The chairman of the RCGP Scotland looks at the challenges to integration, and what we can learn from England
When Dr John Gillies took up the chairmanship of the Royal College of General Practitioners (Scotland) in 2011 he described the time as a critical period in healthcare, with England and Scotland’s NHS diverging on different paths. It proved to be prophetic. The Health and Social Care Act was enacted in England, which saw clinical commissioning groups established and a focus on competition, while in Scotland there has been the integration on health and social care, as outlined in the Public Bodies (Joint Working) (Scotland) Bill, and the Scottish Government’s 2020 vision for health and social care.
“In Scotland we’ve had a more evolutionary rather than revolutionary approach. In some ways that’s good, because it means you don’t have a re-disorganisation of the NHS every 18 months, as appears to have happened in England. The downside of that is you need to make sure that you evolve appropriately to account for the challenges that are facing the NHS in the future.” Dr Gillies says.
The RCGP is a UK body, and had set up a centre for commissioning in England to examine the idea of commissioning and support commissioners. Dr Gillies contributed to some of the work including “a guide on ethics for commissioners, avoiding conflicts of interests, or dealing with conflicts of interests, because you’ll always have conflicts of interests.”
Gillies told Holyrood in 2011 that there might be aspects of the findings which Scotland could learn from. In 2013, what have we learned?
“I think it’s a problematic transition you know. Quite a lot of GPs do have conflicts of interests because they’re providers as well as commissioners, so that has to be dealt with.”
“The other issue, which I perhaps hadn’t anticipated is that a lot of provision is going to non-traditional providers outside of the NHS, so groups like Richard Branson’s care groups, Serco or Harmony which are profit-making companies which are bidding for NHS services.
“I think the lesson for Scotland really is don’t do that. It’s as simple as that. Don’t do that, because in England they’re developing a health service which is fragmented and in which care is decided by contracts are reviewed regularly. Another concern is that powerful well-financed organisations like Virgin and Serco will generally be able to outbid local organisations, because they have the resources and organisational development, human resources contracting which many groups of GPs do not have. We have to see how that plays out but my concern is that you get a fragmented dysfunctional NHS” he says.
The UK Health secretary Jeremy Hunt told the RCGP’s 60th annual conference at the start of October that he would like to be thought of as “one of the most pro-GP health secretaries in a generation”. Dr Gillies was there to see the speech.
“He’s a very skilled communicator and talker, and in fact was pretty well received by English GPs, but I felt there were many questions about how support for GPs was going to be delivered.
“I think perhaps the one thing that I would take from the English reforms is that all health systems: Scotland, England, Ireland, Wales and internationally have to become much more focused on the patient, and the person who is the patient, if you see what I mean. These are different things. We need to think in terms of shared decision making and supported self-management.”
Wouldn’t the integration of Health and social care, founded on the Christie commission, naturally bring about a greater focus on the patient? John Gillies thinks so. “There’s a synergy between that and our thinking in RCGP Scotland. All GPs try very hard to be patient centred. If you look at our examinations and quality initiatives they’re all based on a relationship with the patient and delivering person centred care” he says.
“We need a bill which empowers the front line professionals. Not just GPs, but the social workers, the community nurses, to work with communities. Also we need to realise the potential of the third sector better than we’ve done.”
After practicing in the rural Borders for years, Dr Gillies recognises the important role the third sector brings to integration. “The third sector is often about communities being empowered to support and deliver services. In the Borders we’ve got community bus services, we’ve got community befriending services, lots of things like that and it’s related to Sir Harry Burns’ community assets view, which is supporting communities to do that sort of thing. You just have to be careful it’s not about handing over responsibility but it’s about using the assets of that community to support the vulnerable and elderly within that community.”
The RCGP and the third sector division of Scottish government is working on a project called engaging community assets. Could a general practice be described as a Community asset? “Yes absolutely. We like to think of ourselves as that.”
However Dr Gillies warns that other developing factors could scupper the good intentions. Issues of capacity and workload are hitting practices hard, with consultation rates having risen sharply. An RCGP poll conducted by ComRes in August shows more than 80 per cent of GPs saying that they now have insufficient resources to provide high quality patient care, and nearly half of GPs had already had to cut back on the range of services they provide for their patients. Over 70 per cent predicted longer waiting times for GP appointments within the next two years. The amount spent in general practice per person in Scotland dropped by almost 6 per cent in real terms between 2010 and 2013 as a result of a combination of funding cuts and population growth.
“I think the statistic you generally see is that GPs see over 90 per cent of people in the NHS for about nine per cent of the NHS budget. I don’t mean we should have 90 per cent of the budget by any means but that statistic has been there for many years and hasn’t changed” says Gillies. While numbers of hospital consultants have increased, he points out, numbers of GPs have remained static. In this environment GPs face four main challenges according to Dr Gillies: expectations, demography, multi morbidity and deprivation.
He thinks rising patient expectations of quality of care are appropriate: “The fact that we now have a 24 hour society means there is increasing demand for 24 hour access. I have a concern that sometimes people who get access, because GP practices are often beyond capacity, are often those who make the most demands rather than those who are in the most need.”
With a rising population and increasing inequalities, GPs are “not short of challenges”, and Dr Gillies frequently visits practices and faculties around the country. “GPs on the ground have yet to be convinced that Scottish Government health policy 2020 and the integration agenda will deliver the resources to provide more primary and community based services to enhance quality of care. The health system we have now is not the health system we need for the future. We need more primary and community based resources. We have good models: hospital at home and virtual wards in the community but these really need resourced if we’re to deal with the challenges. Health boards and the government have a problem in that most of the spend is on hospitals. Hospitals services are also pretty overloaded so how do you make that resource shift? That’s the challenge for government” he says.
Dr Gillies also warns that we’ve been here before: “I’ve been around long enough, I remember something called the primary care led NHS in the 1990s. It never happened. It was never led by primary care. It never has been. So we need the NHS to deliver this time. This is not rhetoric. One of my colleagues said, a couple of years ago when we went over this stuff, we have 5 years to save the NHS. That was two years ago. I would say he’s right. We have three years to save the NHS. GPs are not going to save the NHS on our own by the way. When I say ‘we’ I mean everybody.”
Dr Gillies cites the recently published ‘All Hands On Deck’ locality planning paper, a Scottish Government discussion paper on involving a wide range of stakeholders in the integration of services, as an inspiration: “I think that’s a good illustration of the communitarian approach we can adopt in Scotland, at our best. It’s very different to the marketised approach which commodifies health which they’ve adopted in England. I think we have the potential to do better.”
His chairmanship was due to be up in November, but it has been extended for another year, a year which will see the integration agenda furthered and a certain referendum on the future of the country.
“It’s probably going to be the most challenging year of my chairmanship. I would say so.”
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