The private members bill getting its second reading next month, under the radar of Brexit, may release the shackles and allow practices to charge patients.
The government aren't worried about headlines about bankers lining their pockets nor any business except health.
I tried explaining to my son how the NHS is a conglomerate of competing organisations. Doctors used to compete for patients before the NHS was set up and it was very much an apprentice model then. A young doctor would have to buy into a practice and earn his right to becoming a partner. Parity took years and it was fundamentally unfair. General Practice is still not recognised as a speciality(shame on RCGP) and as it still has independent contractor status it can choose what model works. The review will highlight the inadequacy of the model for the modern NHS which is looking for ACO or ICS solutions. Super partnerships will need testing in the legal sense of partnership law. With falling numbers of GP's something radical must happen to lure medics to primary care.
£100million for 85 GP's? £1.2M each? Is there no-one who is determining is it money well spent? Surely better to invest in the incumbent GP's to prevent them leaving.
As has been widely published the health and well-being of a population is not the amount that is spent on health. Health accounts for 20%. It is housing education and employment that makes up the other 80%. Sadly generations of politicians both local and national have failed to acknowledge the facts and so the cycle begins again. MP's are elected on big issues such as health immigration etc and local Councillors on filling holes in the roads! Cutting public health is easy because it is free choice if you smoke overeat and do no exercise. The consequences however are real and have to be solved by an overstretched health service. Gate and horse bolting analogy needed! Investment in long term health and well=being gets results too far into the future for any politician. The results of cuts now have catastrophic effects to people well after the memory of who made them. The only constant is the primary care who has to absorb the impact.
what I have done is removed some reflections from my appraisal which could have been misconstrued to prevent anyone using them against me in a court. We were supposed to be moving to the airline industry standard of no blame reflections so others could learn from near misses or actual events but clearly the lawyers only see the opportunity to use the information to either sue or defame.
The choice of drugs available to GP's depends very much on the local prescribing formula not NICE recommendations. It very much depends on the budget available not the evidence. NICE experts tend to be anyone who has free time to attend and have strong views backed by personal preference, as any hint of conflict of interest precludes their involvement. As a concept NICE is a great idea but needs to use real world people and real world data to make decisions taking into account how their recommendations can realistically be implemented in the current financial envelope.
The drive towards super partnerships and primary care at scale is as a result of the lack of investment in the backbone of the NHS. The lack of recognition of General Practice as a specialty in its own right is part of the issue. The public has yet to be formally asked if the direction of travel is the one they want. In my experience there are two types of patients, those that just want a quick fix and don't care who or where they are seen so long as it is timely and convenient. The second type is the patient who cherishes the continuity of care and the relationship they have with their GP. The two types are interchangeable depending on the problem they perceive to be sorted. Patients also only know two places to access care their GP or A+E yet we persist in commissioning every alternative to prevent access to either. The role of the GP has grown organically and what is provided is determined by the provider. General practice at scale is a way of standardizing what is provided at the cost of continuity of care. It suits some doctors to work in a salaried shift system for others it is the continuity and relationship of the fixed list, cradle to grave responsibility that matters. The business models are flawed to provide the NHS because it is a socialist ideology. The public perceive it to be their right to access every level of care because that has been the political promise to them. What has never been discussed is how it is paid for and by whom. Rationing and co-payments started in 1949 which led to Bevan's resignation yet the mere mention of either is political suicide. There needs to be a proper conversation and a truly national standardized service where the public knows what is and is not available. The models that are being imported from the US don't take into account that they only work because the patients through their insurance schemes have personal responsibility to use their system appropriately or pay more. The insurance companies squeeze the providers so that care is rationed depending on the policy.
The founding fathers of the NHS did not nationalise the GP's because they didn't think they would be needed once everyone was healthy and doing the decent thing and die at 66 before they used the services! The Collings report published March 1950 was the catalyst for the formation of RCGP yet GP's still don't have specialist recognition. The Dr Findlay model is remembered by those from their childhoods who are now entering the autumns of their lives and expect that sort of service. Sadly the system has not supported care in the community even after Keith Joseph tried in 1973 and every iteration of NHS planning is to shift care into the community. The resources never follow because the savings are assumptions and aspirations that get signed off at Board level yet never materialise. The move to any form of ACO ACS or whatever TLA(three letter abbreviation) can be thought up to 'save' the NHS will require GP's to be salaried and standardised and interchangeable so the patients get McDonalds medicine rather than the Michelin star they desire. There is no real career progression for the Dr Martin GP, no long service medal and no recognition of seniority. The job is very much the same on the last day as the first. The doctors that do portfolio jobs or enter medical politics either the GPC route, RCGP or NHSE seem to weather the storm that is modern primary care but not without effecting coalface provision. There needs to be another Collings report for the public and the purse string politicians to open their eyes to what is really happening and react before it is too late.
Sick people need to be seen and treated. Rather than keep blaming different parts of the system for the problems politicians need to understand it is the deprivation and underfunding that causes the pressure. The system is a socialist ideology of free at the point of delivery trying to be run using capitalist business models of profit and loss. The two are incompatible and the country needs to be asked how much they are wiling to pay for their NHS.
Wasn't this tried between 1968 and 1988? Thirty years ago it was split as it was such a big job and too complex for one department. Hopefully it might address the farce of patients remaining in hospital because of lack of social care. How he will deal with the conundrum of means tested social care and free healthcare will be interesting to see.
I worked as a GP in A+E in 1994. It is always useful to have an experienced Generalist to help sort the minor problems that are neither accidents or emergencies but are perceived to be by patients. Payment by activity and clinical governance issues changes behavior of clinicians in hospital to be more risk averse and investigate more because it is easier. Patients think they are getting a better service but it lacks the continuity of care. There needs a fundamental redesign of how the service is paid for or the false battle between primary care and A+E will continue to plague the NHS. Patients are not the problem it is the system that confuses them. If we simplify it and only have two places of access that are funded equally for the work, there is a possibility the system can work as one team to sort out the patients rather than making them the enemy.
“We have to strive to alter our whole mentality about hospitals and about mental hospitals especially. Hospital building is not like pyramid building, the erection of memorials to endure to a remote posterity.” Enoch Powell 1961
“The overall state of general practice [in England] is bad and still deteriorating.” J.S. Collins 1950
Michael is right unless something political changes as happened in 1950 after the Collins report General Practice as we know it will collapse like a deck of cards. Throughout the history of the NHS we have lurched from crisis to crisis. Being pulled back from the precipice at the 11th hour. This time however there does not appear to be the political imperative because all is focused on Brexit. The Budget settlement showed that the NHS is being forced to change, but the inertia is so great will there be enough time to resuscitate General Practice?
The issues are far deeper than just how the system works. The whole profession needs to have a look in the mirror as to how we treat each other. The 'good old days' where doctors who were not thought to be capable of becoming a consultant, went out and became GP's under the apprentice system. They had to buy into practices and work up to parity, which still exists today in some partnerships. Junior doctors in hospital had to keep their noses clean and be seen to be a good sort, in order to be considered to join the ranks of consultants, usually waiting for dead men shoes. To counter the old boys network approach these training schemes were devised,but the flaw was balancing training with the service element requirements. The rivalry between colleges compounds the problem which goes back centuries and is in the DNA of doctors. It is not one noble profession because we don't treat each other as equals. I believe we all went into medical school the same, came out the same and it is our choices after that differentiate who we are, not our branch of medicine. Clearly there are those who choose to become super qualified in their field but they should appreciate those that chose not to go down similar paths. Juniors will be seniors one day and until we start treating each other as equals and a united profession the issues or recruitment and retention will persist. I have counselled my children not to follow me into the profession, not that they will listen.
Headline grabbing schemes announced but the devil as always is in the detail. How to access the money is always bound up with business case protocols committee meetings etc until the crisis has passed and the money is recycled to the bottom line and black hole filling! It is never equitable yet we have a National contract?
My instinct is that it was approved to test the water about item of service payment per consultation. People may like the service but the NHS can't afford it so the patient will be asked would they contribute for the convenience of the service. Short step then to charging everyone like the dentists did.
Financial control is the only target that can't be missed. Patient suffering, experience or quality of care can all be ignored so long as the randomly allocated control totals are met! The Internal market is such a flawed idea it should either be scrapped or opened to all comers. NHS fighting NHS for use of the public pound is so wasteful as there is no winners only losers. Particularly patients who are pawned around a system that treats them as cost burdens!
There would have to be a clear definition of what constitutes a session. Maximum number of patients and administration time with protected time for PDP etc. Once that is the norm then the Government will realise what great value primary care is though there may not be enough left to service the system.
As a self employed independent contractor I don't understand the obsession with what I earn?
The reality is if profits fall altruistic work stops to be replaced by work that pays. Not funded not done.
£48 is less than half the cost of a visit to A+E yet GP's expected to accept unlimited extra workload for the first year?
When will NHSE properly commission primary care?
NI is the test bed for the demise of primary care. When all the doctors resign from the NHS the Government can conveniently blame the doctors for walking away. The insurance based model will have to be implemented to pay for patients to see the private GP. When it looks like it is working offer it to the disgruntled public in England and hey presto all privatised.