Martin McShane on boundaries

Martin McShane“How much does the PCT spend on healthcare for people over the age of 65?” the telephone caller enquired.  An impossible question to answer accurately, but after a moment’s reflection I suggested applying the Pareto principle. Most of our money is now consumed by long-term conditions management or, is it fair to say, mis-management. A back of the envelope assumption would mean about £800 million would be a ball-park figure to begin with.

I know why we were being asked. There are lots of discussions about how to better align the interface between health and social care, especially for the elderly. The difficulty, of course, is the fault line between the services, created by one being means tested and the other being free. Theoretically and intuitively integration between health and social care should benefit use of resources but, more importantly, it should benefit patients. The problem always seems to be clearly tracking the benefits in a complex system. Collecting appropriate data seems to end up in the “too difficult” box. It also runs into the shredder of all great strategies – culture. There are huge cultural differences between a system which is held to account locally, and one which purports to abhor postcode lotteries and has the prime purpose of providing the same level of service no matter where you live.

Integration, however, must be the right thing to do, despite the difficulties. Primary care trusts were constructed to be co-terminous with local authorities, the intention being to foster integrated working.

Our professional executive committee comprises the GP chairs of the clusters (from here on to be known as consortia) with the executive team from NHS Lincolnshire. At the last meeting we went through the emerging policy documents. We picked up the strong emphasis on the role of local authorities for co-ordinating integrated working. We picked up on the strong emphasis that GP consortia and the independent commissioning board will have sole preserve for NHS commissioning.

We also picked up the early thinking from within our consortia that patient flows do not comply with local authority boundaries. Some of our emergent consortia, building on the development and experience which they have had over the last few years, will be created by the fragmentation and coalescence of groupings of practices to focus on patients, not local authority boundaries.

Then it occurred to me that maybe one of the solutions is to stop thinking about co-terminosity and focus on the person. Individual budgets are far more advanced in social care. Can consortia be given their budget for social care? If the money follows the patient then co-terminosity becomes less of an issue. Consortia could then have a clear idea of what resource, health, and social care, is available for their registered patients and make it work in an integrated way.

It’s just an idea.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.