The minister for Health, Social Services and Public Safety in Northern Ireland, Edwin Poots, set up a review team in 2011 to provide a strategic assessment of the health and social care service, bring forward recommendations for the future shape of services and provide an implementation plan.
The review, Transforming Your Care – A Review of Health and Social Care in Northern Ireland, was published just before Christmas 2011. The report to a large extent wrote itself because the problems inherent in the system are well known.
The context of the review is one of a predicted funding gap of £600m by 2014/15 in a budget of about £4.5bn and a system that overinvests in an inefficient hospital sector while underinvesting in community, primary and mental health services. The necessary direction of travel is obvious, with resources and work needing to ‘shift left’ from secondary to primary and community care.
This was reinforced by two reports published early in 2011, by John Appleby, chief economist at The King’s Fund, and by US consultancy firm McKinsey, which highlighted the ‘productivity gains’ that needed to be achieved within the hospital sector.
The Transforming Your Care proposals include:
- A reduction in acute hospitals from 10 to between five and seven.
- A shift of 5% of hospital funding to primary and community care.
- A shift of work from hospitals to community and primary care.
- An increased role for GPs in commissioning and provision of services.
- An emphasis on prevention, focusing on obesity, smoking and alcohol.
- A shift towards greater care at home.
- A robust, ground up commissioning structure.
The commissioning structures in Northern Ireland consist of five local commissioning groups (LCGs) covering populations averaging about 350,000 patients, broken down into smaller commissioning groups known as primary care partnerships (PCPs). These structures are already in place and are beginning to develop roles. They are commissioning services such as community nursing, out of hours, prescribing and hospital services where there are bottlenecks, such as neurology, ENT, minor surgery and diagnostics.
There is a real drive to commission innovative care pathways that will keep patients out of hospital and away from A&E.
Integrated care partnerships (ICPs), described in the review, are a new concept and ‘will be set up to join together the full range of health and social care services in their area’. We see ICPs as a way of engaging and integrating with our consultant colleagues in hospital trusts. It is also planned that GP practices will work ‘on a formal basis as federation of practices’.
The report also deals with future planning around the issues of electronic care records, a single telephone number for urgent care, telemedicine, a stronger role for pharmacy and personalised care pathways for long-term conditions.
General practice in Northern Ireland provides some of the best primary care in the world, with 5.5% of the health and social care budget, but GPs are working at full capacity and cannot take on more work without extra resources.
GPs with experience in commissioning know it is easy to decant work out of the hospital sector into primary care, but the difficulty is in ensuring that resources move as well. Any changes need to be planned, agreed and resourced.
We need to ensure that commissioning is bottom-up. However, we have already seen community nursing resources being organised on a bureaucratic, industrial model that bears no resemblance to patient need, but rather meets organisational exigencies.
Capacity needs to be created within primary care to meet this shift of work with the development of premises, enhanced training and backfill for GPs out of their practices.
All three of the reports published in Northern Ireland in 2011 recognised the effectiveness and efficiency of primary care in providing services responsive to the needs of patients, to the highest quality standards.
That general practice is excellent is an immutable fact. The risk we run of applying this ‘shift left’ is that this excellent service will be destabilised by overloading it with secondary care work.
The Northern Ireland GPC (NIGPC) has agreed to work with the Department of Health and Social Care Board to ensure changes are planned, agreed and resourced. NIGPC believes this work should be organised through the commissioning structures in parallel to GMS. Much of it will be delivered by GPSIs, but this must be done outside traditional general practice to ensure the stability of the GMS model.
The service also needs to focus on patient needs, rather than wants, and insist that the shift from secondary to primary care continues from primary care to self-care, if general practice is to develop sufficient capacity.
Patients in the Republic of Ireland go to their GP on average one-third as often as those in Northern Ireland, yet the morbidity and mortality statistics are essentially the same. This is explained by the finding that patients in the Republic of Ireland do more for themselves, while GPs do more for their patients in Northern Ireland.
There is a salutary lesson in this and a need to promote self-care and to give the public a sense of empowerment about their own healthcare. The current political obsession with increased access creates a dynamic where patients become infantilised and dependent, passive recipients of state largesse.
The review provides us with the opportunity to turn this around and shift the centre of gravity of the health service away from secondary care to primary care and, even more importantly, to self-care.
- Dr Tom Black is chairman of Northern Ireland GPC