The Scottish Parliament on behalf of all our population now faces a simple stark choice. Do we want to continue with our National Health Service and build trust and productivity into our Integrated Health and Social Care Teams, or do we just continue to fragment and destroy the parts of the care service we know work best.
The most difficult diagnosis in medicine to make and get right is to tell a patient there is nothing seriously wrong with them and be proven correct, at least for a time! It is so much ‘safer’ to say there might be something wrong and keep investigating and referring.
It is important to realise all doctors have the same final outcomes-100% of their patients will be born and 100% of their patients will die. This makes it essential to use Place /Locality data to measure productivity and value for money. Nobody can manipulate or selectively use ‘Locality Based data.’
Why is this important?
After the disaster of the 2018 ‘Glasgow biased GP Contract’ we now have the Scottish Government proposing ‘Drop-In GP Clinics’ to provide one million extra appointments. Again this appears to be very much a ‘city model’.
This is just another fragmentation of ‘Continuity of Care.’ Similar in many ways to giving the responsibility for vaccinations to health boards with no IT back up and no capacity. We have repeatedly been assured that vaccination will be returned to a GP/Locality based service but so far we have seen no hard evidence of that being implemented.
So, what are the numbers about which we are talking?
GP Teams provide 720,000 consultations per week= 37,500,000 per year
A&E Teams provide about 27,000 consultations per week=1,500,000 per year
The ‘Drop in GP teams ‘ are said to be delivering about 20,000 per week=1 million per year.
This is meant to help both existing GP Teams and A&E Teams.
Is there a better more productive and value for money alternative? Well, the obvious answer is yes. Expand existing GP Integrated Locality Teams with all their ‘Infrastructure and IT in Place.’
I have argued that the ‘Nairn Model ‘of Integrated Teams based on one site works best and in particular builds that essential trust between individual patients, their family and community and the appropriate use of secondary/specialist care. It is sometimes worth remembering that a lot of the clinical debate is really at heart an old fashioned ‘demarcation dispute’- similar in many ways to the demise of ship building on the Clyde, mainly caused by ‘bad management‘ and ‘bad unions.’
How do we now make sure we are not making the same terminal mistake in Health and Social Care?
My advice is that we encourage urgent sensible contract discussions with the Scottish BMA with RCGP Scotland support and use this opportunity to increase existing GP/Community Care Team Capacity. We have GPs and doctors in training looking for jobs. Contracting on a locality based model will enable no delayed discharges in consultant beds. Our Nairn audits showed 80% of our patients attending A&E in Inverness could have been dealt with in our own Community Hospital A&E/Minor Illness unit ( perhaps our already in place GP Drop in service, with our own GPs, nurses and other staff and IT in place 24/7.)
The KPMG report on Grampian illustrates very clearly that if you reduce GP out of hours services, followed by closing minor injuries and community hospitals, everybody ends up in Aberdeen Royal Infirmary, with 90% of the bed capacity being used for emergency/delayed discharge care resulting in not enough capacity for elective work and producing longer waiting times for all. The multi agency inspections for services for older people showed over 60% of Occupied Bed Days for over 65-year-old patients were in GP led community hospitals previously. Centralisation is a very dangerous route and tool!
A positive way forward is to commit resources, mainly staff, to Integrated community care teams in each locality. This will be balanced by reduction in staff in consultant care, but most importantly of all it will allow the specialist/consultant teams to deliver what they are best at – real specialist care. All other generalist care should be in patients own locality.
In terms of figures and targets, this could mean an increase from 720,000 to 800,000 per week contacts between patients and their GP/locality care team. As long as we staff the localities properly this is a very realistic outcome/target and will allow real monitoring of clinical and financial data.
We now need leadership and courage. It is best for our patients, their friends and relatives, communities and specialist care – what is not to like about it!
It also means we can easily stay within a ‘Fair Share integrated Budget ‘ and in terms of ‘Place Building’ encourage a much better allocation of staff across Scotland, especially helping rural locations.
I think we can make our health and social care world class. We have the best data in the world. Now is the time to use it.
Dr Alastair Noble worked as a GP in Nairn and was awarded an MBE for his work in integrating Health and Social Care in Nairnshire