Morningside Medical Practice
Practice Development Facilitator
South Central Edinburgh Local Healthcare Partnership
Anne has worked in general practice since 1985, and in practice management since the last "New Contract". Over this time she has picked up an AMSPAR Diploma, an MBA and the Prince 2 foundation course in project management. She is currently "enjoying" studying the European Computer Driving Licence (ECDL) syllabus in computing skills. Outside of work, Anne goes to the gym and attends a weekly French class. She has two grown-up daughters, who act as her own personal Trinny and Susannah
The challenges of future population numbers – increased elderly and a diminished pool of people of working age – are well documented. For example, it is predicted that by 2031, 26.6% of Scotland's population will be over 65 years old (see Table 1).(1)
The impact of this will be felt by all public sectors – pensions, benefits and social services, to name but a few. How will the NHS respond to the challenges of a reduced staff and a top-heavy elderly population with its inherent health needs?
Add to this the increasing prevalence of long-term conditions (LTCs) and the number of patients living with more than one LTC, the public's expectation of what the NHS can deliver and continuous innovations in health technology, and it is very easy to understand the temptation to just stick your head in the sand!
The NHS Health Plan (2000) and Delivering the Health Plan (2002) aimed to address these issues by changing the way primary care services are delivered, making them "closer, safer, better and quicker" for patients.(2,3)
The approaches used to realise these plans differ throughout the UK. With apologies to colleagues in Wales and Northern Ireland, this article looks at how these plans are being implemented in England and Scotland, the strategies used and organisational structures that have been adopted.
England has foundation and trust hospitals, Payment by Results, practice-based commissioning (PBC), Choose and Book, community matrons and pilot Kaiser Permanente sites.(4)
Scotland, on the other hand, has resisted PBC, and has taken onboard the vision set out in the Kerr Report (Building a Health Service Fit for the Future, 2005) and Delivering for Health (2005) – ie, integrated community partnerships, including health, social work, housing and education.(5,6)
Both models require changes to working practices – in particular, nursing practices – and focus on delivering care to patients with LTCs in the community and reducing hospital admissions.
Yet the structures used by each country require further explanation.
Healthcare structures in England
Healthcare structures in Scotland
Figure 1 summarises the different approaches and structures used by each country.
Evolving strategies and relationships
English practices have embraced PBC with varying degrees of enthusiasm. The problems with Choose and Book are well known, although a recent DH report claims 81% of English practices used Choose and Book in June 2007 and 89% during May and June 2007.(7) Change has been sporadic and a complete picture has yet to emerge.
In Scotland, the new organisations have appeared at varying stages over the past two years, and each one looks slightly different to the rest. The development of partnership groupings and innovative working practices has meant that, in parts of Scotland, the focus has shifted from working with practices to establishing new organisational structures.
While this is an important first step, it has left many practices feeling disenfranchised, missing the previous levels of involvement experienced in the old structure. However, as these new partnerships begin to embed, attention is returning to practices and the relationships that need to be in place to make new strategies work.
Two structures – one outcome
In both England and Scotland, practices are the last link in the value chain, but without practice participation these strategies will fail – LTCs and care in the community need primary healthcare teams in order to succeed. I am in no doubt that this means more work for practice managers – such as involvement in new organisations, PBC consortia, working with/in PCTs, CHPs and LHPs, and encouraging practice buy-in.
These are interesting times, full of opportunities not only for improving patient care but also professional development for practice managers. If you are not already involved, I urge you to do so. You, and your experience, will be welcomed (and needed!).
As to which model is best … I would not dare comment! Only time will tell.
1. Scottish Executive Health Department. Predicted population in Scotland, 2031. Edinburgh: SEHD; 2005.
2. Department of Health. The NHS Health Plan. London: DH; 2000.
3. Department of Health. Delivering the Health Plan. London: DH; 2002.
4. Ham C. Lost in Translation? Health Systems in the US and the UK. Oxford: Blackwell; 2005.
5. Scottish Executive Health Department. Building a Health Service Fit for the Future. Edinburgh: SEHD; 2005. Available from: http://www.scotland.gov.uk/Publications/2005/05/23141307/13171
6. Scottish Executive Health Department. Delivering for Health. Edinburgh: SEHD; 2005. Available from: http://www.scotland.gov.uk/Resources/Doc/77843/0018803.pdf
7. Department of Health. Choose and Book statistics. London: DH; 2007.