Earlier this year, the BMA took a trip to Greater Manchester (GM) to see first-hand some of the developments that have been happening since funding was devolved in April 2016. The first part of the day involved a presentation by the GM health and social care partnership team and the chance to ask a few questions about the project as a whole. The second, and perhaps more interesting section, was visiting three different sites where they have started delivering care through different models. It is always hard to delve beneath inevitable self-promotion, especially with limited exposure, however many aspects of the work were interesting. It was good to observe that the importance of transformational funding was felt vital to what had been achieved, which is a cautionary note to other systems where this will not be made available to the same extent.
"With Devo Manc I see more opportunities than challenges"- Adam Abbs, locum GP North Manchester Hospital
The aim of devolution in GM is to be able to make local decisions to maximise outcomes for the population. As in many areas, there was recognition that the system was initially very fragmented, with the triggers for intervention set too late.
This created a culture of ‘crisis demand’ and not enough non-medical interventions. The work that the GM partnership team are doing is trying to solve some of these issues, as well as trying to create a sustainable finance structure for Greater Manchester.
GM is much further ahead than most other STP (sustainability and transformation partnership) areas and, arguably, have had the freedom to take a slightly different approach. The priority is around having a neighbourhood community offering, with GPs at the centre of integrated care.
"All the pieces of work we try to do are co-produced so it's very difficult to get everybody's opinion to go and steer in the right direction"- Tracey Vell, associate lead in primary and community care, GMHSC partnership
These neighbourhood hubs would offer wider public services arranged around the GP population. In secondary care, the focus is on standardising care based on the evidence rather than changing the hospital numbers or structures.
The leadership were very clear that the additional funding was absolutely critical. They were given £450 million, after having asked for £500 million plus funding for social care.
This allowed them to build the capacity required to make change while delivery services and allowing for double-running costs where required; for example, to continue with Acute Trust run services while building up the community offer.
We visited the intermediate care unit at Rochdale Infirmary and were all very impressed with the unit itself and the outcomes they have achieved for both time spent on the unit and reducing emergency admissions.
The specialist unit is staffed by GPs and has its own pharmacist, funded by the savings made from the medicines budget.
There are consultants on site to contact in an emergency or for specialist advice. All GPs working in the unit also work in local practices - the unit has a contract with the local GP federation - and have their indemnity paid by the hospital.
"It's holistic person-centred care instead of a 'person with a chest infection', or 'room 22 with the chest infection'"- Karen Archibald, unit manager at the Wolstenholme unit, Rochdale Infirmary
We visited a GP practice working in a deprived area of Oldham. The practice, as well as others within the group, is run as a social enterprise with an APMS contract and has been practising for seven years. They have piloted and are now rolling out a scheme of Focused Care Workers, who work directly with patients who are “not thriving”.
The practice has seen a 46 per cent reduction in A&E use among that cohort. Although originally funded by the practice itself and through some funding from the CCG, GM have now invested in the scheme and are helping to roll it out more widely.
"I get to practise different clinical skills but with the confidence that I've also got the backing of the hospital if I need it too."- Nicholas Lewis, salaried GP working at Five Oaks practice and North Manchester Hospital
The final visit was to North Manchester General Hospital where we met both a GP working in A&E and a GP working in an extended access site located at the hospital. GPs working in A&Es has been a controversial proposal but the reviews we heard here were positive.
The GP was able to see patients who were more appropriately seen by a GP despite presenting to A&E, often avoiding unnecessary diagnostics. The GPs were often able to see twice as many patients per hour compared to a SHO, although that may be down to the case mix.
There was universal support from the A&E staff, including the A&E consultant. One of the GPs, when asked about schemes like this keeping GPs away from practices, was very clear that without these alternative ways of delivering GP care he would not be working in this country.Holly Higgs is a senior policy adviser at the BMA
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So the GP is happy to see GP cases in A&E but if they had to in Primary Care they would emigrate? No wonder General Practice is in a crisis. Some of the examples are just like old GP-run Cottage Hospitals moved to bigger units. Are we not just re-arranging the chairs?
Where are the GP's for Primary Care if they are manning A&E.? we are always being told about the shortage of GP's so is it a case of leaving surgeries short of doctors while their GP's capitalise on monetary incentives to work in A&E?
Doesn't sound particularly different apart from the self-management focus aka the loudest voice wins.
Are we really witnessing a growing shortage of GPs or is it more likely a sharp rise in numbers of people needing to visit doctors is simply outstripping the number of available GPs? Better health and diet education in schools might be an effective way to hit the problem at its root. http://drharoldlong.com