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A secondary perspective - what gastroenterologists would like to see in practice-based commissioning |
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Chief Executive, British Society for Gastroenterology |
Dr. Tom Smith |
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Practice-based commissioning (PBC) offers the potential for GPs to work with their secondary care colleagues and with panels of patients to improve local systems of care and develop services. It holds a lot of promise in bringing clinicians together to shape services, to peg clinical pathways to quality standards and to manage patient care more effectively across the primary and secondary care interface. The problem with the idea is that it seems to remain just that:an idea. From a secondary care perspective, progress is slow and confusing. Hospital doctors are confused about the progress of PBC: whether PCTs retain control of some aspects, and how much freedom GP commissioners will have. Despite a lack of clarity about organisational and financial arrangements, the clear direction of travel is for groups of clinicians to lead the commissioning process. That is a good thing. One fundamental problem is that GPs and consultants do not speak to or meet each other on a regular or routine basis: PBC should aim to resolve this. A recent case study of developing a service for a long-term condition reached a surprisingly simple conclusion: it is vital to make clear to the professionals providing care who the commissioners are. GPs developing PBC should let local providers know, and involve their secondary care colleagues. There are concerns in secondary care about the implications of current financial incentives on clinical quality; and some reassurance from commissioners is needed that new services will be commissioned and audited within a framework commensurate with national standards. The British Society for Gastroenterology’s Clinical Standards and Services Committee, made up of local representatives, can help commissioning consortia to define pathways and monitor quality. Locally, commissioning groups should involve hospital specialists in reviewing, planning and auditing new services. There needs to be a dialogue between primary and secondary care on the management of specific conditions. IBD is a condition that cannot be completely managed in primary care, but where care might be delivered in new ways. Better management of chronic conditions will require a review of how patients are managed across the primary - secondary care interface. Gastroenterologists are keen to work with commissioners in new ways, and to discuss running clinics in different settings or offering new community services. For a real partnership to develop between the sectors, greater financial flexibility is needed. The blocks of money paid through Payment by Results create a financial imperative and incentive to move care out of hospitals and into community settings: some fear that this will be a wholesale shift. The financial incentives risk setting primary and secondary care against one another, rather than ensuring a more efficient and effective partnership. If tariff payments could be unbundled, this would enable the different payments to be unbundled and for different parts of the care process to be delivered in different settings. An unbundled payment might also allow innovative use of consultant time, including the ability to pay for telephone advice and discussion with specialists. One impetus for reform is the need to make healthcare more efficient, yet too often these efforts have been focused on individual entities (like requiring an institution to make 2-3% efficiency savings). Too little attention has been paid to increasing efficiencies by improving the connections across the whole pathway of care, examining interconnections within the system. PBC could spawn the kind of collaboration between primary and secondary care that will help to define good outcomes in patients with functional GI disease, and the best way to manage their care. It is vital that these metrics are also meaningful to patients. Practice-based commissioning provides an opportunity to more centrally involved patients in commissioning, as a sounding board and a pool of experience. For many patients, GI conditions are long-term and many take part in local groups, providing a really important resource for commissioners. Practice-based commissioning has the potential to really transform local services and create a partnership between clinicians and patients, in developing services, but it will only be successful if it genuinely engages hospital specialists and patient experience. |
