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Buckman...on access and the QOF

In the second part of his interview with Pulse's Steve Nowottny, Dr Laurence Buckman outlines the current position on access and his view on the future of the quality framework.

In the second part of his interview with Pulse's Steve Nowottny, Dr Laurence Buckman outlines the current position on access and his view on the future of the quality framework.

The Scottish Executive this week said they were going to allocate £10 million towards extended hours – I know obviously you can't talk about where you are within negotiations, but can you say whether you are at that stage of talking with them?

We are discussing matters with the Employers at the moment, and that's on a UK-basis, and we'll see where those get.

If Scotland were to negotiate, for instance, a Directed Enhanced Service, that would be Scotland and England separately would it?

Well strictly speaking, every DES is separate, but if they turned out to be identical, that could happen…it might not, you know. I believe in fact that it is in everyone's interests if they were identical, assuming we could agree something, but there are several steps between wishing it to be identical and it being identical, and I can't guarantee that it will be.

Have you got a feel for how much would be acceptable? I know Dr Peter Holden said two years ago you did ‘back of the fag packet' consultations and worked out it could cost up to £98,000 a practice a year

It depends what you're doing for that money. If you want me to have my surgery all-singing, all-dancing, all-staffed, running as normal, then that has a cost. If you actually want less people doing less things for less time, it has a different cost. So I don't think you could put a figure on it in that way.

But his figure was not a fag packet, it was fairly well worked out. If you were to run a surgery fully manned in the way that one would expect it to be, then it has a cost. Now the government has never proposed that. The government has never asked anybody to do that, because they have worked out for themselves that this would be incredibly expensive. And I'm not sure that practices would all want to commit to it either, so I don't think it's in anybody's interests to start talking about that. But that sum of money applies to that particular way of delivering an extended hours service, which no one has been invited to do.

Do you think the government is going to meet its goal of half of GPs offering extended opening?

I have no idea. It will depend on whether they make it worth people's while.

Is it realistic?

It's a realistic prospect if you make it worth people's while. It's an unrealistic prospect if all you're going to do is slag them off all the time. And I'm afraid not only will the mood music have to be right, the money will have to be right, and the terms and conditions will have to be right… but we haven't got that far.

In terms of looking at the QOF, are you at the stage where you've looked at the evidence reports?

Yes we have.

So presumably now you're talking about what indicators could change?

Yes, that's largely dependant on the conditions and terms being right.

Was there some talk of, three years on, there being a gentleman's agreement to have a wide-ranging look at the QOF? Was that right?

No. The review is conducted on an annual basis, looking backwards over how people have done, to see whether thresholds can change without actually doing practices any damage. That's the first thing.

The next thing is whether the current square rooting and prevalence adjustments are fair or unfair. I think most people believe there are some very strange things that go on within the prevalence adjustments. The question is, how do you deal with this without introducing other unfairnesses?

The reason for the adjustments was to do two things. One was to enable practices that have very small prevalences to at least get paid something because there was an infrastructure basis for their expenditure. And the other was to make sure that small changes in population didn't have enormous effects on how much money you got. And that was the plan, and a large body of statistical advice led us to the arrangement that exists.

Now I appreciate that you can have adjacent areas of different prevalence where I could have double the number of patients my neighbour would and yet actually wouldn't see very much more money for it, certainly not double, and that is the effect of square rooting, that's meant to happen, but the damping effect… it may have been over-damped. And so we are looking at that, we always agreed we would look at that and we are looking at it.

The question is what do you put in its place? There are people who say let's get rid of prevalence adjustments completely. The difficulty was, that was a decision taken by an emergency conference of LMCs, that said you've got to have prevalence amelioration. I remember saying at the time I thought actually it would create a new set of anomalies.

The other thing that's happened with the same prevalence issue is there are a couple of domains where the distribution is not symmetrical. Where that happens, trying to distribute money symmetrically where the actual patient distribution is asymmetric produces some very weird results.

Particularly mental health and dementia are the two key domains, I think they're probably the only ones, where you get such peculiar distributions where very small practices are providing only care to mental health issues. When that happens, you're going to get the most bizarre distributions where almost nobody else gets any money.

Now mathematically I can see exactly how that happens, but it isn't fair, and what we're looking at is how we sort that problem out. Actually with mental health and dementia, if you sorted that out many of the criticisms of those domains would fall away. It's how that's tackled and whether you finger certain practices and say these are special and they need a special payment that's nothing to do with QOF, or whether you incorporate them into QOF but find some way of sidelining them. There are various ways of doing it.

Then dealing with the domains themselves, yes there are some domains where the evidence has changed and there are some new domains where the evidence wasn't good enough to bring them in where the evidence now is good enough to bring them in. Then you have to decide whether it's feasible, whether it's feasible by computer, whether the Government wants to pay for it, whether it's seen as a clinical priority, so there are lots of hurdles before what looks like a reasonable idea happens.

Is that going to happen?

Yes. Am I anticipating a wholesale of readjustment of the QOF next year? No. It won't look hugely different from the way it does now – assuming we have agreement in other areas as well.

...on changes to the QOF ...on changes to the QOF

Am I anticipating a wholesale of readjustment of the QOF next year? No. It won't look hugely different from the way it does now – assuming we have agreement in other areas as well.

...on the prospect of GPs extending opening hours ...on the prospect of GPs extending opening hours

It's an unrealistic prospect if all you're going to do is slag them off all the time. And I'm afraid not only will the mood music have to be right and the money will have to be right...

Dr Buckman

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