Keep GPs in the driving seatBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3382 (Published 01 June 2011) Cite this as: BMJ 2011;342:d3382
All rapid responses
I'm sorry I confused Michael Crawford with my use of examples about
the power of the hospital lobby. The example about Childrens' heart
surgery was only intended as a topical example of the difficulty of
achieving any change in hospital configuration no matter how clear the
case not as an example related to prevention.
He asks what are the missing measures to keep people out of hospital
(his other comments suggests he doesn't think there are any and we should
just give the overwhelmed acute hospitals yet more money to cope with
their workload). But there are plenty of interventions that work and are
easy to identify. A superficial survey of the literature would suggest
that it is hard to prove they save money, but this arises because many
tests of the interventions are badly planned and implemented so fail to
generate useful evidence.
The sorts of things we are talking about are better care at home for
patients with long term conditions such as COPD, congestive heart disease,
asthma and diabetes. Rather too many of these people are turn up in A&E or
get admitted to hospitals. Too many because good monitoring of their
conditions and simple primary care interventions can often avoid the
exacerbations that result in emergency admission. Care at home both saves
money and improves the patients' lives.
But monitoring the patients and managing interventions using GPs,
district nurses etc. requires a number of things to be well coordinated
and some investment in equipment. Telehealth equipment, for example,
allows routine monitoring of patients at home but has to be installed and
managed (and you have to make smart choices about who will gain from it).
Plus someone has to use the information it generates in an intelligent way
and someone has to intervene when problems are identified (perhaps a
simple call to reassure a patient or a change to a drug regimen).
Obviously this requires investment in primary care and equipment.
But doing it well can lead to big savings across the whole system
when avoided admissions are taken into account. It is worth looking at
some of the evidence. See the Kings Fund report here:
http://www.kingsfund.org.uk/publications/avoiding_hospital.html . See
evidence from recent NHS experiments here:
media/videos/oxleas_telehealth.flv . See links to our work here:
Our recent work on small scale pilots suggest savings of more than
twice the investment in telehealth.
The most spectacular evidence, though, is from the better health
systems in North America. Kaiser Permanente is much better than the NHS at
keeping people out of hospital and much of this comes from better
information and decision in primary care. The Veterans Administration
managed to dramatically improve its quality of care and live with a flat
budget over a decade (a bigger challenge than the current NHS efficiency
targets!). Much of the improvement was due to aggressive use of primary
care monitoring and intervention and better quality patient information
systems for primary care that allowed use of hospitals to be drastically
reduced. This story is vividly told in Philip Longman's book "Best Care
The NHS faces a sort of catch-22 in trying to achieve these benefits.
Commissioners need to find a budget to implement and roll out the
interventions, but the acutes are demanding extra budget to deal with the
activity right now, leaving none to implement the interventions to reduce
the demand on the acutes...
Competing interests: My employer helps the NHS in a variety of ways related to telehealth and admissions avoidance including setting standards for devices, building business cases for telehealth interventions and helping the design, piloting and implementation of interventions.
What a strange example is used by Stephen Black to support his
contention that a powerful hospital lobby is preventing investment in
preventive medicine and in community services. The dispute over the
location of paediatric cardiac surgery is between the patients and their
families and the central authorities with hospitals on both sides of the
debate. There is no question of this work being done in the community and
the relevant preventive issue might be MMR vaccine and this is firmly in
It is necessary to be more specific about prevention; what measures
of demonstrated cost-effectiveness that would keep people out of hospital
in the immediate term does Black think are missing?
The fact of the matter is patients are queuing up to use the acute
general hospitals (AGHs) in their function as healthcare providers of last
resort. These facilities do not have the capacity to deal with them with
the quality of service to which clinicians aspire and far from being
potent lobbyists they are proving unable to obtain the required funding.
No-one would be happier than the AGH clinician to see community services
that could avoid admissions or facilitate discharge. The fact that they
are inadequate, and the financial woes of parts of the care home industry
allow no optimism for improvement in the situation, means that the AGH
needs to be resourced to fill in the gap.
There are positive contributions that a multidisciplinary facility
serving its locality as an AGH does. Private sector facilities are good at
routine hip surgery in fit patients; the management of osteoarthritis in a
patient with diabetes and obstructive airways disease is the province of
the AGH in collaboration with the general practitioner. Timely diagnosis
of cancer and efficient management of patients who are ill with it is an
area where much needs to be done in the AGH setting. Would that they
had the power to secure the resources.
It is important that those who seek to advise on provision of
healthcare have an accurate appreciation of the issues. Black's choice of
an example shows that he does not.
1] Crawford SM. Cancer care in the UK: updating the professional
culture. Postgraduate Medical Journal, 87:243-244;2011
Competing interests: No competing interests
Nigel Hawkes makes a good case for not interfering in the freedoms of
GP consortia but in doing so highlights one of the biggest omissions in
the debate on reform. In short, nobody has sought to clarify what the
problem is in advance of arguments about how to fix it.
So it is worth reflecting on what problem giving GPs the budget is
designed to solve. Historically the NHS has spent too much on hospitals,
too little on prevention and community services. This imbalance arises in
large part because of the combined power of the hospital lobby and public
distaste for hospital closures no matter how justified. Lobby power plus
an inability to close old services when new and better ones are developed
is a huge barrier to improved productivity (which usually comes because
new ways of doing stuff drive out old ways) and a better balance of
investment (we can't spend more on prevention if we keep spending more on
So the power of hospitals is actually a barrier to improvement in the
NHS. For a live, concrete example of how this works to the detriment of
patients consider the current argument about childrens' cardiac centres.
Essentially all the evidence points to having fewer hospitals doing this
surgical speciality, as more experience will reduce death rates. But 20
years after this principle was agreed powerful lobbies are fighting the
closure of the units at their hospitals (eg the Royal Brompton).
So giving the money to GPs might be the first time the hospital lobby
sees its power broken (PCTs haven't covered themselves in glory when
facing down powerful hospitals).
If this analysis is right then diluting it by insisting that
hospitals are part of the commissioning process completely misses the
point. The idea that they need to be involved to ensure collaboration is a
red herring. What is more likely to result is not innovation and
collaboration, but more of the same with hospitals in the driving seat and
more concerned with their viability than with improvement, innovation or
the wellbeing of patients.
GPs allocating the money alone, though, might be able to select from
competing integrated services according to who does the best job for their
patients. Paradoxically for those who ignore how competition works in the
rest of the economy, we might end up with more collaboration and better
services by keeping hospitals away from the levers of power. Hospitals who
can't get more money via lobbying, should resort to attracting money by
doing a better job for patients (even if doing a better job means keeping
them out of hospital).
Competing interests: No competing interests
A Collective Model Of Commissioning- the added value of hospital clinicians and Public Health Specialists
Nigel Hawkes in his article argues against commissioning becoming a
co-operative enterprise that involves consultants, public health, nurses
etc. This highlights the question of what we mean by excellent
commissioning and who should be involved in developing the best
commissioning policies and decisions for consortia populations, specific
patient groups and individual patients. While single stakeholder
perspectives are important and do add weight there should at the heart
of commissioning be a well defined process that identifies and
prioritises commissioning actions on disease areas/risk factors that are
our biggest causes of morbidity and mortality and where there are
demonstrable socioeconomic and geographical inequalities. Once these sub-
populations have been identified there is then the need to identify
effective solutions for improving the outcomes. This will need a search of
the relevant, high quality literature focusing on the distribution of
disease, causes, predispositions, treatments and their relative clinical
and cost effectiveness. Identification of the outcomes that improve
prognosis and quality of life and that we would wish to impact will
require clarity on the models of care as well as service standards that
would successfully deliver the desired outcomes. This preliminary work or
epidemiological needs assessment will have to be done at the outset.
However once this has been done by commissioners independently, it will
need to be corroborated with specialists and checked against current
clinical practice both locally and beyond, to assess compliance but also
to ascertain service gaps and important research needs. Patient groups
will also need to be consulted on their experiences, use of services and
views on unmet needs. Information thus gleaned will then inform the
development of commissioning requirements and specification of an optimal
Only after the above, can contracting options be considered. The
choice of contracting options will be modified by a further set of
considerations: specialist education and training for both the current and
future health workforce; undertaking of research to plug research gaps;
fulfilment of other clinical governance criteria e.g. compliance with
audit, evaluation, national registries/databases; continuity of care
across the patient pathway; critical volumes of clinical activity
(comprehensive, routine and complex case-mix) to maintain institutional
and individual clinician expertise, supporting service interdependencies (
necessary for further investigations and referral to other specialities),
the need for an MDT; arrangements for emergency access, 24 hour care, high
dependency/ICU care and avoidance of service duplication and cross
subsidization between services, and ensuring local access where
All these stages will require even greater and closer working and
collaboration with specialist consultant clinical and public health
colleagues, not less. As medicine becomes increasingly specialised even
within the same specialty, individual clinicians must not forget the
limitations of our own individual education, training and clinical roles.
To do so would jeopardise patient care, safety and risk litigation.
Clinical links between GPs, secondary and tertiary care clinicians and
public health specialists will be required both at operational and
corporate level; day to day and strategic work.
What GPs as generalists and experts in primary care will bring to
the table is their generic medical knowledge, across the spectrum of
health care, of primary care clinical pathways; the factors that fuel
healthcare demand; their holistic and historical view of patients
within family, carer, occupational and societal settings; their lynch pin
role as facilitators of access to NHS, Community Health and Social
care; their referral experience of access, waiting times and generic
quality issues and as providers of regular care.
The active involvement and leadership provided by GPs in the
commissioning process is invaluable and will benefit commissioning by
their influence and ownership on the primary care elements of all
patient pathways thereby providing greater integration of cost effective
care. Positive peer pressure will also play a significant part. This
dimension has been missing so far from commissioning models. However the
multidisciplinary and specialised nature of modern health care, need for
prevention at all levels, maximising use of health care resources,
informed patients and need to commission for populations and patients as
individuals mandates the inclusion of other health care experts. However
these will have to be carefully selected with the relevant education,
training, clinical health service experience, knowledge of health care
systems and the professional motivation to make a difference and make
patient centred- care a reality.
1.Hawkes N.Keep GPs in the driving seat.BMJ 2011;342:d3382.(4 June)
Competing interests: No competing interests