Changes to Healthcare - what it means for GPs and patients

Taken from: NRAS magazine, Winter 2012

By Dr Ruth Burnett, local GP and Medical Director of MSK care in Buckinghamshire

As we move towards clinically led commissioning, there is a lot of uncertainty amongst the general public about what this means, what this involves and how it will affect people. These concerns are understandably particularly high amongst people with chronic health conditions who require regular access to both primary and secondary healthcare, and who may have concerns that their care will suffer as a result.

Clinically led commissioning for England. What does it mean?

Previously GP practices, hospitals, mental health services and community services in England have been commissioned by Primary Care Trusts (PCTs). Each geographical area had its own PCT and was responsible for setting its own targets and spending its own budget. The budget was set by the local Strategic Health Authority (SHA) and Department of Health.

In July 2010 the Government published the White Paper ‘Equity and Excellence: Liberating the NHS’. This set out its long term vision for the NHS with the key principles of change being the abolition of PCTs and SHAs and their responsibility for commissioning, planning, designing and paying for health services. The main aim of the changes was to put patients at the heart of the NHS with greater emphasis on outcomes for patients, rather than simply meeting targets. The hope is that this will be achieved by more independence for healthcare providers and reduced bureaucracy.

From 1st April 2013 PCTs will no longer exist and they will be replaced by Clinical Commissioning Groups (CCGs). This is not a sudden process, but a gradual changeover, with CCGs taking over by this date. Over the past year CCGs have become established, applied for authorisation and approval, and in many cases started to work as ‘Pathfinder CCGs’ which have been shadowing the outgoing PCT to ensure that changeover is as smooth and problem free as possible.

So what is a CCG? CCGs are groups of GPs and GP practices clustered geographically that agree to work together to commission local services. GPs already play a key part in coordinating patient care and acting as advocates for their patients, and they will now have more responsibility, but therefore control, over how local budgets are used for their healthcare communities, and also financial accountability for the consequences of their decisions. This whole process aims to shift decision making as close as possible to patients. As well as carrying the responsibility for planning, designing and paying for the local NHS services, GPs and other involved clinicians and healthcare professionals involved in the CCG would also be responsible for engaging with local people to ensure that the services they are paying for meet the needs of you, the patients. A new consumer body called HealthWatch England will be set up. Local HealthWatch bodies will replace the current Local Involvement Networks (LINks). They will promote public engagement in the NHS, comment on changes to local services, act as advocates for complaints, and deliver advice across health and social care. One of the proposals in the Health and Social Care Act 2012 is that each local authority will have a statutory duty to set up a Local Healthwatch in its area.

What will all this mean for patients?

Hopefully patients will only notice an improvement in care, driven primarily by the fact that each CCG is able to commission services and budgets to best suit its particular population. A CCG in an inner city area may have different priorities from a rural CCG for instance. Similarly, the ethnic or socioeconomic factors within a CCG region may alter the priorities that the CCG feel will maximally benefit the majority of its patients. CCGs will work with patients and healthcare professionals, and in partnership with local communities and local authorities, they will have at least one registered nurse and a doctor who is a secondary care specialist on their governing body in addition to the involved GPs.

Previously GPs and practices have had varying levels of involvement in the development of services and commissioning process, but with the change to CCGs each practice will have to have quite a significant involvement. Generally each practice will have one GP who is more heavily involved than the others, and if this GP is your usual healthcare provider then you may notice that they are not available for as many clinical sessions as they were previously. 

Challenges for GPs

Over the past few years there has been a general move to shift management of chronic diseases, and acute care where possible, out from secondary care providers and into the community. It is generally accepted that this is of benefit to all concerned – hospitals are increasingly stretched for capacity, and patients usually find it easier and preferable to visit their GP who knows them and their care needs very well, than to visit busy hospital outpatient departments. With this occurring over a significant number of disease areas (such as diabetes, COPD, heart disease) it has increased the workload in general practice significantly. As was noted by some members during the NRAS Members Day Q&A session in October, this can mean that at times GPs appear to be struggling under an increased workload, working longer hours and spending a significant amount of time with paperwork and targets. While this is true, it also gives us a greater overall view of a patient’s care and enables us to act as the central hub of care for a patient with a long term medical condition.

GP practices have had to strive to achieve QOF (Quality and Outcome Framework) targets (a financial incentive scheme for GPs, negotiated on an annual basis, which incentivises activity that meets national health priorities) for a significant number of years now, which are generally accepted to improve healthcare provision for patients who fall within the disease areas involved. As was discussed at the NRAS Members Day, there is a move for rheumatoid arthritis to become a new QOF area and this will hopefully help RA to become a priority. It would mean that for the first time GPs will be commissioned to create a register of RA patients, conduct regular reviews for cardiovascular and osteoporotic risk and try to ensure that care for RA patients is optimal.
The changes within primary care commissioning have also resulted in the introduction of Quality Performance indicators which are also targets that each practice and each locality has to strive to achieve. Unlike QOF, these are driven more by the priorities of each locality and CCG, and practices have the ability to set these individually and in discussion with the other practices in their locality. This ensures that the targets are optimised for their patient population and will help to ensure that they increase efficiency in areas of excess spending for a region (for instance, emergency admissions, patients turning up to A&E for assessment when they could be seen by their GP or out of hours service) and that savings achieved can then be put towards improving care in areas that are of benefit to the particular patient population of that area.

How can I become involved and help myself and the areas of greatest importance to me?

The benefit to patients of the way in which healthcare management is changing is not simply that your GPs, the healthcare providers who know you best, are more heavily involved in how healthcare is managed within a region. There are ever increasing opportunities for you, the patients, to become involved and to help us to shape local and national healthcare targets to best benefit you and the other patients in your region.

These include:
• Taking part in a working group
• Attending occasional focus groups or workshops
• Working alongside us on projects
• Responding to questionnaires
• Commenting on consultation documents
• Taking part in discussion forums
• Commenting on our public leaflets
• Taking part in national surveys
• Attending a public consultation
• Attending public board meetings

If you search for your local CCG online, or ask your GP practice for details, there are ways in which you can get involved both with your GP practice, your locality commissioning group, or the CCG overseeing the region. We need patients with balanced views who can put their own personal health problems to one side but bring experience of negotiating the healthcare system to bear, an interest in helping develop services, and a willingness to take part in healthcare input to help us best develop services to help you.