Let’s not pretend we know what should happen.
Often people tell a story of the future they would like and then try to back it up with logic. But this gives a narrow view and makes us argue about whether they are right. Instead, we should look at a range of models.
Locally owned community teams.
Care is delivered by units owned by those who do the caring. The work can be fun and pay well because workers control their work and keep the profits. But they need a system for teams to help each other if things go wrong. NHS management sets the goals but can’t control how they are done. Patients know their clinicians and tend to be more collaborative. Smaller teams risk spikes in demand and need more slack.
Centrally owned community teams
Staff are employed by a central organisation. This gives workers less risk but less control and usually no share in the profits. Teams are larger, and it is hard for a patient to choose a clinician, especially at short notice. Large teams can work near full capacity but remain resilient to random demand. The cost of switching clinicians repeatedly for ongoing problems is great. NHS management control how care is delivered but lack of engagement of staff and patients can affect costs and quality.
Hospital / community integrated teams
Teams span primary and secondary care and so can reduce inefficient work dumping in either direction. However, hospital services can have more influence at the expense of community services. Integrated teams could improve continuity for patients who frequently move in and out of hospital but improving communication between existing teams may be more cost effective. Integrated teams can do secondary care in a community setting although this may not be the best use of clinician time.
Integrating community health with social care teams
Elderly and chronic disease patients often need social care as well as healthcare. Integrating these may stop social needs from causing health needs. Social care is underfunded so pooling budgets can risk reducing the funding for community health. Local councils provide community services which can help the causes of ill health (housing, education, employment, crime etc.). But councils are political, and this may conflict with evidence-based health.
Real world experience
Some locally owned GP teams are highly effective, but not all of them. Centrally owned 111 teams have produced a poorer service than well run GP out of hours but have provided universal coverage. Privately owned teams like Virgin Care and Operose seem to have failed. Local hospital integration moved our GP out of hours from a purpose-built centre near where patients live to a clinic in the hospital grounds. Easy patient access and free parking were lost so work from A&E could be sent to the out of hours staff. Contraceptive services were moved to council control and have been reduced by council cuts (1).
All solutions have pros and cons. We need to appreciate both.
(1) https://www.theguardian.com/society/2016/dec/12/council-cuts-hitting-womens-contraceptive-services-data-shows