It is inappropriate to have a go at a RCGP or their Chair on the issue of poor communication from the hospitals. It is you the GPs who have been commissioners for some time now - as CCGs - have failed in your commissioning responsibilities. In simple terms you the GPs contract out these services and therefore can dictate terms of the contract via performance management. Secondly - I am sure you can hold the hospital doctor responsible for late/delayed letters post discharge or OP clinics under GMP. It is not the responsibility of RCGP - which is an education and training body - to get involved in contracts, commissioning and performance management of the contractor.
@dissident salaried Gp
It is important to differentiate between contract holder GPs and salaried GPs. The first one has role on delivering a contracted services, business continuity and clinical performance. This process is managed by a good practice team. Unfortunately the concerns raised in the article indicates poor understanding of managing a good sustainable GP practice, poor understanding of resources supply, source and managing such risks. To propose that practices will close because one cannot get printing paper, ink cartridges, gloves or other similar non-pharmacy items makes GP contractors/providers stupid and not fit to hold contracts. Delivering a GP contract is not for those involved in education or salaried GPs. There are many good GP contract holders who have provided excellence in Primary Care through worse changes in GMS/PMS/Fund holding/PBC/CCGs/STPs.
I am afraid I do not agree with concerns reported by this article attributed to Professor Stoles-Lampard. It would appear that this GP and many others do not understand resilience building for anticipated non-pharma products or related items and services. This should be part of your business continuity plan. Your practice manager along with your executive team should have this in place as part of your CQC and contractual obligations. With current format of big federations and super practices there is no excuse for not planning for the areas mentioned in the report. The risk to non-availability of pharmaceuticals or others for dispensing practices can be managed along with support from DoH, The view that practices will close is not good analysis and is scaremongering by media. I am in the midlands and happy to help any practice who feels they are at risk of closing or cannot manage building risk resilience.
Waste of public funds by NHS CFS. NHS would be better off improving data quality and NHS CFS should focus on drugs/prescriptions fraud and contracts fraud. In many inner cities with mobile and temporary population no GP can establish accurate record of registered population because patients do not communicate to their registered GPs.
Great article Dr Weston. I completely agree with all the key points you have made. Couldn’t have put it better. We read the new challenges of NHS GP work few years ago and left this sector just over two years ago.
The new contract, extended access, increased mandatory work load, reduced work force and politically driven healthcare will continue to drive more GPs down this route of suicides or mental health break downs. Good luck to GPs working in inner cities and high disease burdens.
BMA and their legal team should take the DoH to court on the basis of unfair and unrealistic contracts for GPs providing evidence of unreasonable work-load detrimental to health of the provider and unsafe clinical practice.
CCGs and referral management leads consistently ignore key quality indicator for referrals- conversion rate from 1st referral to a diagnosis or hospital treatment. Incentive for improving conversion rates, access to high quality ‘map of medicine’ and inter-practice referral group to include mapping of GP based expertise are areas we have used to improve quality of referrals in BIRMINGHAM. It has worked very well and besides achieving high conversion rate, we had lowest referral rate and lowest emergency attendances and admission in the region.
In summary - incentivise for quality indicators and not as hoc quantity parameters.
Good clinical judgement on prescribing OTC medicine is needed. There is evidence that with some patients the placebo effect of the OTC stops them going to A & E (which costs a lot more) than giving them a OTC medicine.
This is not unexpected. Many GP practices in our region have invested in similar Federations with very woolly plans and promises. There are no additional financial resources or funding available within NHS. None of these GP Practices will see any return on their investment in the next 5 years. Some like the one above will go into liquidation. The only people who will make money from these ventures are inexperienced GP Board members of the Federations. The Five Year Forward view for Primary Care is to formulate policies and unsustainable structures leading to break-up of current GP provider model through disruption and underfunding and bring in private providers.
Dr Peter Patel - Development Director. Grange Hill Surgery
A Practice with list of 2000 patients is still viable for a single handed GP or two part-time GPs. While the CCG primary care committee (where members have conflict of interest) block mergers, there good legal and sound methods to achieve transfer of the Practice as long as they it is a GMS contract. There are ways to achieve sustainability in the current market place via alliances or federated models. For PMS contract holders, the way forward would be to change the contract to GMS and then manage the rest. Bankruptcy is not an option for self-employed GPs. They have personal assets and pension funds which will be taken into account for the purpose of bankruptcy. It appears it may be too late to save this Practice. I would have been happy to help this Practice and their GPs or in future any other GPs to manage such problems.
Dr Peter Patel – Non-clinical Partner & Development Director. Grange Hill Surgery. Birmingham
The whole proposal for scaling up is unscientific and poorly constructed. People who come up with these proposals should be sent back to training courses in health economics and business management. Scaling up in Primary Care and merging sites will not reduce the need for GPs. This will remain at a minimum of one GP per 1900 patients. To manage additional workload being imposed on GPs, we will not only need more GPs but also alternative workforce (such as Physicians Associates and Clinical Pharmacists). There is nothing in the current UK workforce development strategy that will build the required capacity of GPs and allied professionals in the next 7-10 years. Even staying in EU will not solve this problem. Meanwhile, our so called experts on transformation and change management will keep on bullying GPs and Practices to accept their new messy models and bringing chaos to the health care needs of the population. There is significant evidence that large practices have poor clinical outcomes as compared to small practices. Many in the health care system believe that the current policy of the government is to bring in disruption to the system and force privatisation on the back of failed GP led system.
This situation raises certain contractual and medico-legal issues. In the past there was a clear ‘Purchaser-Provider’ split. PCTs were the purchasers/commissioners and GPs were providers. During this period GPs could revert to GMC guidelines and still refer the patients to any contracted providers against the directions or wishes of the PCTs. The onus in this case would be up to PCTs and their providers eg Secondary Care/Trusts to inform the patient why they cannot be seen by the Trust and get appropriate treatment.
However, in the current situation the ‘Purchasers-Providers’ are the same - the GPs. GPs are the commissioners/purchasers and also providers of General Medical Services. Therefore the GP led CCG Board elected and selected by the GPs as provider arm are responsible for the decision not to refer non-urgent cases. The CCG operations management are responsibility of member practices who through their constitution and operating structures have endorsed this non-referral decision. There are not many options for the member Practices of this CCG. If they sack the Board then who would be willing to lead a CCG which is already declared inadequate? The second option is for the Board to resign and let NHS England appoint a care taker admin to run the CCG.
I am afraid that Dr Dawlatly does not provide any reasonable business like argument for his decision to join Our Health Partnership. In his last para he mentions about opportunity for savings. These savings can be achieved by a simple SLA through co-operative style organisation with membership without giving up current contracts and individual autonomy. There are no financial figures published by such proposals that the savings achieved by this method will pay for the management and running costs of new Superpartnerships or Superpractices. Enhanced services currently form a small part of practice income and these services are available to the Practices through either national DES or local LISs. In the past many small practices like ours and our former group SBIC (19000 patients and 5 practices) have provided evidence of excellent management of practice based budgets during PBC, improved savings, improved clinical and financial performance and over £2.5 million of reinvestment in new models of care in partnership with local hospitals without the need for Superpractices. The real rational for creating Superpractices/partnership should be for getting new business (NHS and non-NHS), shifting many services such as OP from our outdated Hospital base and currently contracted from Community Health Trusts, bidding for Public Health Services and creating a new Integrated Care Organisation in the community with focus on Population Health. There are no wild seas and storms – most of this view has been created by media hype and institutional interests of few. To be able not only to survive but move forward in the current and future health care market place, one requires tenacity of purpose, resilience and strength. Much of the current focus is on GP profit and not clinical excellence.
Merger or Federation - it makes little difference for potential of such groups to change the way NHS works. Such larger groups have opportunities to shape and develop a UK type of HMO - similar but not identical to Kaiser Permanente, Humana, Aetna in USA. Such HMOs can 1. shift OP care into community setting instead of outdated over priced hospital based model and 2. under new models of care initiative also take over many of the hospital services and make it cost effective 3. bid for and provide Public Health and Community Care services through a single managed contract and develop a new Health Care workforce fit for future. I am still an advocate of small patient focused Primary Care Surgeries. Superpractices and large Federations can provide small patient focused essential medical services by devising a new operating model different to the ones currently being by some of the early superpractices in the region. Most importantly, the Board for such new enterprises will need clinicians who understand and are trained in niche management and not dependent of NHS managers of the old system.