Suppose a pathologist was to say, “Because I am not a GP I do not belong here.” Or a GP was to say, “Because I am not a cardio-thoracic surgeon I do not belong here.” No, (paraphrasing St Paul) we are all parts of one body of medical enterprise, and the patients need different doctors at different times – sometimes more specialised and sometimes more general.
Why then do we tolerate operating in a system that sets up clinical, intellectual, and financial incentives that divide doctor against doctor, primary care against secondary care, NHS against social care? Why do we tolerate working in a system where the outcome is so much less than the sum of its parts? And why does the government allow the mess to continue whilst lamenting that any improvements are not commensurate with the money spent?
The division of medicine into primary and secondary care is long standing, but it is now unhelpful. It prevents innovative thinking about how we could use healthcare system resources well, so that we could treat patients more effectively, systematically, and more cheaply. It is the long standing (pre 1900) reification of this flaw into the GP to consultant referral system, and then the more recent (internal market, post 1990) move to make each referral decision into an itemised and charged for commissioning decision that has led us to the current much needed “listening pause” over the government’s current Health and Social Care Bill.
The financial and intellectual arrangements that divide the NHS and social care into parts are fundamentally flawed. They are mental clutter that should be cleared out. If this was done then we could start to think more usefully about how we make the health and social care systems work well- to give a decent integrated and co-ordinated service to patients- and a sensible work life for the staff.
The division of medicine into primary and secondary care is now administrative and financial rather than clinically relevant. Many diseases, for example diabetes care, now need a local network approach rather than a specialised clinic.
But services are not commissioned across primary and secondary care. Instead each side has to defend its own silo, and so we hear system noise about “unsupported transfers of responsibility and workload” and “bed blocking” rather than quiet discussion of who does what where, and moving the money to support an agreed outcome. Too often in the NHS the form is dictating the function, when the function should dictate the form.
Sometimes the NHS seems to treat patients as problems to be moved from one place to another, and not as continuous people who need care from various resources within the NHS and social care system. This system is poor, and as Lakhani and Baker put it, “Interfaces of care are dangerous places for patients, and their care is often disrupted when it crosses interfaces in health and social care.” That this statement is difficult to deny is an indictment of our current systems. Our present silo based care system is a hazard, not a help, to patients.
I hope that I have demonstrated that the division of medicine into primary and secondary care and into health or social care is a false division that mismatches the needs of patients. This system has inbuilt inefficiency as the parts have to squabble amongst themselves for resources, behaving as if they are strangers to one another, rather than as parts of a larger system.
The current NHS structural and economic drivers towards primary care being seen as commissioning secondary care have been in place for many years. They became especially stark in the current Health and Social Care Bill. In their current guise they are likely to make silo thinking stronger rather than weaker. As Stephen Dorrell put it, “The heart of the problem is that health and social care is riddled with separate bureaucracies. Acute hospitals, GP surgeries, community health services and social service departments — to name only the four principal categories — all run separate budgets with separate management structures and, critically, separate information systems.”
If the NHS is to survive, and if some form of welfare state is to remain affordable, we can no longer afford an inefficient system of squabbling parts. To achieve this commissioning needs to be at a level above direct service provision, and needs to be of whole pathways of care across primary, secondary and social care boundaries. It will not work if it is done to one part of the system by another.
I would suggest these commissioning bodies would be area based and democratically elected. Commissioning must became a specific function in its own right, and not merely something bolted onto primary care- which is already busy enough with its own workload.
At present the NHS achieves a lot less than the sum of its parts. This is its great failing. Moving towards local, integrated and co-ordinated services would be a move forward, both for care standards and for financial efficiency. The whole needs to become a lot greater than any one part of the service, and the financial incentives need to drive clinical and organisational behaviour towards this.
Peter Davies is a GP in Halifax. He is involved in the local commissioning consortium in Calderdale, believing it is better to be involved than not.
Competing interests: I am an elected member of the Calderdale Commissioning Consortium. In this paid role I am trying to make the new commissioning arrangements work to achieve better overall outcomes for patients in Calderdale. I am not sure that the new format is the best possible, but I am doing my best along with colleagues to make it work well for patients. In this article I am writing personally and not on behalf of the consortium or any other body.