|
Annex A
-
Can you give a reassurance that GPs on the ground will not demand to be in
charge of the new Primary Care Community Groups when they are formed, a fear expressed
by some?
While the Fit for the Future document was a result of widespread consultation,
and seemed quite radical at the time, the preferred option in the latest document
appears to rein backwards. Are we losing the plot somewhat?
The Committee took the view that the introduction of the new system for Primary
Care should be deferred for one year to allow for proper planning. Given that
the Acute Hospitals Sector is being currently reviewed as well, is there not a
strong argument that we have a timely opportunity to examine comprehensively the
delivery of Health Services overall with a view to having a seamless robe of medical
care?
What are the panel's opinions on the GP fundholding system, which is to be
abolished? While the two-tier system created inequities in provision, many patients
heralded it as a success for them. [Mr McFarland]
-
There is no question of GPs trying to build empires within the new Primary
Care (PC) groups; GPs have already established effective multi-disciplinary Committees
on the ground, which have proved that communication and teamwork are vital, albeit
they are sometimes frustrated by management issues. The priorities of nurses and
GPs are the same. We do not equate leadership with domination; it will be a matter
of whoever is the most appropriate in the circumstances taking the lead.
A big advantage for the PC group would be for each of its professionals to
have an equally free voice and to be able to make decisions. Consequently, the
principle of everyone's being equally accountable would also have to be clearly
established - GPs would be very wary of being the left as the accountable person
without having control.
Some 80% of GPs in Northern Ireland gave their views on the Fit for the Future
proposals. They were enthused by the recommendations, which were generally seen
as a radical step forward, delivering a bottom-up approach in the delivery of
PC. The issue of who provides the leadership is all-important.
We agree entirely that it is not helpful to look at aspects of Health Care
delivery in separate compartments since they are totally interdependent. It is
important to get the global picture. A contemporary review with the Acute Hospital
Services would provide an opportunity to get common ground on a variety of issues.
If we get this wrong, it could impact adversely on the acute sector.
It is important to make the point that there always was a two-tier system even
before GP fundholding. There is no doubt that those patients under fundholding
practices got a better deal because the better commissioning arrangements were
more effective than those of the HSS Boards. Many patients from disadvantaged
areas got a better deal under fundholding than they had previously. Funding could
be skewed towards priority areas such as cataracts operations and hip and knee
replacements, which benefited patients, and resources cut back on less effective
services.
-
Section 6.14 of the document deals with quality. How do you envisage the development
of mechanisms for establishing clinical governance within PC? Section 6.7 deals
with Governance Arrangements and refers to the need for all professionals in the
group to feel they have equal status. How would this be done? Is there a case
for the development of the role of the nurse practitioner in PC? [Mr Kelly]
-
The 'Confidence in the Future' document highlights the major concern that there
should be effective forms of performance management, and clearly we need structures
to facilitate that in a multi-professional way. We want a cohesive unit of process
of clinical governance. This will require the development of a joint training
process within multi-professional groups on a vast swath of issues. The concept
of developing PC structures in local communities will help with clinical governance.
The Total Purchasing Pilots will help address these issues. For example, the
Target system in Doncaster introduced a half-day per month for staff training,
and it is proposed to introduce this idea into the Northern HSS Board area. Some
Out-of-Hours GP co-operatives have organised training to address issues in the
'Confidence in the Future' document. The Minister has recently announced extra
resources, which are welcome, as we would like to see the initiatives rolled-out
across NI.
Equal status means being truly equal and accountable. The PC model will help
develop a more equitable service but there will still be huge barriers and major
challenges. There will undoubtedly be massive resourcing implications. There need
to be a philosophy among the public that we, as providers, are equal too. For
example, what level of service would be expected from a PC group after 6:00 pm;
after all, it would not just be the GPs but all the professionals involved.
We fully support the development of the role of the nurse practitioner in
PC. They should be empowered, for example, to prescribe in certain circumstances.
-
It is difficult to envisage an integrated, interdependent Health Service with
a bottom-up approach as long as the HSS Boards are in place. In relation to the
proposals for PC partnerships, do you have any examples of good practices in GB,
for example, of PC Groups working well? Has any analysis been done on the costing
implications of moving to the new system? [Ms Hanna]
-
There are true integration examples of pilots in the Downe Lisburn HSS Trust
and pilots working effectively as part of Health Action Zones on the North and
West Belfast Community Trust. A commissioning pilot in Armagh is a good example
of effective teamwork on cardiac rehabilitation and also care of the elderly.
PC groups bring professionals together - for example, GPs, nurses, midwives, social
workers - and can often dispel misconceptions about each other's roles. Building
a commitment to a team approach is excellent. It is hard to make comparisons with
systems in GB as the Health and Personal Social Services are not integrated there.
In fact, a number of English Health Trusts have visited NI to examine our integrated
service.
It is difficult to get figures on costings but moving services is not a cheap
option. We have submitted figures of our own to the Department but have not received
any feedback. The workload has been shifting from the acute sector to the community
but commensurate resources have not followed. There would be a worry about sustainability
and standards of care were resources not to follow workloads. Foe example, we
estimate a shift of £11m worth of services in terms of care of the elderly, management
of diabetes, and prescribing of rheumatoid drugs, without the corresponding resources.
And these are only small items. Therefore, while in the past we tended to look
at primary and secondary care in isolation, we need to examine the whole picture.
-
Demographic trends will place ever-greater demands on the PC service as it
continues to pick up more acute care. You mentioned the fact that multi-disciplinary
training is a big issue, but non-clinical governance too must be built in. Multi-disciplinary
training on areas such as domestic violence should be built into training. I am
interested in what initiatives there are for the service users, for example, is
patients participation in practices intended? In terms of prevention, do you agree
that Community Health Partnerships should also be examining how areas such as
housing and education impact on health? [Ms McWilliams]
-
The care of the elderly is a major concern; once they are removed from the
hospital setting, they are being shortchanged in terms of their ability to access
services such as occupational therapy from nursing and residential care homes.
It is difficult to convince Boards of the major resource problem that shifting
care causes, for example GPs having to pick up the medical tab for those elderly
who move to nursing homes from hospital.
Training in the Target initiative is meant to improve all aspects of the practice,
not just from a medical angle. We would like to see a system whereby guidelines
are disseminated to all the health professionals involved.
In terms of housing, we fully recognize that voluntary organizations all have
a role to play. (Carers are also included in the multi-disciplinary approach.)
We believe that improvements in housing standards in NI have done more to improve
people's health than GPs have. The future lies in effective joined up Government.
It is a struggle to get meaningful user participation but there was a good
example of one group of diabetics getting together with GPs to explore the problems.
An Armagh pilot has also done useful work on user involvement with health professionals.
-
What guidelines will there be for GPs under the new service? Will there be
more flexibility in terms of Out-of-Hours service and GP cover? [Mr Gallagher]
-
There are no guidelines as yet; it would be difficult to develop them when
we do not know what type of service we ultimately have. Appropriate access is
the big issue rather than getting hung up on figures for waiting times. And access,
importantly, means right across the Health Service, involving all the major providers.
So we need to use the team more appropriately. A big barrier is not getting across
to the public the message regarding the best method of access.
It is important to point out that PC practices have a family-friendly philosophy
in terms of working hours, and there is now a majority of female GPs. There is
also a sicker community as more people are treated in the community (for example,
cancer treatment), with the result that GPs have not always been able to keep
pace. Therefore, there needs to be a regional solution involving Primary and Secondary
care, A&E and the Ambulance Service - not just GPs.
-
Some people with whom I have spoken in the acute services have voiced frustration
at the administrative decision-making process. Have you any ideas on how the health
care systems should be managed? [Rev R Coulter]
-
We frankly do not see the need for the present four Boards and 19 HSS Trusts.
We often feel we are talking in triangles. For example, with the flu vaccinations
we thought there should be a regional approach but we had instead to talk separately
to the four Boards. It is vital to get clear lines of communication. Unless there
is a bottom-up approach, the community will not fully empowered to commission
services. While a centralized system may create an impression that those in the
outer regions might be somewhat marginalised, any problems would be overcome by
fully devolving powers to groups at community level.
-
I attended a seminar in Armagh today on Housing and Health, which brought home
to me the importance of creating awareness among the public of the direct link
between good housing and health. Does the panel agree? [Mr Berry]
-
GPs are totally convinced of this argument. Factors such as housing and employment
impinge directly on people's health, and GPs are frequently frustrated with such
environmental factors that are beyond their control.
-
There is a daunting task ahead for the development of PC services. How will
the physical infrastructure be provided in order to accommodate the multi-disciplinary
teams together? With only one year's grace before the end of GP fundholding there
is little time. [Mrs Robinson]
-
You have touched on a very live issue, as there has been a historical underinvestment
in buildings. We could not contemplate decanting services without the proper infrastructure,
and the Minister's recent commitment of £3m to PC for the development of staff
and premises is a most welcome start.
-
The North Down commissioning pilot scheme is working well. But going back to
Fit for the Future at Stage 6, how do you envisage the Health Service operating
at the next stage? Who will run the groups? What would the system look like on
the ground? [Mr McFarland]
-
The service delivery at PC practice level would continue; there would be an
intermediate care level (GP-led) for low-technology procedures; and there would
be the back up of a District General Hospital. The PC service would require administrative/managerial
support, which could be provided from a different building. There would be separate
roles in a PC group for someone to manage the process and a professional acting
in a specialist advisory capacity. This is already working in England but has
taken a lot of work to set up.
-
Costs will dictate what we get in PC. Someone should be dedicated to work proactively
to changing public attitudes, for example, diets. [Ms Hanna]
-
In reality, the funds allocated indicate that the Health Service is only paying
lip service to prevention, which is an area that needs to be focussed on. Patients
must be empowered to take responsibility for their health and use the service
responsibly.
Health and Social Services Minutes 7 February
2001
|
