NHS reforms: Let’s try and make them work

What is it like being chair of a cluster of 10 practices with a combined list size of 93,000 patients?

The Borderline cluster has taken its name from the fact that the practices are within three different PCTs (Primary Care Trusts),though most of their patients tend to look towards Peterborough for the provision of acute hospital or community care.

Despite the increasingly adverse or critical coverage of the healthcare reforms from either within the profession or from political parties opposed to the reforms, we generally have been content to plough our own furrow.

Because of our location most of the practices have had a long historical relationship and have previously been used to working together. Being part of a cluster has certainly fostered closer working relationships between the practices’ managerial and clinical teams.

Uniting services

Over the recent months we spent quite a lot of time formulating our strategy and setting up the organisation. NHS Cambridgeshire, who initially started the ball rolling, has now been joined by NHS Peterborough in helping us make progress, a fact which has become a little easier as both PCTs now share a single senior management team and chief executive. NHS Northamptonshire is now also signalling that it is willing to be supportive to the two practices who wish now to move away from them and into local health system.

NHS Peterborough has now devolved some significant work streams to a GP sub-committee, made up of the clinical leads of the five clusters which used the Peterborough healthcare system. Another of these clusters – rather like the Borderline cluster – has patients within NHS Lincolnshire and will be in the New World seeking to become a constituent part of the Peterborough and district consortium, which will eventually be formed.

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The sub-committee has been given the responsibility for negotiating the acute hospital contract, obviously supported by specialist PCT colleagues. We have also been given responsibility for developing a referral management policy within primary care and a prescribing policy.

More or less at every level now GPs are involved in the major decision-making processes carried out by NHS Cambridgeshire or NHS Peterborough. We have developed a system of clinical leads, so that care pathways can be analysed and optimised with our secondary care colleagues. These pathways are then reflected in acute hospital contracts, which now contain a level of detail which has never been previously possible. Work has also begun on drafting suitable quality standards and methods of monitoring contract performance by secondary care and community care providers.

The organisation and performance review of primary care is also becoming much accepted as a routine. Steps are underway for prospective review by peers or colleagues of all referrals made into secondary care rather than retrospectively as has happened to date.

Interestingly – rather counter-intuitively – this process has brought together primary care teams and enabled them to share clinical cases and discuss ways of managing conditions in the best way and has become a supportive and educational process rather than a negative, challenging one.

Despite all of these good things, however, I’m still left with a sense of foreboding about how we’re going to make the numbers add up and run a balanced budget. Despite all the co-operation and teamwork that has already taken place, I remain sceptical – if not a little nervous – of how we are going to live within our means.

Most doctors are aware of the inefficiencies that exist within the healthcare system but I’m yet to be convinced that there remain sufficient cost savings to to be achieved by reducing variation within primary care or optimising current care pathways. I’m sure the scepticism is certainly shared by many of my colleagues and probably explains why they do not wish to be taking part or being one of the trail-blazers in designing the new system as they do not wish to be blamed for the possible failure.

Having previously been a chair of a GP co-operative, which was set up to deliver medical care in the out-of-hours period, I’m well aware of the suspicion, scepticism and at times aggression, with which changes are sometimes met from within the medical profession.

I live and work in a part of the world which has struggled with NHS debt for some years and I’m not sure that GP-led commissioning will necessarily be able to sort things out. The purchaser-provider split, the incredibly complicated and opaque NHS tariff system as well as the powerful vested interests of monopoly foundation trusts with their business units backed up by Monitor all make the reduction of costs and the finding of efficiencies extremely challenging if not impossible.

The political imperatives of avoiding any price competition and the nervousness around the introduction of private providers who possibly could be cherry-picking simple but well-remunerated procedures add to the complications.

Certainly it appears from reading the media that our group of clusters – and the GP clinicians who lead them – are in the minority as is often the way when new developments come along.

Having previously been a chair of a GP co-operative, which was set up to deliver medical care in the out-of-hours period, I’m well aware of the suspicion, scepticism and at times aggression, with which changes are sometimes met from within the medical profession. I’m hoping, however, that as time goes by the reforms will be adjusted as we pragmatically try and make them work and that they will become more accepted and mainstream.

I hope also that many of the extremely able and specialist PCT employees who currently face an uncertain future will have found a home within a support agency which undoubtedly will need to be set up to enable a consortium to make a success of commissioning.

Dr Richard Withers is a Cambridgeshire GP and chair of the Borderline Commissioning Consortia – one of the first GP consortia to be established.