Moss Grove Surgery
Kingswinford, West Midlands
Sonia is a practice manager within a progressive 14,300-patient, six-partner GP practice. She is also involved in GP registrar training, undergraduate teaching and multidisciplinary training. Sonia is also Business Manager/Partner of a 5,000-patient practice
A key aim of the government's radical NHS healthcare reform in England is for GPs to bring patient needs closer to the commissioning of their healthcare and, at the same time, to reduce bureaucracy by abolishing primary care trusts (PCTs).
It's crucial that patients understand what is now happening in general practice and the wider NHS. Practice managers have a key role to play here in strengthening links with their patient groups, facilitating open discussions between patient representatives and GP leaders and in so doing raising patients' awareness of the work of new commissioning consortia – and the necessary constraints they are facing.
As the purchasers and consumers of healthcare, patients have a significant role. Their involvement will support GPs and consortia boards to purchase services appropriate to their needs. For this to happen, patients need to understand the proposed changes to the health service, as well as the need for savings to be made to enable more cost-effective healthcare and prescribing across the country.
In previous years, patients' attitudes to healthcare may have been characterised by passivity and compliance. This has now changed; we have moved to a culture in which patients' understanding, awareness and involvement in decisions concerning healthcare provision is important to them. Patients are increasingly willing to give of their own time to become more involved within GP practice-based patient groups or PCT-led healthcare forums.
The government's white paper Equity and Excellence: Liberating the NHS, delivered in July 2010, and the publication of the Health and Social Care Bill in January confirmed the coalition's intentions to free providers so they can focus on improving outcomes and be more innovative and responsive to patients' needs.
GPs need to ensure they encourage and utilise patient involvement in the business-planning exercise whereby private providers – some of them GPs themselves – are competing against NHS trusts and NHS providers. Patients need to be sure the services being purchased are appropriate, clinically sound, accessible and cost-effective. At the same time they should be reassured that these services are not destabilising to local hospitals and trusts where services do not operate independently but have a sharing of resources, which may be affected.
As the conduit between GPs and patients, practice managers should be proactive in supporting discussions between both parties. If you already have a patient participation group (PPG), you should look to raise its profile among consortia – or local GP leaders if this has not yet been established – at the earliest possible stage, and make the case for active patient involvement.
If you don't yet have a patient forum or PPG, now is the time to encourage your GPs to establish one. If they are not motivated to do this, they should be aware that consortia have much to gain from meaningful patient participation.
Many patients have said that the restructuring of the NHS and the white paper reforms have been put together too quickly; that the government's call to GPs to 'go ahead and show us what you can do' has not allowed enough time for GPs to get together and decide how they wish to cluster. This, critics say, has meant that patients have not been involved in this decision, even though they are the purchasers/consumers of healthcare.
GPs themselves are being thrown into making quick decisions regarding the future of commissioning cost-effective services and making changes that will 'make a difference' at such a fast pace that change for some may be very difficult. The Royal College of GPs (RCGP), the Royal College of Nursing (RCN) and the British Medical Association (BMA) have suggested that insufficient consultation was given to these huge reforms.
Despite these objections, the deadline for GPs taking over 'real time' budgets from PCTs is mooted as no later than 2012/13. GP pathfinder sites have been agreed across the country and are setting the pace for others to follow nationally. With this fast pace of change already in progress across the country, and with more second-wave pathfinder sites to be announced shortly, GPs engaging with their patients, and including them from the outset, will be doing themselves a favour. They will not only be ensuring they have the backing of their patients to support their decisions and the local healthcare economy, but they will also be reducing the risk of patients retaliating to changes made, arguing that they have not been consulted.
A question of trust
The NHS is funded by patients (taxpayers' money) and the fundamental principle since its conception is that it is 'free at the point of need'. This principle – that taxpayers' money should not be used for profit-making schemes or be allowed to enhance competition to the detriment of patient care – is another reason why ensuring 'adequate' and 'appropriate' patient involvement is at the hub of the decision-making process.
GP practices are currently independent businesses that are contractors of healthcare to the NHS. Concerns have therefore been raised that, with new commissioning consortia, GPs will have to wear two different hats, as both a 'commissioner/purchaser of healthcare services' and a 'provider of the most appropriate healthcare services for patients'. There is a fear that these adverse roles may not always allow the most cost-effective service to be the most appropriate service, and that GPs could find themselves challenged by patients arguing that the services commissioned do not always allow for treatments in their best interests.
Most patients still look up to their GPs and retain a high level of trust and respect within the patient-doctor relationship. However, there are worries among some patients that the reforms mean GPs will have to conform to decisions made at consortia-board level, or run the risk of being thrown out of consortia. For many GPs, the move away from their experience of referring patients for appropriate care will not be easy.
This is particularly true in the case of prescribing where, for many, 'quality' drugs are not necessarily the cheapest or the most appropriate in their own personal experience – but they will now have to keep up-to-date with the latest clinical trials and National Institute for Health and Clinical Excellence (NICE) guidance, and prescribe within local formulary, where huge costs savings can be made to plough back into NHS services.
GPs will need to prove to their colleagues in consortia – through league tables/scorecard data – that they are working together rather than as individuals. In so doing they will need to ensure they are keeping patients engaged with, and educated in, any changes to prescribing/referral processes.
This will give GPs the support of their patients for any changes at a local level that may otherwise be construed as 'competition' or 'threatening' to other NHS providers.
GPs' biggest advocates are their patients; ensuring their involvement in the decision-making processes at the initial conception of changes in service delivery will be key to GPs' success.
The NHS has been reviewed at least 15 times in the last 25 years. For many GPs, patients and NHS staff there is a feeling that each restructure is never in place long enough to determine whether it actually works or is given enough time to make a difference. Throughout all the NHS reviews, spanning many years, is the recurrent theme of patient involvement, patient choice and patient voice.
The government proposes to develop HealthWatch England as a new independent consumer champion within the Care Quality Comission (CQC). Local patient groups and forums will become known as local HealthWatch groups. These groups will represent the interests of patients as consumers and will be underpinned by the NHS Commissioning Board. Within their remit will be the power to recommend that poor services are investigated. Local HealthWatch groups will be funded and accountable to local authorities. However, they will have the right to report concerns about the quality of providers and local services independently of the local authority.
Overall, HealthWatch England will have the power to propose CQC investigations into substandard care, taking over the roles of patient advice and liaison services (PALS), local involvement networks (Links), etc, at a local level.
Furthermore, local HealthWatch groups will also be expected to provide advice to the Health and Social Care Information Centre to support and facilitate patients' choices regarding their care providers. Seen as a patient group to support the local community towards information sharing, complaints-handling structures and service development in line with the needs of local patients, this raises the need for members of local GP practice forums to put themselves forward to become involved within these high-profile HealthWatch groups.
Early opportunistic involvement of consortia working closely with their local authorities should promote the need for local GP patient panels to be at the forefront of the development of HealthWatch groups locally. Their individual experiences and knowledge of primary and secondary care services will support the government's agenda for strengthening patient choice and quality outcomes. At the same time, GPs and local authorities will be working together to develop the nucleus of their local HealthWatch groups.
It is essential that the HealthWatch group is aware of what is happening locally and in communication with a wide range of local patients. In my view, HealthWatch must not become a rebranding of PALs/LINKs, etc. Although these groups are successful in their own right, there is now a need for more 'real time' involvement in local decision-making processes across consortia and local authorities.
It is my view that patients are passionate about their NHS services and the delivery of services at their local GP practice. They want to be involved from the outset. For this to happen, they need to understand the need for change in the way services are delivered or – as in some areas across the country – the way services may have to be rationed in the future. This must be allowed to happen at the right time.
The health secretary says one of the main values of the white paper reforms from a patient's perspective is 'no decision about me, without me'. Consortia boards need to include patients at that level, and ensure appropriate communication of any decision made across a locality that affects/enhances patient care. By keeping patients aware of what is happening, and involving them at an early stage, GPs will gain their support and understanding to new ways of delivering health services at local level.
The new government proposals are very exciting, and at no other time in the history of the NHS have GPs been given so much freedom to make a change to healthcare delivery – this is probably the most opportunistic time for GPs across the country to make a difference.
For some GPs, this is the moment they have been waiting for. For others, it's yet another change. For all, it's a huge risk but I believe if GPs and consortia boards engage with local patient forums, involving representatives of local patient panels/forums at board level, they will reduce the risk of losing trust from patients, gain their vital support to justify changes and at the same time ensure patients are educated, informed and involved in the need for local changes to support a healthier local economy.
Practice managers have a major role in facilitating communication between GP leaders and patients. Approach patient groups to raise awareness of what is happening and how they can be involved. At the same time, approach the chair of your GP consortium or local health board to arrange a meeting with your practice's patients, where they can explain what the reforms mean and how the consortium will be developed.
It may seem small-scale, but if each patient attending informs another group of patients, and this process continues, you will have a more informed and involved patient community that will enhance, and not jeopardise, the trust that exists between patients and practice, and at the same time give support to local commissioning decisions.