Has General Practice passed the tipping point?

Is this the future?

Unless something dramatic or revolutionary happens at the Department of Health after the election have we seen the end of General Practice as we know it?

Here are three possible scenarios.

Scenario 1.

GPs become consultants in the management of patients with complex and unsorted symptoms. Everything else i.e. minor illnesses, uncomplicated long term conditions, social issues, work related problems, etc. will be managed by other members of the Primary Care Team: Pharmacists, advanced nurse practitioners and physician assistants.

The GP will assess, investigate and sort out patients presenting with undifferentiated symptoms and look after patients with multiple co-morbidities and complex needs.

Patients will no longer have direct access to a GP.

Scenario 2

GPs will become disease specific consultants working in the community.  All acute patients will be managed by pharmacists, NHS 11, nurse clinics & physician assistants.

 Patients will no longer have direct access to a GP.

Scenario 3

Co-payments. Patients will pay for their primary care, perhaps with government paying for a set number of  consultations per year.

Personally I do not think that civil servants and politicians do ‘revolutionary’!

I am sure there are others scenarios.  Please suggest some.

What is a 'Benefits Realisation'?

In the summer I asked some questions at our local council Health Overview and Scrutiny Committee about how would the public know that the planned reconfiguration of services at our two local hospitals would benefit patients and what were the baseline measures for the specific services being changed.

The answer I got from the PCT was "in relation to the Better Healthcare in Buckinghamshire programme, a benefits realisation performance dashboard was being developed".

At the time this went straight over my head and all I could think about was that they had not answered my question on baseline measures.  I have described my effort to get the information in a previous blog (Like getting blood from a stone).

Recently there was a twitter discussion (#NHSchange) on measurement for improvement and someone used the phrase 'benefits realisation' in a tweet.  I complained about the use of jargon but was challenged to find some alternative wording.

I had to think a bit but did come up with some suggestions for a patient friendly version.

"Is my experience as a patient better now than it was before the change/redesign/reconfiguration?"

"Is my outcome (better health, less pain, ability to work, feel better) improved as a result of the change in service provision?"

I also did a bit of research and even went back to a PCT paper on benefits realisation.  In the document it said "Better Healthcare in Buckinghamshire will begin the development of a business case from which the benefits realisation plan can be further developed". However I could find no trace of such a plan in the public domain.

The paper also said that it was important to set current baseline against which to measure benefits.  This is, of course, what I was asking about in my question to the scrutiny committee. But it did not appear to have been done.  Luckily I have a meeting with the Trust to discuss this issue in a few days and I can use this information in my discussions with them.  I will report on what happens at the meeting.

As part of my research I googled 'benefits realisation' and first up was the NHS Institute for Innovation and Improvement's (NHSIII) website where they have a paper on the topic. It is interesting and worth a read. http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/benefits_realisation.html

In their view a benefits realisation is

"a tool to make sure you actually get the intended benefits originally planned for your project". 

I like that! Clear and concise.

Further on it says

"A benefits realisation should be a fundamental part of any improvement project running from the projects beginning to the end and beyond".

Now that confirms my view that you need to know the baseline so you can measure the effects of the change you are implementing. It seems so obvious.

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So if you are running an improvement programme and you want to know if it has worked I suggest you read the NHSIII paper and make sure you have a benefits realisation framework established at the beginning of the project.

Great idea - shame about the implementation

There is this great idea.  There is a sum of money available.

Everything is set up, application form printed, lots of publicity. GP surgeries informed of the scheme by email.

The scheme went live - patients and carers informed.

All they had to do was get a signature from a GP.  Oh so simple!

There was lots of interest and so lots of visits to GPs.

Suddenly a problem emerged.  The GPs knew nothing about the scheme.

The first they knew about it was appointments being filled to get the signature. Now we all know how hard it is to get an appointment with a GP. So any appointments being used up in this way, just for a signature was not good news.

There was another problem. Carers were turning up asking for the signature on their own. There were confidentiality issues as the patient was not there to give consent.

All in all a most unsatisfactory situation and the GPs got a bit fed up with it.

So why did it come to this?

Sadly it was the result of not doing things properly.  The Primary Care Trust should have involved the GPs at an early stage in the design of this scheme. They did not!

Result: a good scheme that would benefit those hard pressed carers is delayed.  There are irritated GPs, carers and the other people involved in the scheme.

All the evidence shows that when designing a new patient pathway, a new service or a new scheme of some sort you should involve everyone in the design of the scheme at an early stage in the process.

You also need to develop the implementation of the scheme at the same time as designing the scheme itself.

Typically redesign happens, then they think about talking to the patients and other stakeholders. Its too late then.  Involve them early often and in a meaningful way!

So what is happening? Hopefully they will talk to the GPs, sort out the form, sort out issues of confidentiality and then maybe, carers can get the breaks they deserve.

Cock -up or conspiracy