How to empower GPs and local commissioners to deliver care

When we launched the Kent Health Commission in November, we set ourselves an ambitious challenge: to find the best way of using the health and social care reforms to empower local GPs and health commissioners. We want them to deliver better quality care, improve health outcomes and improve patient experience. We intend to do this by developing a visionary new model of health and social care.

Our pilot area, the South Kent Coast clinical commissioning group, which covers Dover and Shepway, has a reputation for forward-thinking GPs and joint working between health and social care, including planned co-locations of health services with the district council. This made it an ideal test bed. Together with Kent, the Dover district had also been selected as an early implementer of the health and wellbeing boards.

We did not want to focus on the new structures. We wanted to listen to people at the front end: the providers of acute, community and social care; the charities and social enterprises looking at expanding their services; and the GPs who are at the heart of these reforms.

We invited a range of stakeholders to air their views in a series of roundtable evidence gathering sessions. Also taking part in the sessions were fellow health commission members, including Dover District Council leader Paul Watkins, Dover and Deal MP Charlie Elphicke and CCG joint clinical lead Dr Joe Chaudhuri.

The commission is being supported by Kent County Council and Dover District Council, with advice from Localis, a local government think tank, and MHP Health Mandate, a consultancy.

Working together

As health and social care commissioners, we examined how we could work together to:

• redesign Kent’s health and social care services according to local need;
• implement the reforms to health and social care in a way that improves service quality and health outcomes for the residents of Kent;
• harness local expertise to improve services in the way that best meets local needs;
• join up services in the interests of patients, enabling easy access to the services they want;
• empower local health and social care professionals, including GPs, to develop a range of new or improved community health services that are more accountable to local people;
• forge links between different local health and social care providers, enhancing productive working relationships in the interests of patients;
• ensure that new commissioning organisations, such as clinical commissioning groups, have the support that they need to implement change.

Our interim report in December to health secretary Andrew Lansley was only the start of the process. This year, we will develop the work further and begin modelling and investing to deliver this change.

At the heart of our recommendations is a desire to shift at least 5 per cent of activity from acute to primary and community health. Releasing £59m a year in Kent – or £5m per district – will enable new community services to be developed, commissioned and provided to patients in a setting more accessible and suitable for them and their health needs.

This is not something to be “done” to the acute sector. Groundbreaking work with acute trusts in Liverpool, developed by the innovative Folkestone GP Tuan Nguyen, demonstrates how intensive and holistic community support can reduce non-elective hospital admissions by 88 per cent. This approach will also be adopted in Kent.

We want CCGs to have a much greater choice in community health provision. They should be free to draw upon a range of sources of commissioning support.

While accepting the managed withdrawal of primary care trusts and the duty of care they undoubtedly have to their existing staff, it is not acceptable that employees should simply be transferred to the CCGs together with liabilities under transfer of undertakings (protection of employment) regulations, if they may not be appropriate.

Others, including local authorities, may be able to provide this commissioning support and CCGs must be free to make the best choices for them.

Joint commissioning and access to health and social care will be fundamental to the change we seek. Pooled budgets between CCGs and social care must be developed for integrated joint assessment and commissioning while a single point of access for local people has to be made a reality. Issues over who pays simply deflect from patient care.

We must stimulate existing private and voluntary sector community health providers while encouraging new entrants to the sector. A broker model for the emerging community health trust should be explored to ensure the market in Kent is open to everyone offering a top quality service, whatever their size. For voluntary sector and social enterprises, access will be open to our £3m big society fund to assist their development.

What patients want

In setting up the Kent Health Commission, we realised we had a choice: we could remain as we were, or we could use the new health and social care reforms to deliver further improvements to local healthcare, ensure better use of public money, and provide better patient care.

Working with local GPs as the commissioners of health and social care and building on the existing work in the county, we are using the reforms to develop an approach that aims to ensure people are looked after in the way they want and the way they need – whether at home with ready access to community health services or in hospital.

In the commission’s initial meetings, we were heartened by a general optimism that the system could be improved, but then a more concerning inertia began to emerge from a feeling of having seen it all before. There was a feeling of being done to, of being too late to change, and of illusory choice. Clinically driven ambitions were, and are, in danger of being lost in the thickets of managerial process.

But as we explored the potential of the reforms, best practice was identified, new ways of joint working were promoted and patients’ needs were brought firmly to the fore.

Our initial recommendations to Mr Lansley are only the start of this process and achieving the change and outcomes we desire. Utilising the government pump priming grant to councils to develop integrated services between health and social care, we will invest in a significant pilot in Dover and Shepway, developing a comprehensive approach to prevention and community health.

In doing so, we need to be clear what good community health looks like in Kent and how we achieve it. We need to examine in more detail the cost of its delivery and the sustainability of the desired shift from acute to community care. And we need to show how integrated commissioning, pooled budgets and joint assessments can bring about a transformation in health and social care leading to better patient care and outcomes.

We will, of course, need some government support to achieve this. But for many of the changes we propose, their delivery is in our own hands, as it is in the hands of local government and GPs across the country. It is now up to us to rise to this challenge.