22 July 2005
I think I feel a primary care shake-up coming on. The government is finally turning its attention from hospitals to family doctor services, says Noel Plumridge. Its mission? To bring back patient-friendly personalised care
If TV soaps are anything to go by, much of the external attention given to health care concentrates on the blue light ambulance and acute hospital end of the business. From the early Emergency Ward 10 and Dr Kildare to today's Holby City and ER, health care drama has largely meant hospitals and operating theatres.
GP surgeries, district nurses and health visitors are altogether too prosaic, too ordinary. The famous exception is Dr Finlay's Casebook, the 1960s drama that fixed the British image of the family doctor as firmly as Hattie Jacques in the Carry On films cast the mould for all future matrons.
Away from the screen though, attention has begun to switch to the GP surgery and its linked community practitioners. After all, this is where most people have most contact with the NHS. New Health Secretary Patricia Hewitt announced a white paper on choice and 'personalised care' in primary care within a fortnight of the government's election success. It will appear in the autumn, preceded by what health minister Lord Warner has called a 'listening exercise& bigger than anything the government has attempted before in health and social care'.
There have been clear messages from the Department of Health during June that we should anticipate major changes in the GP sector and in the role and configuration of primary care trusts.
So what can we expect the primary care service of tomorrow to look like? And why the apparent change in direction?
Like TV drama, the NHS policy agenda in recent years has been dominated by hospitals, and especially the amount of time it takes to get into one. In the late 1990s the DoH keen to improve public perceptions of the NHS, and needing credible benchmarks for measuring improvement settled on access standards. These initially covered hospital waiting times and waiting lists, then broadened to include, among others, maximum waits in accident and emergency.
One can interpret the re-introduction of a market system into the English NHS since 2002 the whole structure of payment by results, foundation trusts, independent sector treatment centres and the rest as a drive to create extra capacity to meet these increasingly demanding standards.
And the strategy has worked. By last summer, the number of patients waiting more than nine months for an operation was down to around 200 for the whole of England. Waiting lists are now so far off the front pages in England that they hardly featured in this spring's general election campaign. (The same is not true in Scotland or Wales, where new strategies have recently been announced.)
So there was a change of emphasis in 2004. First in the spring, with an initiative for managing the tide of chronic disease that threatens to engulf hospital systems across the western world diabetes, coronary heart disease, stroke and respiratory illness in particular. And secondly, in the latter part of the year, towards improving public health, with high-profile media stories on obesity, binge drinking and the other related mischief of twenty-first century life.
Success requires a proactive and effective primary care sector. Not just because hospital wards are expensive places to treat people with long-term illnesses and the so-called 'diseases of affluence', but also because hospital treatment of the symptoms, though sometimes essential, misses the point. All modern thinking on managing people with chronic disease agrees on the importance of supported self-management, and sees unplanned hospital admission as a failure.
How, then, to create the structures in and around the GP surgery to care for the chronically ill? Actually, primary care, if out of the spotlight, has been far from stagnant. The financial basis of that far-off Dr Finlay world, the beloved 'red book' that had determined the precise terms of GP remuneration since 1948, was still in force only two years ago. (As a community trust finance director, I had a recurring dream of using modern word processor technology to erase it, paragraph by paragraph, slowly and with relish.) It has been superseded by the 'new' general medical services contract, one of several immense changes in the structure of NHS terms and conditions in recent months.
This contract offers hard incentives for practices to create the building blocks of effective chronic disease management, such as disease registers and patient recall systems. Its quality and outcomes framework, commonly known as the QOF, offers, for example, up to 45 points for the management of chronic obstructive pulmonary disorder, a serious respiratory illness: five for keeping a register of COPD patients; ten more for confirming initial diagnoses using spirometry; and 30 for various aspects of the management of the disease, including smoking cessation support, influenza immunisation and checking inhaler technique. With each point worth £120 in 2005/06, and a total of 1,050 points up for grabs, the financial benefits to the practice soon mount.
But so do the financial risks for the system as a whole. DoH funding levels for 2004/05 assumed that an average GP practice would gain 750 points under the QOF, a 74% achievement rate. The final results will not be available until August, but Mike Sobanja, chief executive of the NHS Alliance, suggests that practices might be averaging 900 to 950 points, creating a monetary shortfall of some £0.5m to £0.7m per PCT. In Scotland, the target achievement rate was 64%, the actual 92.5%. QOF achievement in excess of budget was the biggest single item of expenditure for the NHS Bank in 2004/05, accounting for £283m of a £746m total. Some are now asking whether the actual gain in quality has been worth the level of investment, and how practices can be tempted to make further improvements.
The QOF has not been the only controversial aspect of the new contract. Given the option to withdraw from the 24-hour cover that Dr Finlay used to offer unstintingly, most GPs did, forfeiting some £6,000 per year and leaving PCTs to arrange alternative out-of-hours cover. The result has been a patchwork of arrangements, with local GPs often re-engaged via circuitous routes. There have also been high-profile reports of expensive locum doctors flying in from overseas Germany in particular to provide weekend cover. Charges of between £1,200 and £1,800 for a weekend are not uncommon. According to the German Medical Association, more than 2,600 German doctors are now flying regularly to the UK. There are also significant flows from Spain, the Netherlands and eastern Europe.
None of this implies that the authors of the new GMS contract were somehow at fault. The contract, and the creation of PCTs under the 1999 Health Act, were attempts to reconcile two potentially conflicting long-term government objectives. On the one hand, they aimed to bring GPs within the framework of central accountability which, as independent contractors small (and sometimes not-so-small) businesses they had strenuously resisted since 1948.
Simultaneously, the plan was to make the role of the GP more attractive in a changing labour market, one characterised by female domination of medical school entry and a growing reluctance to commit to a traditional GP career path.
There are signs of success. GPs may grumble vociferously about PCTs naming and shaming practices with low QOF scores, about the DoH-imposed 'choose and book' system that underpins Patient Choice but in general they support the government's strategic direction, even if some are withdrawing from the bureaucracy of PCT management. Significantly, word on the street is that GPs are now doing quite well financially.
There are snags, however. There are still not enough GP recruits to meet the mounting expectations of a consumer-led society. The strategies used to overcome capacity shortfall within secondary care encouraging skill mix change, stirring up private sector competition and quietly flooding the labour market with trainees are less likely to succeed in primary care, where it is harder to define 'products', information systems are weaker and there is no tradition of ready compliance with policy. Attempts to interest the independent sector have so far had only limited success.
It is also clear that the traditional GP role of 'gatekeeper' to the hospital, apparently withering under the developing market system, might be the only effective counterweight to a seemingly limitless demand for hospital care. Early trials of payment by results in 2004/05 saw PCT commissioners struggling as financially driven foundation trusts delivered more clinical activity prompted by the new system and then claimed payment for it. Enter the concept of practice-based commissioning cousin, if not daughter, of GP fundholding and the start of a transfer of commissioning responsibility from PCTs to GP practices.
Finally, the potential conflicts of interest in PCTs commissioning primary care from themselves and from the GP practices that dominate their committees have always caused concern. The arrangement, a means to an end when PCTs were first created, appears increasingly at odds with the government's desire for 'contestability' and competition.
So what can we expect to see in the autumn? Certainly a redefined role for PCTs, and a cull of their numbers. NHS chief executive Nigel Crisp told the NHS Confederation conference in Birmingham last month that a 'framework' for the forthcoming Fit for Purpose review would be issued in the next few weeks, and that it would 'define clearly the functions of PCTs in the future'. There have been suggestions that the core functions will be managing primary care, developing networks and boosting public health. Crisp has hinted strongly that care provision community nursing and therapy, for instance will not be included.
Who will provide such services, and will foundation trusts themselves spanning an unclear boundary between the public and private sectors be allowed to step into the vacuum?
Mike Farrar, chief executive of West Yorkshire Strategic Health Authority, envisages a mixed economy of large GP co-operatives, potential private providers such as Care UK and acute providers 'coming down the care pathway'. But he also believes that PCTs should keep a 20% or 25% stake, to 'resist fluctuations in the market' of the sort experienced when local authorities divested themselves of care provision.
And what of the GP practice itself? All the signs are that there will be a strong push for more responsive and patient-friendly surgeries, and particular incentives to register teenagers and young people. The values of choice and contestability, which go to the heart of government policy, are being reinforced by an emphasis on social inclusiveness. Hewitt has expressed concern at how few young men register with a GP.
If the secondary care model is mirrored, we can expect increased autonomy (on, for instance, diagnostics) within a framework of accountability and inspection; further attempts to stimulate competition; and little sympathy for those who fail to respond to the financial cattle prods from the department.
Noel Plumridge is an independent health care consultant and author of CIPFA's Payment by results: new financial flows in the NHS in England and Financing long-term illness in the NHS