The challenges involved in GPs commissioning social services

Can GPs’ surgeries provide a one-stop shop for health and social care needs? Claire Seneviratna looks at some of the pitfalls and benefits to expanding GPs’ remit.

When health secretary Patricia Hewitt announced that she wanted to see the NHS move onto traditional local authority turf and use some of its money to buy social care services, many observers felt a discernable shift underfoot.

The idea that family doctors could soon be prescribing anger management classes for temperamental teenagers, counselling sessions for people returning to work after a long illness, and air conditioning units for people with chronic lung conditions, hints at a revolution in the making. But, while many doctors recognise the potential benefits of such a move, there are concerns about the practicalities.

Dr David Jenner, practice-based commissioning lead at the primary care representative body NHS Alliance, says the main problem with the idea is that social care as provided by local government is means-tested, whereas the health service is all about providing services which are free at the point of delivery. “These are two different cultures so I think people are struggling to envisage how this would work,” he added.

The proposals, included in a commissioning framework for health and well-being put out to consultation last month,(1) encourage GPs and their primary care colleagues to buy social services direct for their patients.

John Dixon, vice-president of the Association of Directors of Adult Social Services, says: “While there is already a certain amount of co-operation between GPs and social services, this announcement actually represents a culture change. It is saying to GPs that it’s OK to use money from their mainstream budgets on services that councils have traditionally provided.”

While commissioning itself is not new, bigger primary care trusts and the acceleration of practice-based commissioning are firmly placing GPs at the forefront of a radical redesign of services around the needs of patients.

However, the prospect of local surgeries becoming one-stop shops for all the health and social needs of a community is a step too far for some doctors. There is too much pressure as it is, says Dr Jenner. “GPs are already being asked to control budgets, keep a check on patient referrals and, of course, focus on achieving the government’s 18-week waiting time targets.”

While the proposals have been accompanied by a government cash injection of £8.9m to get the scheme up and running in the poorest areas, the reality is there will be no new money to help GPs prescribe social care. Expecting cash-strapped PCTs to “get creative” with not very much is considered by some to be a little disingenuous.

“While social care commissioning is something we’d like to see happen, at the moment commissioners are more worried about their financial deficits,” says Royal College of General Practitioners chair professor Mayur Lakhan. “Purchasing social care is not among PCTs’ top priorities.”

Dr Chaand Nagpaul, chair of the British Medical Association’s commissioning and service development subcommittee, describes the proposals as a “framework of aspirations” which doctors have heard many times before.

“Telling us to be flexible and creative with our budgets is just too vague. The only way joint commissioning can work is if there are proper pooled budgets for certain care areas, like older people and people with chronic diseases. At present there’s no system or formula in place to make this aspiration a reality.”

So how could it work in practice? In St Albans in Hertfordshire, a consortia-model is being used to improve mental health services at a primary care level. Six practices have put together a multi-disciplinary team aimed at providing talking therapies as opposed to routine drug prescribing.

Steve Knighton, programme director for mental health and learning disabilities for the East of England Strategic Health Authority, says: “If you can put these multi-disciplinary teams together, which include social workers, community psychiatric nurses, psychologists and therapists, you can contain an awful lot of patients at primary care level without the need for referrals to secondary services.”

To improve the knowledge of GPs when it comes to prescribing social care services, Dixon says there will need to be very close co-operation between local authorities and PCTs, particularly around chronically ill individuals who are well known to both GPs and social workers.

“GPs can’t be expected to have the same expertise as social workers, so for instance it wouldn’t be right for a GP to prescribe a nursing home for a patient when the right social care intervention could help them to remain independently at home,” he says. Commissioning support managers to advise doctors on services and products they wouldn’t previously have considered would be helpful, says Professor Lakhani.

While extending their remit may be acceptable, if a little fanciful to most GPs, adopting the means-testing approach of councils is almost universally rejected.

“We certainly would not want to get involved in means-testing,” says Professor Lakhani. “We remain committed to the principle that NHS services are largely free at the point of delivery.”

Practice-based commissioners
Department of Health figures show that 93 per cent of GP practices are now involved in practice-based commissioning.

Under the scheme, GP practices are given their own “notional” budgets with which to buy health services for their patients. Commissioning practices are accountable to their PCTs, who negotiate and enter into contracts with providers and remain legally responsible for the funds.

The budgets cover any NHS services their patients receive, including trips to A&E, drugs, and out-patient and in-patient treatments. Under the framework, these commissioners would be encouraged to “explore using NHS funds more flexibly”.

This could involve providing alternatives to hospital admission, such as providing carer support or respite care, or taking action to tackle obesity, such as prescribing physical exercise.

Quids in: saving NHS money by spending it on a special care expert
Since 2005, Lorraine Saunders, a hospital care manager from Devon Council, has been funded by Devon PCT to come to the Claremont Medical Practice in Exmouth, Devon, each morning and work alongside doctors and community nurses.

In one year alone, the move has already shown the huge potential savings to be made from combining health with social care services.

“Within a year of starting the scheme we had reduced A&E admissions by 15 per cent and saved £450,000 on acute hospital care,” says Dr Tom Debenham.

“The service we can give to patients is much quicker and more seamless now,” he says. “For example, if we know of an elderly man who has started to fall often, but doesn’t want to go into a home, we would tell Lorraine and she would be able to visit him quickly and talk about the options open to him from a social services perspective. Those arrangements could avoid further falls and a trip to hospital or a stay in a rehabilitation unit. It’s proactive and preventive.”

But while the practice has commissioned the services of a social care expert, it is not footing the bill for the services Saunders purchases on behalf of patients. This avoids the possibility of patients being means-test for GP-funded services.

“It seems to be a good way of doing it,” says Saunders. “I’m able to help people who wouldn’t otherwise approach the council, and the GPs don’t have to spend their time on the bureaucratic referrals process and admin.”

Saunders is now a fixture in the practice, attending daily meetings with nurses, talking through the cases of patients deemed at risk and sharing assessments. Dr Debenham believes providing money up front, and giving practices the authority to invest it, will be crucial if similar arrangements are to become widespread among GPs nationally.

Further information
(1) Department of Health, Commissioning Framework for Health and Well-being, March 2007

This article appeared in the 12 April issue under the headline “Doctor knows best”