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GPs and specialists must form integrated providers

The future means integrating GP and specialist services in the community, says Dr Minoo Irani.

The traditional model in the UK health service, where GPs work predominantly in primary care while specialist doctors are exclusively confined inside hospital boundaries, is changing for a variety of reasons.

The evolving health needs of the population, emphasis on patient choice and satisfaction plus the challenges of balancing quality of healthcare with cost-effectiveness are just a few examples.

The rational way forward would be for clinicians to lead on change, using a collaborative approach across primary and secondary healthcare to set up integrated provider organisations (IPOs), rather than letting policymakers or private organisations impose their own solutions.

Overcome differences
I believe that the primary/secondary care divide is artificial and expensive, and drives down quality.

There is plenty of evidence in medical and health management literature about the advantages of integrated working practices across primary and secondary care.

Increased communication and educational exchange, improved patient satisfaction, greater efficiency and improved health outcomes have been reported.

The difficulty has always been to overcome the culture differences that have come to dominate relationships between GPs and consultant doctors.

More importantly, there has not been a truly successful model of partnership working between primary and secondary care clinicians which preserves all the benefits of integrated working while being cost-effective.

The NHS Alliance, in its paper 'Specialist Doctors in Community Health Services', which was published in September, proposes the IPO as a new model of service provision. IPOs would encourage partnership working in its true sense, between generalist and specialist doctors.

It would also, for the first time, create a sense of ownership of the organisation and its values, where GPs and consultants would have the opportunity to look beyond the traditional biomedical model and explore population-based healthcare.

Better than polyclinics
IPOs would be a much more pragmatic model than polyclinics. In its simplest form, an IPO would be expected to run local health services (generalist and specialist services) within the community rather than merely grouping them together.

It would comprise generalists (GPs and GPSIs), specialist doctors (consultants, staff and associate specialists), nurses, allied health professionals and a simple management team.

These organisations would be allocated a budget to provide general and specialist medical services in the designated locality and for commissioning secondary and tertiary services as determined by population needs.

The polyclinic proposal for providing health services in London has received little support from primary care GPs.

There are widespread concerns about multinational companies setting up in expensive buildings and providing primary care and some specialist services with profit as the main motive.

Local services
IPOs would have completely different objectives; the emphasis would be on 'purpose-oriented health services' rather than 'purpose-built facilities'.

The starting point for IPOs would be groups of generalist and specialist doctors and patient representatives agreeing on the priorities for local population healthcare and designing and leading an integrated local health service.

Existing facilities (GP surgeries, community health centres) could be upgraded or purpose-built facilities funded via competitive financial schemes.

Enhanced commissioning
IPOs would also enhance the effectiveness of practice-based commissioning (PBC). This offers GPs a unique opportunity to shape health services for their patients and local communities.

However, while there are some excellent examples of successful PBC resulting from the enthusiasm and innovation of small groups of GPs, the current model is limited in its depth and breadth when it comes to having a broader view of population-based healthcare.

Some examples of PBC are clearly divisive between primary and secondary healthcare and may not withstand the scrutiny of quality or cost-effectiveness in the long term.

Unless PBC can demonstrate rapid universal uptake by GPs and a level of maturity by including specialists for a true partnership in population healthcare, it remains at risk from private providers.

The IPO model would encourage PBC consortia consisting of generalist and specialist clinicians to take over the responsibility of commissioning and provision of various elements of primary, community and secondary healthcare via different contracting mechanisms.

It would also allow the NHS to meet the challenges of prevention, productivity and policy that are emphasised in the recent King's Fund report 'Our Future Health Secured?' by Sir Derek Wanless and colleagues.

IPOs would preserve the benefits of partnership working between GPs and specialists while ensuring that GPs have a greater say in how specialist services were provided for their patients.

This model would allow a common governance structure for GPs and consultants and align their priorities for a truly modern health service.

This would be committed to quality patient care where population needs were addressed and infinite demand for healthcare controlled.

Dr Irani is a consultant community paediatrician in Berkshire and the national lead of the NHS Alliance's Specialist Doctors Network Resources

NHS Alliance

King's Fund

Why the NHS needs IPOs
  • The current primary/secondary care divide in the NHS contributes to higher healthcare costs, drives down productivity and results in a fragmented approach to population-based healthcare and prevention.
  • There is an urgent need to bring about integrated working practices between generalists and specialists to help create a truly modern health service and avoid monopolies of private providers.
  • Practice-based commissioning consortia consisting of GPs and specialist doctors should take the lead in commissioning and providing the various elements of primary, community and secondary healthcare.
  • These consortia, named integrated provider organisations (IPOs), would be designed around true partnership working between clinicians and would be sensitive to the health needs of the local population.
  • IPOs would facilitate joined-up, preventative healthcare, improve productivity in the health service and control limitless demand for healthcare.

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