Primary care: gatekeeping or weaving?

warp_and_weftThis is a slightly revised version of an article submitted to the BMJ on 5 October 2016.

There is an interesting article in the BMJ this week[1] by Greenfield et al on ‘Rethinking primary care’s gatekeeping role’ that covers only one element of primary care, and in excluding other, more important, aspects of the role risks these others being left out of the debate entirely.

Greenfield’s premise is based on a model of health care that is currently fashionable, but which is simplistic and linear in its philosophy: ‘I’ve been diagnosed with prostate cancer, it needs treating, I need to see the right specialist as quickly as possible’. Such a symptomatic approach to medicine is clearly important, but assumes an entirely straightforward, physical spectrum of disease.

The reality of modern health care is that it is being overwhelmed by complex illness that combines multiple physical diagnoses, often chronic in nature, with social and psychological overlays. Treating my prostate without considering my diabetes, my hypertension, the impact of my illness on my job, income, and mental wellbeing is reductive and sub-optimal, not only in clinical terms, but also in terms of cost-effectiveness.

Whilst the role of general practice clearly includes gatekeeping, that function needs to be put into the context of care co-ordination and the management of complexity. In the multilayered fabric of the NHS, the warp of clearly defined clinical pathways being organised in efficient straight lines needs to be held together by the weft of primary care, weaving the intricate patterns that make up genuinely effective care. Just as the conductor of an orchestra balances the dynamics of the different sections of the orchestra to produce an harmonious melody rather than a cacophonous row, so effective primary care juggles the different (and often conflicting) drivers that influence us all, to produce coherent and effective care.

When this is done well, the whole system benefits, and researchers such as Barbara Starfield[2] have pointed out that the cost-effectiveness of health services is proportional to their degree of primary care orientation, not because of gatekeeping per se, but because of effective and appropriate holistic case management.

The risk is that an article like Greenfield’s (which doesn’t mention anything outside the linear referral model) is that it reinforces our increasingly symptomatic approach to medicine, where we treat diseases rather than people, with the inevitable result that demands and costs rise, duplication and inefficiency ensue, and everyone suffers from care that is completely at odds with the human condition.

What is required is a model that is more co-ordinated professionally and organizationally, that aligns incentives appropriately, and that carries public opinion with it. As long as the public continues to expect the linear simplicity described by Greenfield and colleagues, that is what will be provided; only when there is a better understanding of the subtlety and complexity of health care will we have any chance of rebalancing the system. Articles such as this risk moving the debate in precisely the wrong direction.

[1] BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4803 (Published 23 September 2016)

[2] Starfield B: The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998 Health Services Research Volume 38, Issue 3, pages 831–865, June 2003 DOI: 10.1111/1475-6773.00149

Visual ref: http://commons.wikimedia.org/wiki/File:Kette_und_Schu%C3%9F.jpg

Jo Cox: politics as they should be

Jo Cox

A young, inexperienced MP died horribly yesterday.

I didn’t know her, never met her, had barely even heard of her, yet several aspects of this dreadful event have really stuck with me with me, and made me think a lot about the state of our Society today.

My first reflection is the fact that Jo was obviously in politics because she cared. Unlike many of our MPs, she had had a career before politics, and so had ‘found herself’; she wasn’t using her role as an MP to put herself on the map, and justify her existence. People like David Cameron, George Osborne, Peter Mandelson, Nigel Farage, even Tony Blair, none of these have known much of the real world outside Westminster, having moved from education (often in the rarified atmsopheres of private schools and ancient universities) straight to the Westminster Club, whereas Jo was on a genuine mission to make a difference, having already made a significant mark in her first career at Oxfam.

My personal view is that one shouldn’t be allowed to become an MP until one can point to real achievements in other, more tangible areas of work, but that’s by the by…

My second reflection is how Jo’s inclusive attitude to people and issues were at a stark contrast with the whole tenor of political discussion in this country at the moment, as can be seen in the debate about Europe. Next week, we will all vote whether or not to stay in the EU. Most of us will cast our votes on the basis of beliefs and emotions, largely uninformed by any real evidence, thanks to the destructive, aggressive way in which any facts and statistics have been used.

I believe (and I rather think that Jo would have agreed) that the UK lives in the ‘society’ of Europe, and that it makes no sense to drop out and abandon these old friends in the hope of finding a whole new set of allies in the broader world. It smacks of childhood fantasy to jump into a completely unknown future in the Micawber-like expectation that ‘something better will turn up’.

Moreover, the self-centred ‘me, me, me’ philosophy of the Brexiteers shames me; any balanced, successful society has to balance self interest and altruism; it’s the way we build trust, and work with others to mutual benefit. To have got this SO badly wrong smacks either of childlike selfishness and lack of understanding, or of a genuinely malevolent egotism that thinks it’s OK merely to ‘look after number 1’. The flavour and sense of  Jo’s speeches, and of the way that the causes she espoused were so broad and inclusive, suggest that she might have shared this view of the politics of the referendum.

The obverse of this, the one potential silver lining to this unmitigated misery, may be that everyone involved in the current debate will now take the time to rethink their approach, and (dare one hope?) even their philosophy, so that we approach the referendum next week in a calmer, less heated way.

And of course, none of these reflections cover the human tragedy that has occurred; to see a young, vibrant, motivated, attractive, lively mother and wife, woman and campaigner, snuffed out so senselessly, makes me cry every time the thought comes back to me, and I’m a (very!) grown man….

Rest in peace, Jo, and may some good come out of the senseless waste of such a valuable life.

General Practice: Jack of all trades and master of one

The NHS media profile is dominated by hospital crises, with the rock of growing demand (based on increasing need and rising expectations) meeting the hard place of static resources.

In this ‘perfect storm’, the whole welfare state colludes in damage limitation: Social Service departments expediting the transfer of hospital patients into care homes, and GPs helping deal with patients before and after admission.

There are several dissonances here: facilitating access to hospital services jars with a ‘primary care led NHS’[1]; the episodic treatment of malfunctioning body parts isn’t ‘people based;’ and the focus on institutional services is hardly ‘care closer to home’[2].

So it seems appropriate to revisit some of these concepts and see whether and how they fit into a modern healthcare system.

At the NHS front end sits primary care, based on general practice. GPs were central to the creation of the NHS: generalists running their own (for profit) businesses, often singlehandedly. They treated whom they could and referred those they couldn’t to specialists, a balance depending on individuals’ skills and interests.

Over time, circumstances and legislation have produced larger practices, becoming more systematized and providing ever more services ‘in house’. These changes have focused largely on treating diagnoses, with less attention on looking after people who happen to be ill. The triple diagnosis[3] (the physical, psychological, and social aspects of any illness) is a key attribute of holistic care, that acknowledges that sickness is determined by more than physical symptoms: dis-ease does not equate to disease. Without acknowledging the difference, healthcare systems are doomed to treating the symptoms of ever more people without addressing their broader underlying causes.

Barbara Starfield was an eminent American researcher who understood this distinction. She researched the impact of primary care on population health in many OECD countries [4]. Firstly, she described the roles of general practice, demonstrating several unique attributes in its most effective configurations:

  • first point of access to care (hence ‘primary’ care)
  • offering comprehensive services (defined by patients’ notions of illness, not clinicians’)
  • using referrals to control access to institutional care
  • coordinating patients’ journeys, wherever in the system they find themselves

Secondly, she showed a direct correlation between primary care maturity and overall healthcare efficiency. For instance, the UK and Scandinavia have deeply embedded general practice systems, and highly cost-effective health services; the USA, in contrast, has poorly developed family practice, and the world’s most expensive healthcare, whose impact on health is disproportionately poor.

However, the current UK zeitgeist is rapidly undermining all these precepts:

  • initial access to services in acute illness increasingly seems to be through A&E departments rather than primary care
  • that care focuses on physical diagnoses, a reductive definition of ‘comprehensive services’
  • the control of spending associated with holistic approaches to care is being subsumed in the drive for measurable ‘KPIs’
  • there is little coordination of care, even within the acute sector itself, let alone across the whole health and social care system

In Starfield’s typology, the NHS is losing its inherent advantages and becoming more expensive and less effective. Could this be reversed?

The short answer is ‘yes’, but concerted efforts are required in areas including policy, resources and determination. There need to be changes to hospital services and to public attitudes, spearheaded by a significant reinvention of general practice.

In a society that values medical specialization above everything else, GPs are seen as ‘jacks of all trades and masters of none’, and are gradually evolving into ‘consultants-lite,’ increasing their technical skills and reducing their emphasis on holistic care. Policy initiatives focus largely on new technology, often in the form of tablets (pharmaceutical or electronic), and the inexorable pressure to treat symptoms rather than people becomes ever more deeply embedded.

In reality, to achieve the kind of integration described by Starfield, general practice does require Specialists, but ones who specialise in the complex field of Generalism, that vague concept that encompasses empathy, psychology, pattern recognition, synthesis, and the ability to manage both people and risk, as well as excellent clinical and organisational skills. If we really want ‘joined up’ care, then GPs need to reclaim their position as the conductors of the health care orchestra; their training will need to acknowledge and include all these skills (despite the difficulties in quantifying them), and society at large will need to rethink its attitudes to these ‘soft’ skills, and celebrate them.

For if managing heart failure is complicated, then case management and whole system co-ordination are truly complex, an order of magnitude more difficult to carry out effectively. General practice at scale has the potential to offer a genuine paradigm shift, but any mooted ‘super practices’ must be based on holistic, coordinated care if they are to succeed; ersatz out-patients clinics are the last thing we need.

[1] Department of Health (1994) Developing NHS purchasing and GP fundholding: towards a primary care-led NHS. London: DH (EL(94)79)

[2] Department of Health (2007) Shifting care closer to home; London: DH

[3] Marinker M (1981) Whole person medicine in Teaching general practice (Cormack J, Marinker M. Morrell D eds); London Kluwer Medical

[4] Starfield B, Shi L, Macinko J (2005) Contribution of primary care to health systems and health; Milbank Quarterly; 83(3): 457-502

Clinical commissioning groups: how to ensure their first birthday isn’t their last

Cake

It is more than a year since clinical commissioning groups (CCGs) formally came into existence in England, and although strategic plans are slowly beginning to emerge, CCGs continue to struggle with an infrastructure originally designed to control a national system.

The 2012 Health and Social Care Act saw CCGs as the mainspring of commissioning, capitalising on general practitioners’ twin roles: dealing with patients at the ‘front door’ of the NHS and referring and coordinating their journeys through its complex institutional pathways when necessary. The notion was that general practitioners’ (albeit anecdotal) knowledge of local services could be synthesised to inform operational and strategic commissioning throughout the NHS. Giving CCGs the freedom to change services in their local health economies was intended to encourage innovative models of care that were more user friendly and (hopefully) better value for money.

However, CCG leaders found themselves the late arrivals at a party already in full swing. NHS England had established the ground rules, subsumed specialist commissioning and primary care, and determined how CCGs should work and be managed. And adding to the harsh financial pressures, CCGs found their budgets being raided for contingency and efficiency funding as well as for augmenting specialist commissioning, maintaining pre-existing private finance projects, and supporting social care initiatives.

In terms of how to engage and enthuse newcomers, this is not what textbooks recommend, but for the current policy to work CCGs must pull their weight. How can this be achieved? CCG development seems to parallel adolescence. By the time children leave home to live independently, they need to be able to deal with the physical, financial, and emotional hurdles that they will inevitably face: they must shoulder responsibility and risk.

Similarly, CCGs were intended to assume increasing responsibility for services and develop a mature relationship with NHS England through the area teams and commissioning support units. Many have commented that this is not happening and that a form of indirect cajoling has developed instead. Despite a few signs of change (such as NHS England accepting an annual survey of its performance by NHS Clinical Commissioners), the general sense is that CCGs are under-resourced in human and financial terms and that the need to cope with what is operationally urgent is preventing them from dealing with what is strategically important. If CCGs are not allowed to develop sufficient self determination, their growing frustration and enduring dependency will drive their participant general practitioners to lose interest at best and throw adolescent tantrums at worst.

CCGs were intended to be clinically driven by autonomous professionals who function better as volunteers than as conscripts. However, such professionals (especially independent general practitioners) traditionally lack experience of corporate working, and so encouraging them to consider collective needs as well as those of their individual patients and practices is key to the success of their CCG.

This is a complex challenge that needs tackling at various levels. Overt CCG leadership requires organisational expertise as well as a thorough knowledge of local context. Many of the clinical chairpeople and accountable officers still need to learn more about strategic thinking, which takes commitment as well as protected time and funding. Whether it is even possible remains to be seen; CCGs vary greatly in their arrangements and ambitions and even the roles of clinicians and managers differ considerably.

Leadership needs to be mirrored by support among members; clinical commissioning cannot succeed without ‘grass roots’ input informing strategic thinking. Support will vary, and senior (strategic) CCG staff will have different perspectives from frontline (operational) clinicians. Such differences have never previously been bridged, and consequently individual clinical decisions have rarely influenced high level strategy. If CCGs are to exploit their potential fully, this aspect of their functioning needs a lot more development, which also takes time and money. So far, neither has been prominent, with most attention being paid to traditional senior NHS leadership, and almost none apparent to its corollary, what we might call ‘followership.’

Another obstacle to the successful development of CCGs is that the commissioning of primary care is separate to that of secondary and community services. CCGs control most of the latter two but none of the former. If a CCG decides to replace a traditional hospital service with a primary care alternative, it can decommission the first but cannot directly commission the second.

If CCGs are to hold responsibility for providing healthcare for their populations (the idea implicitly underpinning their creation), then this mismatch must be removed to give them the tools and accountability needed to provide services. If we believe in localism at all, then how they use these tools should be their decision; if they choose to provide services within their own organisation rather than subcontracting with local NHS Trusts, then that needn’t constitute a conflict of interests as long as the accountability is in place.

Outcomes such as agreed levels of morbidity, patient satisfaction, timeliness, and financial probity all offer measures of accountability irrespective of the agency involved. As it stands, CCGs are unlikely to change their paradigms of care because current mechanisms discourage change rather than rewarding it. Moreover, any existing momentum is likely to dissipate as those involved become increasingly disillusioned.

With the NHS caught between rising demand and lessening funding, the system will increasingly have to do more for less. Giving working clinicians some responsibility for achieving this, by connecting their daily activity to strategic leadership, seems logical. But CCGs will have to be supported much more emphatically, politically and operationally, if we want health service policy, local services, and the needs of the whole local population to be brought together coherently.

This is a slightly revised version of a paper prepared in collaboration with Michael Dixon, and first published in the BMJ (online 2 April 2014 as BMJ 2014;348:g2306).

Alcoholism: heartsink or microcosm?

ImageFew GPs get excited by seeing known alcoholics walk into their surgery; they are the classic ‘heartsink’ patients, with a host of problems, often insoluble. They range from the physical (you really do destroy your body with long term drinking), through the underlying psychology (there are often personality disorders and depression), to the day to day consequences, such as social isolation, unemployment, and homelessness.

Dealing with all these issues is difficult, as it entails the interaction of many different people, each with their own rules, cultures, and bureaucracies: alcoholism is perceived in very different ways by say, policemen, social workers, and nurses. Moreover, the patients themselves are often unwilling or unable to take control of their own destinies, and this makes the oversight and management of alcoholism all the more difficult.

However, with patience, experience, and the ability to work across many professions and disciplines, progress can usually be made. It may not be possible to overcome the problem completely, but at least one may be able to reach some form of stable balance between alcohol and the external world, a modus vivendi that allows life to continue in a relatively sustainable way.

In that sense, there may be lessons to be learned from alcoholism as an example of modern medicine’s new Big Issue: the treatment of all long term conditions.

The first half century of the British NHS were dedicated to the creation of super-specialists, able to diagnose and treat ever more precise conditions, thus defining their patients not as people, but by their illnesses (‘the leg in Bed 4’, ‘the appendicitis in A&E’). This approach may be useful when everything is running smoothly apart from one small problem, but such a ‘Kwik Fit’ approach to medicine fails utterly when there are several major issues to be addressed at the same time, especially when they include social and psychological determinants as well as physical ones.

Increasingly, health services around the developed world are finding that it is these complex cases that are exercising their services (and increasing their expenditure) rather than simple mechanical failures. Managing a sixty year old lady who has diabetes, breast cancer, and has recently been widowed is very different from mending a broken leg, or even treating a straightforward heart attack, and it is here that there may be useful lessons from the enlightened management of alcoholism. The key messages in both instances are:

  • Take an holistic, person based approach to the problem, don’t try to fragment it into reductive components to be treated in separate silos.
  • Be prepared to work with other teams, disciplines, professions, and organisations, without assuming that only you have the answers
  • Care is at least as important as cure: many of these conditions will last a lifetime, so we have to move away from the idea that absence of cure is failure.
  • Work with the patient, and not at them; in the end, it is their illness, and their involvement and expertise are key to its management.

I wrote this piece for the blog site of the Health Services Management Centre (HSMC), where it was posted last week.

Open letter to Simon Stevens

writing-query-letterDear Simon

 

Despite the fact that most open letters probably never get read by their addressees, I thought that I would join the throng of correspondents writing to you: after all, if ‘crowd-sourcing’ can raise funds and drive international campaigns, maybe it can influence policies too…

As I’m sure you’ve recognized, the NHS is in a weird place at the moment. The cognitive dissonance we all accept as part of running a state controlled (i.e. politically sensitive) system in the 21st century has reached new extremes, with the rhetoric of localism (Clinical Commissioning Groups, local choices, patient involvement) being totally at odds with the reality of national inspection regimes, the imposition of ‘Clause 119’ and the central pressure to save costs that is currently exercising us all.

The short term ‘patch it and move on’ measures of the past few years have led to so many unintended consequences that we seem to be tying ourselves into ever tighter knots physically as well as politically. Here are just three examples, but there are many more:

Emergency departments are very busy because they’re available and GPs aren’t, so we try to discourage people from attending by….extending the range of services provided at A&E.

Lewisham Hospital is really successful, so its staff are rewarded by… their assets being threatened in order to prop up the failing South London Healthcare Trust.

CCGs are tasked with responsibility for the health of their populations, and encouraged by… having their resources cut and their nascent power diminished.

And so on and so on….

If we are ever to cut through this Gordian knot, here are just a few simple principles that might help:

  1. There should be clarity about the separation between procurement and provision of services: the Government is the commissioner, and the NHS is the provider. That boundary is where the strategic overview needs to be implemented, and where the money is exchanged. The NHS is then supposed to consider how services might best be delivered, with the CCGs intended to be pre-eminent in this process, providing what services they can through their GP networks, and subcontracting the rest to agencies such as hospitals and other specialized providers.
  1. Work with human nature rather than against it: people work best when they agree with their organisation’s overall purpose and when they can see some benefit from what they are doing. Thus, a consistent approach with obvious logic works better than a series of mixed and contradictory messages, especially when those messages are clearly disingenuous and even dishonest. NHS staff don’t have to agree with everything, as long as it is clear how decisions were made, and they can rest assured that there will be consistency and stability in their working lives.

Moreover, those benefits don’t have to be financial; people join the NHS because they want to make a positive difference to the lives of ill people, and want to be proud of what they do. Approval, appreciation, peer recognition, these are all useful and not nearly as inflationary as monetary markers, whose price has to constantly increase to retain their value.

  1. Make policy and stick to it, even if the Media pundits don’t like it: democracy is great, but where long term policies are concerned, the ballot box is a better place make judgments than the daily press. Populist government leads to uncertainty and instability, and in the end, loses the respect of the populace anyway, so the system should think in years, not weeks, when it makes policy.
  1. Society needs to acknowledge the clash between rising expectations and finite resources; efficiency is clearly a good thing, but no amount of cost improvement is going to keep pace with a population that expects everything, constantly, and for free. At some stage soon, we are going to have to grasp the nettle of putting the brakes on demand, whether by formally introducing the notion of rationing, charging, or excluding.

With these suggestions in mind, Simon, perhaps you should empower the CCGs to do what they are being asked to do? That’ll mean giving them more control of (and tighter accountability for) the mechanisms and the money; they’ll need a lot more development too, internally and in the way that they deal with the rest of the service.

Perhaps too, you should think of simplifying the fog of micromanagement and punitive regulation that has descended over the NHS? At a local NHS acute Trust for instance, the 200 pages of specific measures that have to be discussed at every Quality and Safety committee bring its members to their knees. Most clinicians have a positive intent, and are prepared to have their effectiveness measured, but to do it in such prosaic, reductive ways is not only counterproductive in the short term (the measures aren’t usually helpful) but in the long term too (they de-professionalise the workforce). A few outcome measures, measured by peers and patients, would pass the responsibility and ‘ownership’ of the service back to those who are best placed to run clinical services.

Another (albeit more difficult) objective would be to resist the pressure from the acute sector; crises are always more interesting and newsworthy than chronic and often insoluble problems, but they divert attention from what is truly important to what is often merely urgent. To achieve such an objective would be countercultural in today’s world of instant gratification, but if we don’t manage to stem this tide even a little, then the future of a sustainable service is bleak.

On a more positive note, almost everyone in the NHS (and most members of the public) are aware of these issues in some way, and would be willing to throw their weight behind policies that begin to address them. Sure, the traditional tribalism of the different parts of the service will always exercise us, but there is nothing like common purpose to bring people together, and there is plenty of that where the NHS is concerned.

It’s a daunting task, that will need stamina as well as a thick skin; but modernising health services is a worthy end, and we’ll all help where we can.

Good luck, and kind regards

Jonathan

CCGs need to evolve and mature, NOW!

I have writEvolutionten before about the difference between ‘unconscious incompetence’ and ‘conscious incompetence’, and how one has to recognise a deficiency before one can address it, but I have rarely seen such an acute example as the one that currently exists in the CCG world.

As new organisations, often incorporating senior GPs with little if any experience of strategic leadership, it is perhaps not surprising that CCGs have taken time to grasp the breadth and the depth of the issues that face them; not only are they notionally responsible for an annual budget of over £60 billion of public money, they have to ensure that their own primary care house is in order, and deliver a degree of corporacy amongst their members that has never even been envisaged, never mind achieved.

However, now that they are nine months into their first ‘live’ year, one might have hoped to see more recognition of these issues, and a wealth of initiatives both locally and nationally to try to jolt the young groups into a maturity that admittedly needs to be well beyond their years. It is disappointing therefore to note that (certainly in my universe), there appears to be little if anything happening at a systemic level. The Leadership Academy seems intent on setting up a production line to manufacture senior leaders (an oxymoronic concept if ever there was one), and attracting mainly managers from provider organisations.

Others that might be expected to be compiling effective, accessible programmes to fast track CCG development (NHS Confed? BMA? RCGP? NHS Clinical Commissioners?) seem at best merely to be considering setting up such initiatives. They appear to be more concerned with meeting DH/NHS England operational edicts and maximising contractual benefits, beginning to replicate what CCGs were intended to end once and for all: doing things right at the expense of doing the right things.

In the meantime, NHS England, in its unreconstructed macho fashion, is starting to exert more direct pressure in the only language that its political masters seem able to understand: reductive operational targets. The whole notion of culture change and clinically led progress is rapidly being diluted, to be replaced by structures that will look more and more like PCTs, or the even older Health Authorities.

So what is required? The first thing is for CCGs themselves to recognise the need for internal development; even in my own small way, I have been trying to encourage the development of locally focused leadership programmes, learning sets, even stand alone workshops for CCG staff and their members to start to get to grips with the agenda, but it is proving to be a steeply uphill task. CCG chairs and accountable officers should think about resourcing such work themselves, as large scale mass produced products can never achieve the kind of cultural and organizational ‘fit’ change that a ‘bespoke’ programme can. The larger players (see above) should support and facilitate these local processes, and some central resourcing would be very helpful to oil the wheels and get the show on the road.

Do it now, applying a bit of welly to the process, and progress will be satisfyingly fast; leave it much longer, and those in the rank and file of the CCGs, the GPs who really need to ‘think differently’ to achieve systemic change, will have lost interest and gone back to the day job. Without them, not only will CCGs not succeed, the ‘supply side’ drivers (hospital crises, by and large) that have steered the NHS for so long will come to dominate even more strongly, with the only levers available to control them being the traditional blunt, insensitive, centrally controlled levers that have never really worked.

As the adage has it: ‘if you always do what you’ve always done, you’ll always get what you’ve always got.’ Isn’t it time that CCGs started taking control of their own destinies?