News / News analysis: Minding the gap

Finance managers who have picked up this magazine, attended conferences or read a thinktank report in the past year or so will be aware that the NHS needs to change. Yes, services will be transferred from hospital to the community, but what does this transformation mean for those who need the NHS most – the elderly and those with long-term conditions?

The answer could be the introduction of a group of doctors and other clinicians, dedicated to caring for these patients, according to NHS England. This extensivist model would see community clinicians – most likely GPs – in dedicated accommodation, looking after and acting as advocate for patients with chronic illnesses.

The model was given a boost in March, when it was named in Monitor’s report, A call to action: transformative ideas for the future NHS, as a way of transforming the care of the vulnerable elderly.

NHS England national clinical director for long-term conditions Martin McShane floated the idea and he has been joined in his enthusiasm for the model by his NHS England colleague, strategy director Robert Harris. Dr McShane says extensivist GPs – he prefers complex care practitioner – is a reaction to the increasing complexity of care that could and should be offered to patients in the community.

While an extensivist GP would provide services to their more complex patients, the traditional GP model would stay in place for the rest of the population. The idea is to fill the gap between hospitals and community and primary services for the 5% of patients whose care takes up 40% of NHS resources – patients with complex multiple comorbidities.

Skills gap

In parallel with the emergence of this group – which is likely to become bigger as the population ages – the gap between the skills of hospital specialists and generalists in the community, and the patients they treat, is greater than ever, Dr McShane said.

‘There is a greater specialisation in hospital care, whereas GPs have increasingly been asked to do more complicated work – for example, under the quality and outcomes framework. But the management of the really complex patients has been abdicated. No-one has a real focus on them.’

Professor Harris added: ‘We are trying to look forward to a health system that meets the demands in 15 years. We need a different model because of the emergence of multiple comorbidities and because of what people have told us they want.’

A number of building blocks are needed to implement the model:

• The GP registered list
• Computerised healthcare records
• Social care records.

If these databases could be interlinked, services could be delivered to suit patients’ needs, they added.

The idea borrows from some US-based models, such as the Evercare system in nursing homes, and Care More, where seniors are cared for as a medical group. The outcomes of these initiatives have been impressive – better clinical outcomes, greater patient satisfaction and greater financial sustainability, Professor Harris said.

While there are caveats to consider when comparing US and UK healthcare, the Care More results are remarkable, he added. Its integrated approach delivered a 90% reduction in patient falls, 80% reduction in amputations, 50% fewer mental health interventions, 30% fewer bed days and a 20% overall reduction in costs.

Professor Harris said extensivist GPs could be one of a range of initiatives a local health economy may wish to consider. ‘It will improve clinical outcomes and the use of resources, particularly money.’

It would aid the shift to patient-centred coordinated and integrated care, he added.

The extensivist would be a general clinician with a broad range of skills, able to act as patients’ champion and guide them through the labyrinth of primary, secondary and social care. They would have full accountability for the patient – in the case of the elderly with long-term conditions, this would meet one of the government’s policies of having a named clinician for each patient.

Each community would have between two and four general doctors or extensivists, supported by multidisciplinary teams of nurses, therapists and social workers. Each team would look after between 1,000 and 1,500 high-risk patients – individual GP lists are generally around 2,000 patients.

With reduced lists, extensivist doctors would have more time to care for their patients. An average patient sees their doctor once every 11 months, but the high-risk patients will be seen more often. ‘The more frequent contact will be a huge advantage. For example, they can build up trust and introduce education and shared decision-making so the patient is better informed about their condition or conditions,’ Professor Harris said. ‘They can provide care to vulnerable groups of people, with better outcomes, better patient satisfaction and within a budget.’

Dr McShane insisted complex care practitioners might help take some of the pressure off general practice. Research has shown that the average number of consultations per patient has increased and among those aged over 75 can average seven or eight visits a year.

Financial incentives were needed to deliver long-term care management using the model, Dr McShane said. They have not reached the point where they have developed payment mechanisms, but Professor Harris said they might have to think differently. A successful outcome for an 80-year-old with multiple comorbidities might be no acute intervention.

‘It will require a different type of reward. We need to do some work around how we reward this and how we build in incentives, but we could start to do this right now,’ Professor Harris insisted.

Indeed, Eldercare in St Helens, Merseyside – a GP home visiting service for the over-65s run from the local hospital – is based on the existing PMS contract, Dr McShane added. New contractual arrangements could form part of the work NHS England is carrying out alongside Monitor on flexibilities in the tariff and in pilot sites, he said.

Dr McShane said NHS England would not mandate a complex care practitioner model. He believes different models will emerge, each suited to the area in which the clinicians operate. However, he acknowledged that creating the capacity to deliver the model will be a challenge.

However, he reiterated it already could be, and was being, achieved with existing contract mechanisms. As well as the extensivist-like model for dementia patients in parts of Staffordshire, Dr McShane highlighted the work initiated with GPs by University College London Hospitals NHS Foundation Trust to manage the care of the homeless.

Service for homeless

The London Pathway service, set up with funding from UCLH Charity, includes a GP-led ward for homeless patients and a nurse practitioner who coordinates all aspects of their care, including plans for their discharge. According to the trust, during 2012 the pathway had reduced bed days due to homeless admissions by a third and had made cost savings of £100,000.

Professor Harris said the doctors need not necessarily come from primary care – the skills required were held by both primary and secondary care medics. ‘The models we are working with are not abstract. They are policies we are going to implement. We are already seeing geriatricians saying they would be prepared to break away from their secondary care organisations and primary care physicians saying if we can free up their time they could do this and that it would make their jobs more fulfilling.’

While the idea is in its infancy, Professor Harris and Dr McShane are keen to set up pilots soon and encourage interested commissioners to ‘get on with it’ under current contracts rather than waiting for nationally-developed contracts and payment mechanisms.

Extensivist or complex care services appear to match the direction of policy, including on quality, efficiency and patient experience. Watch this space.