SECOND OPINION
ments can, as described, be lessened sig- nificantly?
In fact the future existence of stand-alone large outpatient departments needs to be seriously questioned. Unlike the successful managed care organisations in the USA, we have a comprehensive primary care medi- cal system.
We also need a radical shaping of hospital- based elective care. Decision support sys- tems for patients and clinicians lessen the need for hospital care.4
There has been related evaluation and policy development. Fundholding, which in turn led to some experiments in total budgets being devolved to GP practices – Total Purchasing Pilots (TPP).3
There was evidence that some 15% to 20% of those groups holding real budgets were able to secure shorter waiting times, achieve lower referral rates and, in the case of TPP, reduce emergency bed-days.
And to increase responsiveness and cut down on the numbers of missed appoint- ments, the NHS launched the Choose and Book initiative in 2006 as part of the Free Choice government policy introduced in April 2008. Technical glitches with the re- lated software however delayed the roll-out and indeed clinician acceptability of the continuing potential of Choose and Book to bring a long overdue responsiveness to elective care.
And there has been much policy develop- ment on long-term conditions care, condi- tions that generate an enormous amount of medical outpatient contact, much of which should be obviated if the NHS sys- tematically implemented the Department of Health’s strongly evidenced-based Long Term Conditions Framework of 2007.
Currently we have the opportunity offered by an even longer overdue systematic in- volvement of clinicians in commissioning. Commissioning takes place at many levels, by clinicians in the act of referral to other services and by small organisations such as general medical practices.
The responsibility of the commissioner is
The use of electronic communication will lessen the need for face to face contacts. Professor Lord Ara Darzi envisaged an 80/20 split for future planned surgery. ‘Lo- cal hospitals will carry out 80% of surgery, mainly as day cases and short stays, with the remaining 20% of planned surgery be- ing carried out at specialised centres, such as those for trauma and cancer. Some of the 80% could be carried out in community hospitals, health centres or even large GP practices.’
And why not direct access to the surgery list?
We can at long last align the incentives of commissioning and provision for cost ef- fective care. The time has come for radical challenges to the complex edifices of the past.
not to subsume that activity but to support, challenge where necessary, co-ordinate and be the strategic leader for the many levels of commissioning.
Clinically-led commissioning can and must facilitate an improved clinician-led provi- sion so as to align clinical-led activity with budgetary responsibility. It is, after all, cli- nicians and particularly doctors who spend the money.
Furthermore, unless some budgetary re- sponsibility is devolved to practices them- selves, CCGs may not get the systematic clinical involvement that is required for transforming care. Transforming all elec- tive care including unwarranted admis- sions will of course disproportionately hit hospitals who make a tariff ‘profit’ from elective care to offset frequent urgent care ‘losses’.
The answer must be to also transform ur- gent care and hospital care in total. And where better and arguably easier to start than with outpatient care, where both re- ferral and especially follow-up appoint-
Dr David Colin-Thomé is an independ- ent healthcare consultant, and honorary visiting professor at Manchester Business School, Manchester University and the School of Health, University of Durham. He is a former General Medical Practi- tioner at Castlefields Health Centre, Run- corn and National Clinical Director of Pri- mary Care. He also sits on NHE’s editorial board. Visit
www.dctconsultingltd.co.uk
References
1 Bailey J et al. ‘Is follow up by specialists routinely need- ed after elective surgery? A controlled trial.’ Journal of Epidemiology and Community Health 1999; 53: 118-124.
2 Florey C et al. ‘A randomized trial of immediate dis- charge of surgical patients to general practice.’ Journal of Public Health Medicine 1994; 16: 455-464.
3 Smith JA, Mays N, Dixon J, Goodwin N, Lewis R, Mc- Clelland S, McLeod H, Wyke S (2004). ‘A Review of the Effectiveness of Primary Care-led Commissioning and its Place in the UK NHS.’ Lon- don: The Health Foundation.
4 O’Connor et al., Cochrane Library, 2009.
Dr David Colin-Thomé
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