Health: Primary and Community Care

Baroness Finlay of Llandaff Excerpts

Thursday 24th June 2010 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I must declare an interest as a true Dr Finlay. I am a practising clinician; I am president of the Chartered Society of Physiotherapy; I work in palliative medicine; and I have links with many hospices around the UK. I hope that I have made all the declarations before I start.

We are facing change and I am sure that the Minister is inundated with advice and pressures but in the time preceding change, I hope that he will be cautious so that we do not have change while ignoring the potential unintended consequences of such change. One of the difficulties is that often we do not know what we do not know, and in the rush to bring about change we may not do the background research or explore the issues. I want to address the specialist services providing care for patients, the role of the third sector, particularly for terminal and palliative care, and the needs of patients out of hours.

In 2006, in England and Wales there were 503,000 deaths. That figure is anticipated to rise to 586,000 in 2030, which is a massive increase. Only about 20 per cent of patients die at home, so we have to think how the needs of all these patients will be accommodated. With that there has been pressure to move patients out into the community. The need for integrated care pathways for complex conditions increases as high levels of expertise are required to meet patient needs and there are more patients with complex conditions. I am concerned that in trying to save money substitution has been looked at but it is not without its dangers.

Despite a priority of providing care closer to home, the Audit Commission report, More for Less, found little evidence to show that PCTs have been successful in removing care from hospitals. There is little evidence that patients with rare, complex conditions are not prepared to travel to get expert care, because they know that they need accurate diagnosis and a really good management plan. The challenge is: how do we get patients seen by the right person at the right time in the right setting, as well as trying to move care out into the community? That is a stark cultural challenge that needs multiprofessional teams working in managed clinical networks to encourage collaboration and co-operation between primary, community and secondary care. That must also cover other aspects of home care provision, including social care.

The new commissioning arrangements must cross traditional NHS boundaries. The publication by the Royal Colleges of Physicians and General Practitioners, Teams without Walls, identified the need for integrated systems, clinical leadership in commissioning and aligned incentives, underpinned by patient involvement in commissioning systems, especially for those with long-term conditions.

The current problem is that payment-by-results tariffs in their present form incentivise against integrated care. The current tariff-based system encourages hospitals to treat more patients while, simultaneously, GPs are under pressure to refer fewer patients. That creates a tension that can work against the development of integration and against quality in patient care. It works against earlier diagnosis, particularly in recognising rarer and complex conditions. One way to rebalance the disincentive is to introduce payment by pathways or payment by conditions, to ensure that high quality generalist and specialist care have a sustainable future, for the benefit of patients.

Patients must enjoy equitable access to specialists when required. I have just chaired a joint report on allergies for the Royal Colleges of Physicians and Pathologists, and we have found a stark inequity in provision around the country. Specialist resources must be at the heart of any clinical network or community-based service. It is essential that we have services available 24/7. The current five-day provision does not meet patient needs. That service does not respond to the true, seven-day need of those who are really ill, including at night. In Wales, we have moved from five-day to seven-day working by clinical nurse specialists in palliative care, and we have shown in a short space of time a dramatic change, because problems that occur on Saturday will be dealt with on the Saturday or Sunday. By the Monday, it would have been too late to address them.

There are some specialist service needs where integration is essential. There needs to be a one-to-one relationship between the GP, the patient and the specialist in secondary care to ensure patient safety and that people understand the complexity of the patient's background. Repeated handovers do not work well. We know that information is being lost in a kind of conveyor-belt hand-over between clinicians. We need to restore patient safety and quality of care and ensure that the lead clinician has a comprehensive understanding of the patient to reduce complications and near misses, particularly in surgery.

Some things should be done only in places well equipped to do them. An increasing amount of so-called minor surgery has been done in general practice, but there have been some awful situations where melanomas have been removed, the margins have not been adequately marked, the resection was inadequate and the subsequent surgery was much more extensive and expensive than if it had been done in a specialist dermatology surgery centre at the outset. The Anaphylaxis Campaign has sent me horror stories of GPs giving advice to parents about children suspected of having a peanut allergy that was completely inappropriate and would have jeopardised the child’s life, not just their health. It was just as well that the parents phoned the campaign with their anxiety.

There are real problems out there, and there are risks as well as opportunities in moving towards a largely GP-commissioned framework. Academic GP is essential to driving up the standard of evaluation. We need to evaluate patient outcomes in any change. This is not about having a fashion for one model or another; an evidence base must underpin commissioning. As PCTs are divested of their commissioning responsibilities, GP consortia are expected to take up the mantle, but their skills and background knowledge, and even their willingness to do this, are really deficient in some places.

There needs to be a national view on minimum access rates and the provision of highly expert services to avoid a postcode lottery, particularly where there is a low critical mass in a smaller population, otherwise you get a bidding war between GPs and consultants that works against quality. If you do not have adequate dual provision, community-based services will have fewer places to turn to for training specialists for the future, for continuing professional development and for research. Driving that forwards will drive up standards of care in the future, particularly for those with more complex conditions.

I ask the Minister to consider some specific things: that promoting the idea that engaging doctors in the spirit of collaboration is required for successful commissioning; that commercial loss leaders might appear at first sight to be useful but may lose expertise and undermine quality in the long term; that the repudiation of unhealthy forms of competition is essential, as is encouraging jointly commissioned models for integrated health services; that choice for patients means the ability to access specialist scientifically based clinical excellence to diagnose and plan their management, which can then go back for ongoing care in primary care if there are good pathways; and, lastly, that the incentives and disincentives of payments by result need to be rebalanced to bring integrated generalists and specialist care closer to the patient’s home.

I am grateful to the noble Lord, Lord Alderdice, for flagging up the importance of the whole person and the whole family, because the third sector provides that par excellence in hospice care. There is a need to specify minimum levels of service, such as in hospice care, across the UK, and to have centrally agreed three-year contract with an agreement on how the service is delivered locally. At the moment, Marie Curie has to negotiate 200 separate contracts across the UK. That is a waste of time and a duplication of effort when models such as the fire service or the police demonstrate that you could have a national framework with local agreements on implementation.

Hospice grant money has to be negotiated at a local level by small hospices that often do not have much expertise in negotiating with all the different people from whom their patients come. Competitive tendering is punitive to the third sector, because it does not have the resources to tender or the expertise of larger bodies. Punitive contracts in the third sector can really work against them. If they miss a level in their service they may incur a penalty, yet they provide a key service to the NHS.

Commissioning must become outcome-related, as much in hospice care as anywhere else. Currently, it seems to be process-related. It has to be integrated across the whole pathway, and this need to commission across the whole pathway means that the professional competency framework needs to be driven up to promote higher levels of competency. There is a real concern and a danger that private companies will come in and commission against a whole pathway, and one questions why they are needed as an intermediary. The danger is that increased income will go in profits to shareholders and not be reinvested in the not-for-profit third sector that the hospices epitomise.

In summary, there needs to be 24/7 provision, which should be addressed urgently. There is a large shortfall in district nursing. Only 53 per cent of PCTs have 24-hour district nursing, which is grossly inadequate if you are trying to care for critically ill patients at home. There has to be a closer link between health and social care. Care assistants can often be the key people to keeping patients at home.

On incentives, we should remember that healthcare professionals are proud. They want to deliver a good service. If you embed direct patient feedback into the system, as we have in Wales for palliative care using iWantGreatCare, it can become a powerful driver to quality improvement. One team does not want to perform less well than another, but patients need to provide feedback in an anonymised way so that they are not fearful that their comments might antagonise the clinicians looking after them.

There have been unintended outcomes from the current arrangements where financial incentives or punishments drive provision rather than need. Patients feel particularly lost out of hours and it is really important in commissioning healthcare that we get it right. There is a steady stream of horror stories coming through. It is not simple; it is not like shopping for shoes; and I hope that the Minister will think carefully about the unintended consequences of change.