I am an enthusiast for health services management married to clinical leadership. That does not sound very glamorous, but for me it underscores what the new NHS is all about.
When the White Paper was launched on 12 July, GPs in England ended the day about £70 billion richer in healthcare funding terms. My practice did not as our share was already in my locality's back pocket.
In Cumbria, integrated care consortia have had hard budgets distributed on a fair shares basis since April.
Cumbria has been divided into six consortia or localities for the past couple of years.
Each locality covers roughly a 100,000 population and follows local authority boundaries. We are not precious about this. If there are clear benefits to practices being within a neighbouring locality's sphere they can switch and a couple have done so.
Our localities' sizes suit the White Paper's proposed GP commissioning consortia. Size really does matter.
If your consortium is smaller than the 'magic' 100,000 population then chance variation alone could bust your budget within a year.
At the moment, our budget covers prescribing, community services and tariff-based secondary care - emergency admissions, outpatient referrals and their consequent procedures.
'Sounds like GP fundholding', I hear you say. 'Not so,'
said health secretary Andrew Lansley when he visited us shortly before the White Paper was published. He felt it was more like a development of the total purchasing pilots that succeeded fundholding.
Mr Lansley said that fundholding's aim to promote competition, raise standards and make providers more responsive might apply in large conurbations with many providers. But in many health economies, such as Cumbria's, secondary care held a monopoly and a different model was needed.
For me, our model's attraction is being able to stand back and look at our population's healthcare needs armed with good local intelligence. I know that the suicide rate in one area is twice the national average and, out of the 600 people living in residential/nursing homes in another area, one in three will have an emergency hospital admission this year.
Our system takes this background picture and gives us the tools and support to get the most bang out of each healthcare buck.
For example, in trauma and orthopaedics, on the emergency side, we perform badly and disproportionately large numbers of patients are admitted with fractures. How can we improve this?
I like the analogy of the crocodile-infested swamp. Once you have fallen in and been bitten, you are in A&E with your fractured neck of femur.
To help you out of the swamp, I want best practice around patient pathways, timely surgery and co-ordinated discharge arrangements to get you home or into a recuperation facility with appropriate nursing and therapeutic support.
Better still would be the ability to operate upstream and drain the swamp. There are a host of options, many of them non-medical, such as falls prevention strategies and mobilising friends, neighbours or relatives to say: 'Gran, let's get someone to fix you another handrail on the stairs.'
Medical options include identifying the population at risk with osteoporosis. Often, this can be done with simple algorithms rather than population densitometry. Primary care can be incentivised to identify and treat these patients with pharmacy support to tackle associated medicine management issues.
Exactly the same analogy applies to managing COPD, which costs millions in emergency admissions each year. Upstream action is to encourage smoking cessation - some of my local wards have smoking rates double that of urban Newcastle.
Highest risk patients
Midstream primary care measures are around detailed care planning for the highest risk patients. Theses include ensuring the requisite antibiotics, steroids and oxygen are to hand and that the specialist community respiratory team is 'upskilling' all the community staff rather than trying to deal with the tide themselves. Is the out-of-hours service on board? Is it worth investing in the Met Office health forecasting scheme?
Downstream is about difficult conversations with patients and families about the real benefits of admission during an exacerbation and making better use of end-of-life strategies and domiciliary support, such as the palliative care services.
With a system of engagement to foster genuine ownership and responsibility with smaller groupings of practices each with their own clinical lead, community services lead and managerial support, we can implement actions that directly improve our health services.
On a larger scale there are health and service improvements I want for my patch that we cannot engineer as a mere locality. For example, to introduce a percutaneous coronary intervention (PCI) service in Carlisle, I need the support of my neighbouring localities and some of the more distant ones so we can mobilise resources of 500,000 patients.
PCI is a basic service recognised worldwide as the treatment of choice for acute coronary syndrome, but it is not available in Cumbria.
To make it happen, I need to have the support of local specialist secondary care and the staff concerned are right behind it. But we are yet to get the support of the regional tertiary centres?
I see the opportunities presented by the White Paper as around facilitating collaborative working across the healthcare spectrum from home right up to intensive care.
- Carlisle GP Dr Weaving co-chairs the Clinical Senate of GP leaders of six integrated care consortia in Cumbria