More for Less - NHS Growth Money is coming to an end

"All bets are off" as David Nicholson tells NHS to prepare for cuts (HSJ 4June). Massive investment over the last 8 years hasn't improved productivity (HSJ 28May). PCTs aren't making use of the wealth of experience and enthusiasm available through Practice Based Commissioning (PBC) (Primary Care Today May/June 09). The same old ideas are put forward as the solutions to all our problems - more care out of hospital, more innovation, more work led by nurses, more Health centres, more salaried GPs.
Why haven't these 'obvious' solutions delivered? I'm not convinced that inertia is the complete answer.

• Changes which deliver better care, more effectively, can only occur at decision points on care pathways. Many health service staff are engaged in the delivery of care according to a protocol. Therefore we need to focus on the decision points, and necessarily on the decision-makers. For example, GPs decide which pathway to refer a patient onto; community nurses very often provide the care on that pathway, but don't change it. ECPs (Emergency Care Practitioners) make a diagnosis and a decision where to refer when they attend the scene of a fall, an accident, an emergency; advanced paramedics or alternately trained paramedics have limited protocols and limited options.
• salaried GPs employed by PCTs are no substitute for the family doctor. A salaried GP does not become a point of trust for a doctor (70% of GP appointments result in no referral and no prescription; patients attending to be told that they can carry on as they are, or to be listened to - by an old friend or a family friend, not by a stranger); a salaried GP moves from practice to practice according to their state of life, perhaps in the big city when young, in the suburbs when the children are school age, and to the country when the children leave home
• care needs to be given in the most APPROPRIATE location, and by the most appropriate staff, regardless of politics and organisation. For a great many patients and a great many conditions, hospital is the best place for treatment. For a lot of other health care, the hospital staff may be the best, even if care is to be delivered in the community or patient home. All the suspicions about hospital staff steering patients towards their hospital for maximum income appear to be unfounded
• "Redefining Healthcare" by Porter & Teisberg looked at different ways of delivering healthcare across USA, and clearly concluded that the UK system of GPs as the first point of contact is not only the most cost-effective, but also delivers the highest quality health care

Healthcare is improving (although QOF rewards for process, this is resulting in for example higher proportions of those on the CHD register with low blood pressure - see HSJ 28May 2009, same article). We do need innovation, but we must not throw the baby out with the bathwater - keep what is good, find ways to encourage what will make it better.
All we are saying, is give PBC a chance.