CEO blog - Will left shift really happen or provide better patient care?

I always ask the question what do you mean by left shift. I don’t always get the same answer from ICB or other colleagues. I normally expect it to mean moving care out of hospitals into a community setting. Patients would almost always wish to be treated closer to, or at, home. I know I would unless the treatment was highly complex or specialised, or I was very ill. But moving a patient’s care out of hospital does not, by itself, make that care easier to deliver or better quality.

Someone still has to provide the care, arrange follow-up and decide when specialist input is needed. If the hospitals move staff and teams into the community the premises and resources needed must flow into the community. If that work moves into General Practice the funding, workforce and responsibility need to be worked through too and agreed with other parties BEFORE it happens.

Care closer to home is a sensible ambition and one that the NHS has strived for at least the last 25 years. Technology, treatment options and outcomes have improved. But if the receiving service is expected to absorb more activity without the resources to manage it, we risk moving the pressure rather than improving the pathway. The money and resourcing has to follow the work. It should not be assumed that care in the community is cheaper or even that the community services, including general practice can deliver it for the same unit cost as in the hospital.

The NHS wants to strengthen neighbourhood services while hospitals are under enormous pressure to stabilise their finances and performance, and ICBs want to reduce costs. That creates a difficult tension: the system wants care to move, but the financial pressure keeps resources in hospital and no one at NHS Englnd or at ICB level has suggested how the financial levers could work. Hospital colleagues need to be involved in designing the answer. General practice and community services also need a meaningful role in shaping what they will be expected to deliver.

Same-day community hubs, for example, might improve access and support local practices, but that depends on who staffs them, who pays for the estate and who holds the clinical risk. It also depends on what happens after the first follow up appointment. General practice cannot simply absorb the gap.

The ‘left shift’ terminology and ambitions for general practice keep expanding: more prevention, more proactive care, more access, more continuity, and more neighbourhood working. Each of those ambitions creates practical work which the NHS leadership is silent on. Additionally, some of the new technologies, drug regimes, and treatment options need to be looked at carefully in respect of what the proposed pathways asks of a GP practice. New ways of treating patients may support important NHS priorities while creating additional reviews, monitoring, or follow-up for an already stretched family doctor team. ICB teams need to understand that workload before assuming the practice can take it on. Commissioners need to engage widely and in a timely fashion with each of its practices and PCNs. Pushing responsibility for this engagement to local provider collaboratives is just rearranging the deck chairs. General practice being central to the plan does not mean it has the spare capacity.

We need a stronger emphasis on regular interface dialogue between primary and secondary care providers. We need to then widen that discussion and exchange of ideas to other sectors including local authority colleagues and the third sector. And somewhere in there we also need to capture the views of service users past and present. Neighbourhood working could offer that opportunity to encourage service redesign and delivery. However, history is against us as political pressure to reduce costs and individual organisational cultures are resistant to change.

What can you do in your practice, PCN, Neighbourhood or local health and social care system to start the change?

William Greenwood

Chief Executive