Note of a workshop in the House of Commons, Monday 10th July 2000
1. 'I see no reason why patients should have to be referred to and from hospital for services which could be provided in their local GP surgery. This is a win-win situation for everyone. GPs are keen to broaden the range of services they can offer, patients want quicker access and less hassle in getting the care they need while hospital clinics and consultants want to reduce waiting times for their specialist services.' (Alan Milburn, 23 June 2000)
2. Anecdotal evidence from health professionals backs up this view held by the Secretary of State for Health. Many health professionals believe that there is scope for a 40% downward shift in healthcare delivery from hospitals to GPs, and from GPs to nurses and pharmacists. The agenda for this workshop asked participants what types of work could be 'downshifted' in this way; what benefits or (negative) implications might result; and what should be done to bring this reallocation about.
A. Reallocating work: from secondary to intermediate / primary care
3. The workshop saw some benefits in downshifting of work. Some general practice surgeries already provided a limited in-patient service (David Pelta's practice in Southend and Tim Richardson's in Epsom were quoted as good examples). The use of GP surgery beds could prevent some unnecessary emergency admissions to acute hospitals, and (for certain categories of patients) could provide a better service both clinically and in terms of cost-effectiveness. However, the financial relationship between hospitals and GP surgeries needed clarification. Surgeries did not really have the resources for in-patient care; funds would need to be transferred from local hospital budgets. This was easier said than done; most health authorities prioritised the needs of acute hospitals.
4. Participants saw scope for efficiency improvements not only in moving work from secondary to primary levels of care, but by improving the interface between the two. For example, consultants usually discharged patients from hospital with 4-7 days' supply of medication which had often run out by the time the consultant's letter reached the patient's GP. This wasted time and could have health impacts. A simple e-mail system would solve the problem. Participants wondered whether other wrinkles at the interface between secondary and primary care could be ironed out with equally simple solutions, if resources were put into tackling them.
5. 'Intermediate care' was seen as an underdeveloped concept, requiring further consideration both inside and outside the Department of Health. What functions should the term cover? Which establishments might provide intermediate care - nursing homes (from which health care purchasers could buy weeks of care), GP surgeries acting as 'cottage hospitals' with a few beds, and so on? Intermediate care was often seen as a low-status option by nurses; how would staff recruitment problems be addressed?
6. Subject to further clarification of the term, participants did feel that there was a role for intermediate care. There were particular categories of patients - for example, the elderly and confused - for whom acute hospital admission could be profoundly depressing and damaging as well as clinically unnecessary. Greater flexibility in the continuum of care would do more to accommodate such patients.
7. The workshop also discussed several negative implications - for patients, carers and doctors - of downshifting work to primary level. The longer that patients were kept in the community and hospital admission was delayed, the higher their anxiety level (and that of their carers). For doctors, there was the added worry of liability problems if they erred towards delaying hospital admission for too long.
8. Several participants commented on the need for resources to follow patients. Support from the primary care workforce would be crucial to the success of any downshifting strategy, but the negative experience of fund-holding (in which many GPs had seen their patients suffer in comparison to those of non-fund-holding GPs e.g. in terms of referral waiting times) might discourage many doctors. GPs must therefore be sufficiently remunerated, and their surgeries adequately equipped, to take on downshifted tasks.
9. Doctors and other health professionals would also need training for new duties, which would impose a cost both in terms of the training itself and of health professionals' time away from their jobs. Arguably, funds to cover these costs should come from hospital training budgets; but were primary care actors powerful enough to access these?
10. Some participants also suspected that the trend for GP surgeries to offer beds owed less to patients needing overnight medical care than to GPs filling a gap left by inadequate social services. A better option would be a flexible budget system allowing health care purchasers to buy a number of weeks of nursing home care for patients.
11. Finally, participants noted some tasks which should continue to be performed in secondary care establishments because they benefited from economies of scale. Radiology and blood tests, for example, would be extremely expensive to perform locally.
B. Reallocating work: from GPs to pharmacists and nurses
12. At primary care level, medicines management would be a suitable block of work to downshift from doctors to pharmacists. Mandating pharmacists to deal with patients' problems in taking their medicines would bring undeniable benefits:
* free up doctors' time (at present GPs are estimated to spend five hours per week processing repeat prescriptions);
* avoid some adverse health outcomes;
* cut wastage by providing a more responsive, accessible medicines management service to patients (£1.5 bn worth of medicines are currently thought to be wasted each year by patients who often fail to inform medical practitioners of their difficulties in taking medication).
13. Participants hoped to see pharmacists given the powers to review and alter medical prescriptions, provide repeat prescriptions, discharge patients from medication and issue certain initial prescriptions (e.g. the morning-after contraceptive pill) in the near future.
14. Political decision-makers would need to be warned that again (as with the downshift of tasks from secondary to primary care) resources would need to follow patients. Pharmacists would need to be adequately remunerated, and pharmacies equipped, for these new duties. Decision-makers should also be aware that this downshift of work would probably not reduce the NHS drugs bill, but ought instead to improve the case management of ambulatory patients, thus saving on a proportion of current secondary care.
15. Finally, participants identified a category of patient consultations which did not require medical expertise, and could theoretically shift from doctors to other health professionals - but should not do so. These were patients who required little more than face-to-face contact and reassurance from a doctor. This was not necessarily a cost-ineffective use of medical time; keeping people well via a five minute chat per month was seen as 'a good deal'.
C. The way forward: how to bring about reallocation of work
16. In summary, participants felt that few people would argue with the principle of the workshop that in theory, it would be desirable to drive work down from secondary to primary care levels and from GPs to other health professionals. In many cases this would not only increase autonomy and job satisfaction for the professionals involved, but provide better clinical outcomes for the patient.
17. However, participants found difficulties with the practicalities of downshifting:
* They doubted that resources would follow patients. Would money really be forthcoming from hospital training budgets to train primary care providers for their new tasks? Would adequate resources be found for new equipment for example for pharmacists taking over new areas of work?
* They wondered whether providers at lower levels of the NHS hierarchy would given the necessary autonomy to perform downshifted work appropriately for their own local context. Was there not a danger that central decision-makers would try to retain control over downshifted work by over-regulating? The key to delegation would be trusting the local health professionals who dealt face-to-face with patients.
* Education of the public was crucial. Patients needed to understand that their treatment was being undertaken by a team of professionals and that (for example) a specially trained nurse undertaking work which had previously been done by a doctor was not inferior care. Health professionals would need to be prepared to deal with public doubts and fears during any downshifting process. If patients found that downshifting in the NHS led to shorter waiting times, they would be readier to support it. But where was the evidence that shorter waiting times would emerge?
18. There is already a growing body of research on these obstacles and the feasibility of overcoming them. An NHS Research and Development programme on the interface between secondary and primary care and the scope for shifting the balance between the two, has been up and running since [1994/1995]. Workshop organisers were advised to contact www. to find out whether the programme had produced evidence on the benefits (or otherwise) of downshifting work.
19. Finally, the workshop felt that even if evidence pointed to benefits from downshifting work within the NHS, the change would not happen unless NHS leadership embraced it as a higher priority than at present. The allocation of work between secondary and intermediate care, GPs and other health professionals was compared to a relay team. Realistic decisions needed to be made about how, and with what resources, to equip different members of the team; when the baton should be passed; and with whom responsibility should lie if the baton was dropped.