post

Save the dragon receptionists from slaughter.

The public perception of access to GP services is already at an all-time low and as such this is having a devastating impact on our health service. In a recent analysis by the Royal College of GPs, this perception and now ‘fact’, is set only to worsen over the next five years. That is unless the actions promised within the GP Forward View begin to become a reality.

In 2015/2016 there were 9 million occasions when patients tried to access GP services and could not, but did not seek healthcare from an alternative provider. Whilst it can be safe to assume that not all of those patients would have required further intervention and follow-up, an ageing population means that a large proportion of them would have needed to have been seen. It is widely acknowledged that there is more risk of harm to patients within the system than ever before.

When patients do seek to access alternative health care providers, then this is often through 111 and more inappropriately via A&E. This just compounds the financial crisis and pressure on the system further, as bottlenecks develop in places that they shouldn’t and patients face referrals and investigations that they do not always need. This is unnecessary demand and waste on expensive services!

Why is it so difficult for the government to recognise, that by investing the finance and resource at the front door of the health service, this will ease the pressure at the back door? It doesn’t work if you do it the other way round ! Yes, patients need to be seen and cared for in the community, but they also need services they can access easily and they also need to feel supported enough so as to avoid going to hospital, unless it actually is an accident or an emergency.

The fact that Primary Care receives only 8% of the total budget assigned to the NHS in the face of so much reform is ludicrous. A new Prime Minister and a major cabinet reshuffle gave hope to many GPs that the inequality between primary and secondary care resource and funding would be addressed. These hopes were dashed when news was released that despite the cabinet reshuffle, Jeremy Hunt remains the Health Secretary. One can only hope that the new Prime Minister therefore honours the pledge and promises that David Cameron made, and funding increases significantly, giving primary care a chance of long term survival.

If not, then the RCGP’s analysis goes on to conclude that of the reported 69 million occasions whereby patients had to wait more than 7 days for an appointment in 2015/2016, is likely to rise to 98 million occasions by 2020/2021. GPs and patients around the country are being ‘called to arms’ to ensure that this situation is not allowed to escalate to the figures being forecast. The impact of doing nothing risks health care across the whole of England. And let’s face it, our poor GP receptionists take a hard enough hit as it is when patients can’t access our services, and they become branded the dragon on the other end of the phone.

post

Integrated Care – Why the big fuss?

A fundamental rethink of how healthcare should be organised and provided is now necessary if we are to ensure the long-term sustainability of Health and Social services, and meet the increased demand now being faced on our healthcare system, on all fronts. Demand has increased exponentially in recent years, due in some part to the success and advances made in modern medicine. People now live much longer than in previous years, there is a better understanding of disease aetiology and, as such ageing patients live with varying degrees of quality of life, with one or multiple long term health conditions. With increased specialisation and new options for diagnosis, treatment and care, these successes make healthcare much more complex and therefore more costly than ever before. Despite these successes more coordination of care is needed, not only between Primary and Secondary healthcare services, but between Health and Social services.
Pressure on the healthcare system arises in the form of sub-optimal care, avoidable ill health, inappropriate use of care and services, duplication and waste. These factors need scrutinizing and improving to ease unnecessary burdens. They are a result of how services have historically been set up, how the budgets have been divided and how care is organised across Health and Social care boundaries. If we were to consider only healthcare, then Primary and Secondary Care have both been treated as separate branches of one system and the many structures, governance and management arrangements that have developed across each branch have done so in silo. ‘The left arm doesn’t always talk to the right arm’. Now Introduce Social care into the equation, and once again the differences in their structures, governance and management arrangements become even more apparent. In the past little thought, if any, has been given in relation to the impact that these services have on one another. Often there has been no risk assessment of the impact changes to one service will have on the other, especially if it crosses professional boundaries. This is a fundamental design flaw and one which must be addressed if we aim to provide services that focus on quality, are less fragmented and have improved channels of communication that enhance care.

There have been many attempts in the past to integrate services, none of which have yielded any lasting and positive results. The fact that previous attempts have failed will act as a significant barrier to reform and this ‘elephant in the room’ will need to be addressed by Leaders and Clinical staff before any redesign work can proceed. Other barriers to Integration include:

– Separate budgets in key care areas, for example, between Primary and Secondary care, and between budgets for Health and Social care.

– Institutional separation between Primary Care – independent small businesses generally owned by GPs, Secondary Care – entities owned by the NHS, and Social Services – owned or commissioned by local authorities.

– Professional separation between the staff working in all three domains, resulting in different cultures, pensions and contracts.

– Lack of integrated data and information systems between major care providers.

– Repeated reforms of NHS commissioning bodies that have disrupted efforts to develop effective joint commissioning.

The approach considered by the vast majority of professionals as now being able to deliver on integrated care, is through the creation of Integrated Care Organisations. Various models of the Integrated Care Organisation are now being piloted across England, with their primary goal being to improve coordination of care, prevent avoidable ill health and provide more cost effective services.

So, why then is this approach more likely to deliver than previously explored approaches? The driver for change now centres on an unsustainable system and finally the realisation that if Organisations continue to work in silo, they will just bankrupt each other. Health and social care therefore need to come together and look at the system as a whole and work out how to spend the whole system budget collectively to create a sustainable system. This is driven out of the fact that the system was designed to cure ill health, not manage long term disease.

Now that leaders finally agree that they need to work this way, we are in a much better position than in previous years to design a new integrated model of care. The blockers to this work can also be identified and this is where ICOs are especially useful, as they facilitate the removal of blockers, especially when these are people working for and within different organisations. With this in mind, there is a real potential that the use of expensive hospital services will be reduced by redesign of current services. Collaboration provides the opportunity to overcome the fragmented responsibility for the commissioning and provision of care in the NHS – all with the patient at the centre of the chosen model.

The various models of these Organisations include:

– Networks of provider organisations operating under a single, integrated budget (‘virtual integration’).

– Organisational mergers (‘real’ integration) to bring together different care sectors (acute trust ownership of GP services, for example).

– Integrated commissioner–provider organisations that combine commissioning care for a designated population with the provision of some or all of these services.

This is an exciting time for many working in Primary Care and Social services, as Secondary Care has in the main, always been the priority for funding and development. Whilst it is still too early to assess the impact that these Organisations will have, never has there been more of an exciting opportunity to be involved in improvement work that will promote whole system change. One can only hope that GPs are freed up from some of their clinical commitments so as to collaborate on the best possible designs for patients. Otherwise, a potential pitfall is they will be under represented and whichever model is introduced will be rebuffed through fear that it is another model imposed by the hierarchy and professionals feel forced rather than engaged and empowered.

post

GP workloads are now at saturation point.

During recent years, there has been a widespread and shared belief, amongst many GPs and others working in Primary Care that workloads have increased exponentially. The Government has failed to resource adequately for this and, as such, not only is this having an impact on the health and wellbeing of GPs, it is also at times affecting their ability to provide safe and consistent levels of care.

It is now commonplace for the media to sensationalise issues occurring within Primary Care concerning the supply and demand of services and the impact that this has on other frontline services. Most GPs want the best for their patients and, as such, the increase in workloads has been raised repeatedly and consistently with the Government, only for these concerns to be rebuffed, by both NHS England and the Department of Health, with promises of thousands of extra staff in Primary Care by 2020.

Despite the attractiveness of thousands of more staff in 2020, a new study in the Lancet led by researchers from the BMA and the Royal College of GP’s, provides clear objective evidence of what GPs have been saying for years and demonstrates that action must be taken now.

The key messages from the study, which covered over 100 million GP and Nurse Consultations at 398 practices in England during 2007 and 2014, include:

– ‘There is a substantial increase in practice consultation rates, the average duration of the consultations being given and the total patient-facing clinical workload.

– GPs are facilitating more consultations than ever before for patients who are living longer, who often have multiple long-term conditions resulting in a complex presentations of symptoms that cannot be dealt with in the previously allocated time.

– Due to the change in nature and volume of workloads, GP practices and their teams are working harder than ever before, but struggle to provide basic levels of care as services are overwhelmed.’

The impact of inaction in the face of such significant objective data could be disastrous not only for staff but for patients also. With many GPs now facing the prospect of burnout or feeling the impact of being overworked, over tired and exhausted the results could be damaging for patients especially if this results in substandard care, harm or misdiagnosis.

Compounding these issues are figures released from Health Education England, who have revealed that one third of GP training places still remain vacant. Despite this representing a 1% increase on last year’s figures these results are second lowest recruitment results of all the specialities. This is not unsurprising as in 2015; GPs in England reported having the lowest job satisfaction rates since records began in 2001.

The solution for many of the problems reported across the NHS, according to the Government, is a greater shift towards ‘place based care’, a new model being explored to reduce the burden on the acute care system. However, without a serious focus on patients’ and communities abilities to self-care and make the most of non-traditional services, such as the extended pharmacy offer, the ‘place-based model’ will only once again serve to shift the burden from acute to primary care and resulting in further pressure to under-resourced and overworked GPs, and once again endanger the whole system of collapse.

post

Fallout from EU Referendum.

On the 24th June 2016 the people of the UK made the decision to leave the EU, a decision that has since sent shockwaves across the entire global community. Politically, this has sent the country into chaos with changes and challenges of leadership across the three main political parties. Economically, the impact is widely expected to result in recession in the UK, which could then have a knock on effect and force other EU countries down the same path.
With the decision to leave predicated on strong views concerning NHS Funding and Immigration policies, it now seems ironic that these two issues, along with economic gloom, once again plunge the future sustainability of the health service further towards uncertainty. Furthermore, with the ‘Leave’ campaign distancing themselves from claims that were made indicating that funds previously sent to the EU could be reinvested into the NHS, this is an uncertain time for many of the 110,000 EU healthcare workers who already work tirelessly to deliver more with less resources.
Previous estimates relating to shortages in both the future Medical and Nursing workforces may potentially pale in comparison to the reality, especially when one considers that the UK has traditionally tried to fill existing gaps in healthcare workers from abroad. A huge majority of these workers – 10% of Doctors and 20,000 Nurses, have come from other EU countries. With already rising social unrest and concerns over existing immigration policies the current challenge of motivating, recruiting and retaining an already disenfranchised GP profession will continue to escalate, especially if no help is perceived to be coming from anywhere other than inside the UK. The GMC is currently exploring how doctors from the EU will be granted access to the UK medical register once the UK is no longer a member state. As it stands, the EU vote will have no impact on the current registration of any doctor on the register, but there may be implications relating to regulation in coming years.
In the aftermath of a heavily sensationalised and manipulative leave campaign, many of us now ask if it was right to trust such an important decision to the people, especially when the outcome now stands to jeopardise so much. Should this have been left in the hands of people with the power, knowledge, experience and understanding to assess the impact on our services, our economy and our health care system? It’s too early to be able to ascertain with any great certainty, but one thing is for certain there is an ageing population. By limiting free movement of skilled workers, we are widening the gap concerning demand and supply for our health care services and we are pushing our already heavily burdened finances a step closer to the brink of destruction.