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Focusing on frontline workers

8 February 2016

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The workload that is flooding into general practices is continuing to increase and the pressure is building for both staff and patients. Stephen Dorrell discusses how he and the NHS Confederation see the burden lifting

The NHS Confederation’s stated mission is to “influence [government] policy in the interests of patients, the public and NHS staff”. But Stephen Dorrell, who was appointed chair of the NHS Confederation in October 2015, voted in favour of the Health and Social Care Act back in 2012 when he was chair of the Health Select Committee. Yet the Act, and the NHS reorganisation that it enabled, continues to be deeply unpopular with coal-face clinical and support staff, as well as much of the general public. Will Dorrell be able to reconcile his political record with his new mission? Management in Practice met with Dorrell at his offices in London to see where he stands now.

Q What positives do you think have come out of the Health and Social Care Act 2012?
A There are three changes that came in from the act that I think will endure. The first and simplest to state is the transfer of public health out of the health service into local government and Public Health England, so that it becomes a separate voice with a much broader view of the concept of public health than just health services. I think that is completely right; I have not heard anybody argue against it. There are all kinds of resource and practical consequences for that need to be worked through, but public health is a function of government, it is not a function of a healthcare delivery system. So that is one change that I think is very positive.
The second change is the engagement of the professional communities in the commissioning process, and I think that is sometimes described as GP commissioning; I think that is wrong. It should be about professional communities, not just GPs. I am a strong supporter of empowered, effective commissioning

Q What is your view of effective commissioning?
A Commissioning that first of all engages with all the professions in the health and care system, every one; the social care specialists, the nursing profession, the medical profession and all the others, so that ideas about what good practice look like are reflected in commissioning decisions. That is one important principle, but another is that commissioners have to look across the silos of traditional care in order to start with the needs of service users and redesign services, or encourage the redesign of services, to reflect the needs of the people who use them.

Q And what about the third change you mentioned?
A It’s the health and wellbeing boards, which I think are still in gestation. But if what we want – and I think it is what we want – a more joined up health and care system, then a health and wellbeing board bringing local government to the party as part of the accountability mechanism for a joined up health and care system, I think, is an important step forward.

Q There has been drive to encourage people to attend general practice instead of A&E. What do you think practices can do to handle this extra workload?
A It is exactly right to say that there is no solution to the demand pressures in an acute hospital solely within the acute hospital. But it is equally true to say that simply transferring that demand to the GP surgery gets nobody anywhere. Understanding why people feel a need for healthcare support, that is where we need to start, not how we change services to respond to rising demand.

Q There is a GP shortage across the UK and budgets are limited but there is still a drive to extend GP services to seven days a week. What do you think practices can do to survive the current crisis?
A It is actually not about relieving the load on GPs or, even worse, saving money, it is about enabling people to enjoy their lives, which is what this whole sector ought to be about.
And then it is also about making certain, of course, we have got proper training, but actually it is about making certain that the way in which people who choose to devote their lives to community medicine, their working environment is rewarding.

Q How can general practices do this?
A We should be looking to see why the demand rises in the first place, and quite a lot of it is around social isolation. One of the issues I sometimes raise is if, in a traditional primary care setting, you ask yourself why people are there, quite often you will find significant numbers of them are there because they are worried about their debt problems or they are there because mental health issues have arisen because of social isolation. That doesn’t need a prescription pad to solve either of those problems, which is why I stress the importance of a joined up health and social care system that is looking for what I sometimes describe as, the root cause of dependency.
A lot of GPs will talk about the dangers of overmedicalisation. Recognising that the needs that lead people to come to see a GP are quite often social care; they are about their social context, they are not about their medical condition.

Q So do you think social prescribing has a place in general practice?
A I do. If you deal with the social cause then you have avoided the medical condition. Most importantly, you have then enabled the citizen to enjoy their life. I come back to the point about enjoyment; it is quality life years, not just life years.

Q With the changes general practices are facing at the moment what do you think it could learn from businesses in order to survive?
A Well, I think there are two important principles in the health service here. First of all, the core principle, the values around which the health service is built, is the delivery of equitable access to high-quality healthcare. And that is largely taxpayer funded, although of course looking at it as a single health and care system it is, in fact, mixed funded. But securing equitable access to high-quality care is what the system, both health and social care, ought to be about.
The delivery of those services, whether it is a hospital service or a primary care service, or a social care service, is another form of economic activity; others refer to it quite often as ‘the healthcare industry’.
It is a service business, so [it’s about] using modern management techniques, using information more effectively, being comfortable with changing demands made on the service, using modern technology more effectively in a prompter way.
We should be more open to new uses of technology, human resource management. But whether you look at it as information technology, other forms of technology, human resource management, and basic management – all of it is about securing effective change.

Q Financial pressures have, in some cases, resulted in private companies taking over general practices. This and other policies have led to accusations that the Conservatives want to privatise the NHS. Why do you think people often accuse the Tories of this?
A I think it is a political slogan used to attack the Tory party. I am a lifelong Conservative. I remain an active Conservative, but I always remind people that the NHS has been a public/private partnership from the day it was founded. And the first person to make the case for a public/private version of the NHS was Aneurin Bevan [Welsh Labour Party politician who was the minister for health from 1945 to 1951], who was not a Tory.

Q Is there ever an argument for services to be charged?
A Well, in a single system we already do charge for social care on a means tested basis. So with the health service, although people like to say it is free at the point of delivery, apart from a very brief period in the 1950s, it never has been. We charge for prescriptions, we charge for eyes and teeth, and people forget that eyes and teeth are both an important part of total wellbeing and healthcare. But I am not in favour of changing the free offer.
But I am in favour of being honest about how much of it is free and how much of it is not.

Q With the numerous changes the NHS is facing and in particular general practice what does the NHS Confederation plan to do to help its members?
A Well, our members are clinical commssioning groups, provider trusts, and what we want to do is to develop a closer understanding with them of what it feels like, to be delivering health and care services day-to-day.
But also, following through all the things I have been talking about, to engage with the public health community, with the social care community, so that the NHS Confederation is leading the way to the development of a joined up health and care sector that is more focused on patients and less on traditional structures.