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EDITORIALS: Chris Salisbury and Sarah Purdy Providing care closer to home BMJ 2007; 335: 838 [Full text]

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From Policy to Implementation

Minoo Irani, John D Dean and Michael Dixon   (30 October 2007)

From Policy to Implementation 30 October 2007
Minoo Irani, Consultant Community Paediatrician Upton Hospital, Slough SL1 2BJ, John D Dean and Michael Dixon Send response to journal: Re: From Policy to Implementation	The Government’s vision for healthcare outside hospitals and closer to the patients’ home is a significant strategy of the recent healthcare reforms and supported by the opinion of people elicited in two major public consultation exercises (1). This policy was based upon international experience that hospital care was expensive and patient satisfaction was improved when integrated healthcare was provided in convenient non-hospital settings. The implementation of this policy was unfortunately divorced from evidence and the delicate balance of quality and cost-effectiveness was given little thought in the planning stages, when a range of enthusiastic healthcare professionals across the ‘closer to home’ demonstration sites participated in innovative provision of specialist healthcare through selective and sometimes fragmented provider models in six high volume specialties. The findings of the evaluation report (2) hence come as no surprise. In an otherwise well balanced commentary on the report, Salisbury and Purdy (3) however fail to emphasise one of the more important findings of the report—that models where consultants worked outside hospitals were successful in changing barriers between primary and secondary care and that consultant involvement was one of the factors responsible for the successful elements of the demonstration sites. The policies of care closer to home, practice based commissioning and payment by results can lead to practice which is divisive between primary and secondary care – hardly the desired outcome if quality and cost- effectiveness are aimed to be at the heart of the reforms. What options do we now have? Any further centrally imposed healthcare reorganisation would be unpopular with healthcare staff and public alike. It would be more acceptable if the Department of Health were to facilitate evidence based clinician led approaches to providing integrated healthcare across the primary-secondary care divide where the emphasis was upon true clinical partnership. That coherence in policy and implementation is urgently required, is further supported by the recent Wanless health care spending review (4) which emphasises the need for strengthening policy, prevention and productivity in the health service. A recent report published by the NHS Alliance Specialists’ Network (5) proposes ‘Integrated Provider Organisations’ which would enable clinicians from primary and secondary care to lead innovation and change within the health service, share aligned objectives for high quality and best value patient care and facilitate the move of appropriate specialist services from hospitals into primary care. These working arrangements would serve as cost-effective model for providing high quality patient care where health needs are addressed by ‘the right service, at the right time, by the right people, in the right place’ while patient and provider led demand are adequately controlled. Integrated Provider Organisations (IPOs) could be realized via practice based commissioning consortia, Community Foundation Trusts or PCT provider arms. Only if successful in pilots across the country, a case could be made for exploring IPOs as new provider organizations in the future. To achieve care close to home that meets the needs of patients and ensures quality and value for money, specialists and generalists will need to work in a collaborative model of care that requires consultants to work flexibly outside hospitals and embrace a more holistic approach to healthcare as is often the working practice of primary care doctors. REFERENCES 1. Department of Health. Our Health, our Care, our Say: a new direction for community services. London: DH, 2006 2. National Primary Care Research and Development Centre, University of Manchester And Health Economics Facility, University of Birmingham. Evaluation of ‘Closer to Home’ Demonstration sites. Final Report. June 2007. 3. Salisbury C, Purdy S. Providing care closer to home. Editorials. BMJ vol 335 p 838 4. Wanless Sir D, Appleby J, Harrison A, Patel D. Our Future Health Secured? A review of NHS Funding and Performance. King’s Fund. 2007 5. NHS Alliance. Specialist Doctors in Community Health Services; opportunities and challenges in a modern NHS. September 2007 Competing interests: None declared