Early days, but the Darzi report was published last week here. I'm trying to produce an internal briefing on implications for our sector. Does anyone have any initial thoughts? or know of a handy guide to you/your local PCT may have produced? Yes it would help with my briefing, but I am interested to guage feeling amoung the respected minds of this forum - is it really the death of GP practice as we know it, as some doomsayers are predicting? any thoughts welcome.....

Hugo Luck
national programme lead (policy) NTA

Whenever Darzi gets mentioned it seems to be at the same time as either pained expressions of misery or with long streams of invective. I think some rational debate of the implications would be great. Does seem to be the death of single handed GPs though at the very least. -- Shipman did most of that work previously, though.

I have recently agreed, (very foolishly as I don't have time, I know, I know) to be part of one stage of the PCT procurement process that is going to implement the equitable access to primary care bit of this, and its very early days but i can refelct a couple of early insights
1. yes Jim you are quite right the amount of cyniscism is breathtaking - I can't imagine going to all those meetings and reading all those papers, not to mention the vilificatiion of one's colleagues aftermath, unless I believed what I was doing was going to be helpful

2. I guess it depends on the attitude of the PCT as well as the clinicians, but it is possible to make the most of this opportunity, i believe. Our PCT is using the money as an opportunity to provide new services in the 5 most deprived areas of the patch, and address proven health needs. Many of the 5 are underdoctored, which gets round the problem of closing people down to some extent. The 5 site model makes for a cumbersome to tendering process, but makes more sense in a rural area than one central polyclinic - the London model - but many other rural PCTs I heard about at a meeting I attended last week are planning a central polyclinic in the main market town anyway.

3. I am more worried about lack of continuity of care, than closed-down GP surgeries, to be honest. The National Programme for IT should have been up and running by now. (mental note to see how we are going to deal with communications locally). But it does set GPs in competition with each other in a way the old MPC would never have allowed, and I do see how that's unsettling.

4. It seems highly likely that a clinic designed to provide equitable access is going to be a perfect setup for some primary care-based service provision for substance misuse, as they should be designed to attract patients who are not very good at accessing care. Even better they must provide care from 8 am to 8 pm.

5. I would encourage any GPs who are bidding to provide equitable access services, to address provision of substance misuse services as part of the bid.

6. Also just to mention from the meeting that ALL the PCTs are desperately searching for relatively indeopendent clinicians. Substance misuse docs often fit the bill, as many are practising in other areas or are not principals so avoiding the conflict of interest problem. So, if you fancy getting involved....

Hope this helps.

Susi

very interesting Susi. Should have guessed it would be somewhere in your nineteen jobs Obviously my ears pricked up at the sound of extra money. Is htis detailed anywahere (i.e. who gets what?)

Hi

Saw Lord Darzi interviewed on sunday.

BBC NEWS | Programmes | Andrew Marr Show | No GP surgeries will close
http://news.bbc.co.uk/1/hi/programmes/andrew_marr_show/7491912.stm

I am still trying to wrap my head around all the potential implications.
I hope substance misuse treatment is on the agenda and very integral.
I hope easy/low-threshold access is embedded throughout and i worry that
the consultation process and opportunity to be part of that process will be
limited and tokenistic.
When scoring treatment is easier than scoring drugs we may see the tide change.

jimi

Hi -

Have recently done quite a lot of work on the Equitable Access/DARZI agenda myself.

Just on the Equitable Access stuff, I think there's some big issues about the inclusion of services for drug users that could have been grafted in there. We're now a fair way into the procurement processes (post PQQ I believe in all areas but pre formal tender - though the specs are well developed) and the results for drug users are going to depend largely on the perspective of the PCT, the priority that was given to drug treatment by the SHA and what came out in the public consultation. It would be fairly straightforward to check through the Equitable Access Strategies for each of the SHAs to find how high up the agenda they'd placed the needs of drug and alcohol users. The outline specifications are available on individual PCT websites. You can find an example here:
http://www.coventrypct.nhs.uk/documents/misc/moi_annexc..._led_hc_19may082.pdf

From the initial outline specs I've seen (just in three regions) I'd say that services for drug users were included in less than 5% of them - which is not great. I think that the real opportunity would have been to ensure that certainly all the new practices (as opposed to centres) included core drug treatment services. The opportunities with the Centres could be/have been massive - particularly if you looked at the potential for vertical integration of specialist and primary care services. I don't know how many PCTs have got drugs in there though. More seem to have prioritised alcohol.

In terms of overall Darzi stuff the momentum behind World Class Commissioning and the focus on broader health outcomes may be a challenge for the sector - partly in terms of marrying the emphasis on local priorities with national monitoring and the championing role many see as necessary to keep the amount of investment in drug treatment at its current levels - tensions could arise around the different levels of investment in drug and alcohol. The shift to the focus on the patient journey and the provision of personalised "joined-up" care may be very welcome for those looking to move investment away from secondary services into primary care.

The extension of choice of GP practice is obviously fraught with organisational and ethical difficulty. How this impacts on this sector remains to be seen. the intention is to create greater flexibility, which is laudable, however the possibility remains that this will restrict the numbers of practices willing to take drug users on still further. This is why it would have been cool to make sure that the new practices under Equitable Access were providing those services.

I understand your concern about tokenistic consultation Jimi, and I think to an extent this has been the case for much of the recent development in terms of Equitable Access. This is partly a feature of the rush in which this element of the Darzi agenda has been implemented. I'm not sure how acute the problems around under GP-ing were across the country but do wonder if another 6 months to consult more widely would have made a whole heap of difference. As it is, the opportunities for greater involvement and consultation may well come through the World Class Commissioning Process which prioritises community consultation, but it remains to be seen how closely aligned to this drug treatment commissioning will be, or for that matter how real it will be - fingers crossed.

It is still worth talking to your PCT and SHA about the priority of services for people who have experienced problems with drugs in the new practices and centres. I don't recall a bigger national piece of commissioning than this taking place in quite the same way ever before so its probably fair to say that some of the processes are being developed as people go along. No bad thing if you still want some influence.

There's obviously a lot more to Darzi's report - one of my interests in it is how far the prioritisation of drugs and alcohol in his final report will impact on local engagement - and where the health and social care integration stuff might take use in drugs. I'd be really pleased to hear from anyone who's been pondering this or any of the other stuff that might help get more treatment in primary care using a Darzi shaped lever …

Sara

www.saramcgrail.co.uk

Hi

Some GP'S are converts & some are convertible but the vast majority still refuse to address substance misuse issues.
I guess expecting Lord Darzi to improve substance misuse issues in primary care is naive given the range of complexities
that need to be addressed.

I guess I was hoping he would embrace policy nudging techniques similar to the way the tories intend to reduce domestic
energy consumption. Cameron has explicitly invoked the idea of nudging in his proposal to reduce domestic energy
consumption: he wants householders to be told, at the bottom of their gas and electricity bill whether they are using
more or less energy than there neighbors. By this subtle use of peer pressure, Cameron argues, people will be coaxed
into being more energy efficient.

I hoped that nudging towards re-defined default positions (opt out as opposed to opt in) and some contractual tweaks
would radically improve shared cared capacity across the nation. To opt out you declare your continued professional
development needs and agree to skill up within a pre-defined timeframe or we all ponder why your so thick type thing.

I guess he had tight remit and such radical blue sky thinking is to marxist for him ?

Ho hum

jimi

Jimi

I have to disagree. We have about 40% of practices involved in enhanced services nationally. Also substance misuse is now a core compnant of the new MRCGP exam which all new GPs have to take. So this does not equate top the vast majority not engaging with this field. I know that where you are based there is very little engagement but in other parts of the country it is anywhere up to 100%.

I have to say that the attitude in general practice has changed considerably since i entred the field and now when people decide not to get involved it is more likely to be as a business dicision vis a vis enhanced services rather than out of prejudice or ignorance.

several thousand GPs have now been trained in this via the RCGP part 1.

I guess the question is should providing healthcare to people experiencing problems with substance use ever have been made a part of an enhanced service?

Jimi's suggestion that Doctors should be asked to opt out rather than opt in is similar to the model used in Spain - where I believe they're now experiencing rates of engagement of over 95% (this is anecdotal - and I'd welcome confirmation of this - or to be disabused).

I agree with you Jim, that 40% is certainly a major improvement on where we wre a few years ago, but its still a minority, its not regarded as a core part of primary care services and whetehr people opt out for business reasons or dislike of drug use/drug users its still problematic. There was an opportunity for those with influence to lobby at SHA level to ensure that all new practices and centres under the Equitable Access programme included services for people with drug and alcohol problems as part of the specification. It doesn't appear that this opportunity was acted on, which is a shame. If the programme is repeated, it may be worth those with influence making some more concerted efforts around this. Darzi had a huge agenda. i guess a question is, was it up to him to engage with the drugs field, or for the drugs field to engage with him?

For those interested the Kings Fund briefing on Darzi is a fascinating read - you can get it at:
http://www.kingsfund.org.uk/document.rm?id=7829

This message has been edited. Last edited by: Sara McGrail,

GPs can't opt out of giving healthcare to people with drug dependency problems, but as an enhanced service they have to 'opt into' treating their drug dependency. This is a crucial distinction, there are 12 or so nastional enhanced services, including, minor surgery, alcohol problems, MS, Depression.

As a result of this you can't insist that GPs treat drug dependency by you can insist they offer general medical care.

Hi Jim,

Yes, I'm aware of the distinction, I just think its arguable that its unnecessary and unhelpful - which I think was Jimi's point. After all problems with substance use are often quite poorly differentiated from a whole range of other patient health experiences, particularly when we include alcohol, and as such may well lend themselves to more effective treatment in primary than secondary care for many people. Helping people tackle problems they experience with substance use is surely a fundamental part of healthcare for those patients?

well I do agree with you Sara, but unfortunately you'd have to renegotiate the GP contract to change it. In the meantime I think its quite impressive that so many GPs are delivering an 'opt into' service, I wouldn't be surprised if it has the greatest take up of all the enhanced services.

It certainly is impressive that so many GP's are engaging - and it would be interesting to look at how this does compare with other enhanced services. If the take up is so much higher than others one could suggest its indicative of just how close to mainstream GP-ing this is.

Notwithstanding the desirability or otherwise of changing the GP contract (and lets remember nothing seems to be set in stone nowadays) the fact remains that the extension of primary care access offers opportunities for SHAs and PCTs to begin to expand primary care services for drug users. It would be a shame if the bus left without us ...

Its certainly interesting to see that in Calderdale, the 5 proposed new surgeries will be exactly where our drug misuse patients are. I'm keen to see it being possible for patiients who work to avail themselves of the 8 till 8 opening hours instead of having to trek to core service for reviews as now.

quote:

several thousand GPs have now been trained in this via the RCGP part 1.

Its a tremendous achievement.
I feel sure we can nudge some more into taking the RCGP part 1 cert.
Instead of using a minibus' we'll drive them to it in fleet's of gaudy stretched limo's
We'll considerably enhance the lunch and use embossed parchment with a wax seal on the certificate.
To cap it off I'll get Carmon to print their success on the bottom of their neighbors domestic energy bill
so everyone will know just how much they care!

when I rule the world... etc etc

jimi

quote:

in Calderdale, the 5 proposed new surgeries will be exactly where our drug misuse patients are

Locality & broad opening times are a major benefits. One stop shops ethos is also crucial.

When scoring treatment is easier than scoring drugs we may see the tide change.

Sincerely believe that & as do many service users.

That's why Primary Care is so important.

Jimi