GP - Providing healthcare closer to home
December 2006
This briefing paper applies to England only
Contents
- What is ‘care closer to home’?
- Summary of the BMA’s position
- Service reorganisation
- Financial assumptions
- Quality of care
- Secondary and primary care collaboration
- Capacity and workforce limitations
- Pace of change
Chapter 6 of the Department of Health White Paper ‘Our health, our care, our say: a new direction for community services’ published 30 January 2006 introduced the term ‘care closer to home’. The Government wishes to see a move in England towards more services being delivered in local and community settings and the White Paper identifies six specific specialties to lead this agenda: these are ear, nose and throat; orthopaedics; dermatology; urology; gynaecology and general surgery.
The Department of Health has set up a ‘Care Closer to Home Demonstration Group’ to select and monitor five demonstration sites per specialty, which it is hoped will provide suitable models for shifting care which can be rolled-out across England. The evaluation of the thirty sites will be completed by March 2007 and this work is being carried out by National Primary Care Research and Development Centre (NPCRDC) at the University of Manchester. A ‘new generation of community hospitals’ is cited in the White Paper as being central to the ‘care closer to home’ agenda.
Summary of the BMA’s position
The ‘care closer to home’ agenda cannot be considered in isolation of other key aspects of the Government’s current reform programme, which includes practice based commissioning (PBC), patient choice, multi-sector providers, contestability and payment by results (PbR). The BMA supports the concept that an increase in the range and accessibility of services that are located in more convenient settings for patients would be a positive outcome. However the BMA has some serious concerns about the implications and limitations of the ‘care closer to home’ agenda, particularly in view of its major role in wider service reorganisation and within the current financial climate.
Service reorganisation
Any service change must be based upon a clear clinical strategy and be both planned and consensual. It is wholly inappropriate for important decisions around service change and reorganisation to be made in accordance with purely political and/or financial priorities.
All change must be sustainable. Increasing the impact of market forces and that of PbR could well destabilise or lead to the closure of existing hospital services, which might in turn create new, long term problems for the local health service and economy. Short-term solutions to current problems or financial difficulties must be avoided.
It is misguided to believe that hospital services can close with just a promise that there will be new services in the community to replace them. The funding for these new services cannot be released until hospitals lose a portion of what they are currently commissioned to provide. The BMA believes that no significant changes to existing hospitals services should take place before there is agreement of clear plans for alternative services in the community, and full details of the interim arrangements that may be necessary. Where service change is needed, it has to be planned, led by doctors and be subject to public debate.
Financial assumptions
A number of financial assumptions underpin the work underway, principally that moving ‘care closer to home’ will save the NHS money. This will not necessarily be the case. Whether correct or otherwise, it is questionable to use this assumption alone as justification for downsizing general hospitals.
Quality of care
There is some concern over whether or not the current quality standards delivered in secondary care settings will be maintained when moving ‘care closer to home’. This consideration appears largely absent from the proposed evaluation of the demonstration sites.
Secondary and primary care collaboration
In the absence of a joint approach between secondary care and primary care, the current programme of system reform has the potential to set secondary and primary care clinicians against each other. The BMA is concerned in particular that the ‘care closer to home’ agenda does not automatically stimulate effective collaboration between primary and secondary care clinicians. In order to minimise the potential for conflict between the two sectors, cross-sector collaboration must be encouraged and incentivised. In part this could be facilitated by establishing some basic, shared principles including that service redesign is clinician-led, the focus is on improving patient care, and that the proposals are evidence-based and provide economic value.
Capacity and workforce limitations
Some additional barriers to effective implementation of the ‘care closer to home’ agenda are the restrictions on increasing primary and community care capacity as a result of inadequate infrastructure and manpower.
Since the mid 1990s there has been no large-scale, sustained government policy of premises development in primary care. A BMA survey conducted in May 2006 revealed that three quarters of practices felt their premises were not suitable for their future needs. The survey confirmed therefore that for many practices, there was a complete inability to absorb any further work simply because of the lack of space and room availability. Consequently, the BMA believes that any plans to shift patient care from hospitals to the community will remain largely unfulfilled unless dedicated funding is made available in order to address this issue. Furthermore, practice and primary health care teams are already stretched; in recent years, the BMA has seen the depletion of wider community teams that have played a vital role in supporting GPs in delivering coordinated and high quality care for patients.
Pace of change
Taking into account the concerns expressed above, the BMA believes that the current pace of change is too fast to allow for adequate planning and consultation to take place with regard to service reorganisation at a local level. As a result, in some areas there may be decisions taken that will not result in an improvement in the range and quality of services available to patients nor will they prove to be of relative economic value.
For further information, please contact the Parliamentary Unit:
Email: parliamentaryunit@bma.org.uk