorstep and the GPs had a more interesting and fulfilling clinical life.

There is nothing new in the White Paper. Experiments with reinvented cottage hospitals, polyclinics and community care models have all been tried and tested, but always on a limited scale.

Put to the test
The White Paper heralds an opportunity to test these ideas more widely over the coming decade and will put some serious money behind such thinking.

On the back of the White Paper, Secretary of State for Health, Patricia Hewitt, has advised all Primary Care Trusts (PCTs) in England to halt the planned closures of small community hospitals. She has put on hold the massive planned Private Finance Initiative (PFI) scheme at Bart's and The Royal London Hospitals Trust.

The message in the White Paper is clear: big palaces of illness called hospitals are not the future; community-based solutions near to people's homes are where it is at!

Emerging technologies, such as robotics, digitalised telecommunications, telemedicine and sophisticated information technology, suggest that much more can be done outside a traditional hospital setting. In Canada and Australia, with large land masses and a scattered population, telemedicine has been in use for decades. There is no reason why it cannot happen in the UK.

But these ideas are potentially revolutionary and will have powerful vested interests opposing change.

Change of power
The traditional powerbase in the NHS has always been in acute hospitals and, in particular, with hospital consultants.

In the current NHS financial crisis, it is clear that the big overspends are in the acute sector and it will be community and mental health services that will have to bail out overspending hospitals short term.

As a nurse and NHS chief executive, I have witnessed this depressing pattern for more than 30 years. The government is now telling the acute hospitals to expect 5 per cent less cash over the coming years and to shift services out.

To deliver the goals in the White Paper of greater choice, easier access and a greater plurality of providers, many acute hospitals will need to downsize and reshape while others will have to close, particularly those with a weak clinical and financial reputation.

As this happens, we can be sure that many hospital consultants will object and local community protests will happen. Will ministers have the courage to face the protesters and stick to their guns?

This will be the acid test of the new policy and there will be a need for robust public consultation and education if these changes are going to work.

The White Paper is short on ideas about how to carry communities through periods of change in service reconfiguration and the track record of NHS managers on this has not been good.

It suggests that Primary Care Organisations (PCOs) of the future should be more focused on commissioning, be a minimal provider and harness local commissioning around clusters of GP practices.

Fresh ideas
If real incentives are put in place for creative GPs, hospital consultants and other entrepreneurial health professionals, then the White Paper could allow some very interesting service models to emerge.

In many disease areas it is clear that repeat interventions and outpatient activities need not be done in a hospital. Renal dialysis, ongoing acute physiotherapy, diabetes diagnosis and management, follow-up after acute coronary episodes, dermatology and other areas are all ripe for fresh thinking.

If this shift is to be real, it will need genuine partnerships to emerge in all sectors including acute hospitals, GPs, PCOs, community services and especially with local government.

Sadly, current NHS structures, including Foundation Trusts, inculcate a mindset of insularity and competition. The White Paper will definitely increase competition, but strong partnerships could create better services and a scenario where all parties can be winners.

A smart Foundation Trust, working closely with good GPs and the PCO could easily create a range of hub and spoke services in many long-term conditions, but it will require the hospital to think beyond its walls. Why can't a hospital renal department run a bespoke community service beyond the hospital wards? The White Paper is going to require all stakeholders to think outside the box.

For the industry, the NHS customers are going to be having a turbulent year and we are not likely to see the shape of the new NHS until after April, when decisions on the number of PCOs will be made.

Be gentle on PCO colleagues until then; many will not know if they will even have a job. The Health Service Journal predicts that 3,500 management and other posts could go in the shake up in Strategic Health Authorities (SHAs) and PCOs in England.

It will be important to track locality commissioning frameworks as they emerge in each PCO, as pharma will need to build relationships with emerging commissioners, especially GPs who elect to get involved in the new frameworks.

For many bread-and-butter local services, commissioning and spending decisions will be delegated to the localities as much as possible. The new PCOs will keep a Professional Executive Committee (PEC) and knowing the membership of the PEC will be important. The PEC will have GPs, nurses and allied health professionals in membership. It will influence strategic thinking in the PCO and scrutinise locality commissioning.

It is the locally-based fieldforce and NHS liaison teams that will be best placed to gather and use this intelligence.

In the longer term, as we see some PCOs divesting themselves of any provider functions, whole swathes of services will shift elsewhere. Pharma may find a raft of new providers emerging in primary care; they may be from the private or voluntary sectors, so new relationships will need to be built.

For long-term conditions, pharma may want to think of developing partnerships with local entrepreneurs or Foundation Trusts that want to build social enterprise, or not-for-profit organisations, to take over from current NHS providers.

Some companies may want to bid directly to run services; but bear in mind that any provider will have to work within the frameworks of the NHS planning cycle and will be subject to regulation and inspection by the Healthcare Commission.

Finally, there will be a lot of talent looking for work. Staff in senior roles in either PCOs or SHAs carry a lot of knowledge and intelligence about the health service. Brighter people will also have great networks and a good understanding of the politics of the NHS.

Could that set of skills help you to understand better the needs of your NHS customers' and gain appropriate access to new commissioners?

The Author
Ray Rowden is an independent health policy analyst

2nd September 2008

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