How CF and heart surgery reveal a gap in GP commissioning

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March 8, 2011 by sharonbrennan

As GPs across the country grapple with how best to commission care for their users, the King’s Fund raised serious concern last week about how groups of GP consortia can be expected to understand the complexities of our nationwide hospital provision.

In a report out earlier this month called Reconfiguring Hospital Services, the King’s Fund says that sorting out how to improve the quality of hospital care may well result in closing some hospitals or consolidating what services each hospital offers. They are concerned that the impending abolishment of strategic health authorities, along with Primary Care Trusts, means that there will be no umbrella view of hospital services and stress that, in their opinion, “Market forces alone are unlikely to result in improvements in quality of care for patients in many hospitals, and could result in deterioration in some cases”.

A classic case of such complexities is the current Government review of Specialist services which is currently looking into which hospitals in the UK will provide congenital heart surgery for children. It is recommending that such procedures are carried out in just six or seven hospitals in the future which means that of the four current London providers only two will remain.

The reasons for consolidating care aren’t just concerned with funding. There is evidence to suggest that the more surgery a surgeon performs the better he becomes at it and, in addition, the larger the hospital the better the survival rates. This isn’t rocket science: one of my first ever posts discussed a surgeon’s success in terms of Malcolm Gladwell’s theory that it takes 10,000 hours of practice to become great at something.

But while there may be a case for reducing such nationwide congenital surgery centres from 11 to 6 or 7, there are unexpected consequences for those patients who don’t have congenital heart conditions but also receive treatment at the hospitals under scrutiny.

The Government’s review currently favours maintaining congenital heart surgery at Great Ormond Street Hospital and Evelina Children’s hospital, which means Brompton Hospital in London would lose its ability to offer this treatment. I was surprised to hear that the Cystic Fibrosis Trust is campaigning against the Brompton hospital losing its congenital heart care. I’m a CF patient at Brompton and I didn’t see the connection.

But the CF Trust is worried that if Brompton loses its ability to provide congenital heart care then it will not have the patient base to justify it having a children’s intensive care unit and anaesthesia service. Which means that the care available for paedeatric CF patients will be inadequate. This in turn places additional stress on the other three London hospitals that look after CF patients as they would need to find clinic space and bed space for over 300 additional patients that are currently looked after by Brompton.

And for me, an adult CF patient, it makes me worry that there will be a knock-on effect on the care I receive at Brompton as there would no longer be a future patient base of CF children that would grow up to need an adult CF service. Brompton provides world-class care for Cystic Fibrosis patients so surely it can’t be intentional that this service is now under threat?

This does all sound complicated, but it is this detailed understanding of the demands on individual hospitals and the ability to foresee the effects of curtailing certain patient services that the Government must retain. The concern is whether GP consortia will be able to get to grips with the reforms that hospitals will require without the quality of care being affected for all the many patient types that use each hospital.

The King’s Fund believes that GP consortia will not have the experience or size to implement major service improvements in hospitals and is urging that the Government’s new NHS Commissioning Board be given greater powers to strategically plan hospital services. It argues that without these powers the system will gravitate to a ‘market forces’ model and this will not provide any improvement in the quality of care patients receive. And remember, the Government promises that a key aim behind its proposed overhaul of the NHS is to improve care – it is clear to me that to do this the Government must start looking at the limitations of GP commissioning as well at the advantages.

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