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Last Updated: Monday, 23 January 2006, 15:20 GMT
Q&A: Out-of-hospital care
GP at work
Community care covers GPs as well as social care and sex health services
The government wants to reform community NHS services from GPs to sexual health clinics.

What is happening and what are the consequences?

Q: What are community services?

Community services covers all health care out of hospital.

It includes GP surgeries, district nursing, social care, physios and chiropodists.

About 90% of patient contact in the NHS is carried out in the community.

Unlike hospital care, where there is a small but significant private sector involvement, primary care is almost entirely NHS run with the exception of a few services in areas such as sex health clinics and palliative care.

But there are signs that is about to change. In January, United Health, the biggest health firm in the US, won a contract to run two GP surgeries in Derbyshire.

Q: What is happening?

To date, much of Labour's health reforms have concentrated on hospitals, but ministers are now turning their attention to NHS community services.

The white paper on out-of-hospital care sets out how access to services outside hospitals can be improved.

Options on the table include extending GP surgery hours, better integration of social care and helping fund a new generation of community hospitals, providing diagnostics, minor surgery, intermediate care and basic primary care.

Patients are also to be offered "health MoTs" at key points in their lives to check for the risk of conditions such as heart disease, cancer and diabetes.

Better support is also planned for the army of informal carers - many of who are looking after elderly relations.

At the same time, ministers are planning a shake-up of local health bodies called primary care trusts to introduce more patient choice into the system.

As well as providing services, PCTs also control three-quarters of the NHS budget, commissioning services from hospitals and GPs.

The government has said from 2008 PCTs can relinquish their providing role to concentrate on commissioning.

GPs, nurse co-operatives, foundations trusts, voluntary organisations and controversially, the private sector are all expected to step in.

Q: Are these reforms needed?

Most politicians and health professionals acknowledge some degree of change is necessary.

During the white paper consultation, patients said once they got access to NHS services they were broadly satisfied with their care. It was just that getting an appointment was not always easy.

Some also said they wanted direct access to professionals such as nurses or physios without having to go through GPs as most do now.

The problems were most acute in disadvantaged areas which suffer from a lack of doctors and other health professionals.

Patients also complained they were not given enough support for long-term conditions such as asthma or diabetes with many not having structured care plans to help them manage their conditions.

This is of particular concern to ministers as it leads to unnecessary hospital admissions, which cost the NHS heavily.

Q: How will it be funded?

One of the major criticisms of the white paper is that it will fail without extra investment, but the truth is there is little new money.

Some of the social care elements will be funded by a central pot at the Department of Health and some of the new community hospitals might be built using private money.

However, the vast majority of the reforms are to be paid for by shifting resources from hospitals to the community services.

Over the next 10 years, ministers say they want to see 5% of resources redirected so that a third of the NHS budget goes on primary care.

It will mean much of the extra money earmarked for the NHS until 2008 will go on primary care.

But this will come at a time when hospitals are struggling to balance the books, forcing them to close wards, freeze recruitment and delay operations.

Q: Is there opposition?

Of course. Health professionals, and doctors in particular, would point out that much of what the government wants to achieve is already possible under the current system.

Some GP surgeries are operating extended hours and nurses have already set up their own practices.

The problem is that these need funding by PCTs - nearly a quarter of which finished last year in deficit.

Doctors have also expressed opposition to some of the moves to give others extra powers, pointing out it will put patients at risk.

In November, the government said senior nurses and pharmacists were to get full prescribing powers from April to bring them in line with GPs.

The move would allow them to become more involved in patient care, while family doctors concentrated on complex conditions.

GPs have also given a lukewarm response to taking on responsibility for their own budgets - a scheme which has been designed to encourage doctors to develop innovative community services such as GP-run diabetes clinics. Only one in four have agreed to assume control of the purse strings from PCTs.

And, as always, even the mere hint of private sector involvement in the NHS has caused controversy.

Unions, nurses and doctors have all made warnings about the proposal to allow private firms to get involved in primary care.




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