The new contract for England’s GPs from 2014 is a significant demonstration of two things: the increasing momentum towards joined up policy on out of hospital care, and the queasy tension it can raise for patient organisations.
Largely designed to produce better home and community care for older people, the contract makes the GP the ‘named accountable clinician’ overseeing 24/7 care for each person over 75.
GPs will be expected to:
- offer these patients personalised care plans and same day telephone consultations;
- be available immediately to advise other care partners on handling their emergencies;
- review their hospital discharges to ensure they get the handover care they need; and
- formally monitor out of hours primary care.
The moves were agreed by the BMA on behalf of GPs. Shortly before the announcement, it had produced a welcome statement on Developing General Practice, signalling its own recognition of the need to provide better coordinated care with more focus on planning for the individual.
At the same time, the first recommendation of Sir Bruce Keogh’s review of accident and emergency provision, was emphatically in favour of better support for people’s self-care and personalised care planning.
National Voices is increasingly optimistic that messages in its ‘9 big shouts’ list of demands, two years ago, are beginning to be followed through.
We called for ‘integration, integration, integration’ as the right framework to create the conditions for better care in the right places, and have helped provide a common system definition that promotes person centred coordinated care.
With the ‘pioneers’ leading, all local areas are now expected to plan for this shift over the next five years.
We called for a new deal for people with long term conditions, and have thrown our weight into supporting NHS England’s domain 2 team to develop and promote its strategy around the ‘House of Care’ concept.
We called for and won a duty for commissioners to promote individual patient involvement, made sure it was in the NHS England Mandate, and supported the development of statutory guidance to CCGs which carries many of our messages.
We argued that personalised care planning was at the heart of all these approaches, and we are gaining increasing support and endorsement for our Principles and toolkit as they continue to develop.
As this shift towards better, more personalised, joined up out of hospital care continues the role of GPs becomes absolutely central.
The things that the Secretary of State wants for over 75s are the things we want for everyone with a need for coordinated care.
GPs do not have to do everything or provide everything, but they need to demonstrate the capacity to move towards shared care and support, in which their accountable functions can be delegated across multidisciplinary community teams, whose boundaries should be ‘invisible’ to patients.
Although we have supported these strategic moves, there can be downsides.
For example, the realignment of GP responsibilities is paid for (in time and money) by dropping more than one third of the indicators from the Quality and Outcomes Framework.
Many of these rewarded doctors for completing checks, tests and processes for specific condition management (such as giving lifestyle advice to people with hypertension, or assessing the risk of fracture in people with rheumatoid arthritis).
It may be painful to see some of these checks go, when much of our advocacy time is spent trying to ensure people get the standards and ‘steps’ to which they should be entitled.
As charities we are often skilled at supporting people with specific needs and conditions, advocating for better strategies and standards for those conditions, and working with those who can affect their direct care.
The world we are pushing towards involves whole system, population health management, and generic provision to meet people’s complex and continuing needs.
The generic should never drive out the specific. People with complex conditions will still need access to their specialists, for example. But the question of where and how we argue for better care and support will challenge all of us, and face us with potential trade-offs.
What we do want, is proper engagement and consultation to take our sector with the changes, ensuring such trade-offs are understood and acceptable to patients.