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At the heart of general practice since 1960

Debating the NHS reforms

Pulse editor Richard Hoey sat down with some of the leading figures in general practice last week to discuss the new world of GP commissioning and ask what it means for the future of the profession. Here are the highlights from a vigorous debate

Pulse editor Richard Hoey sat down with some of the leading figures in general practice last week to discuss the new world of GP commissioning and ask what it means for the future of the profession. Here are the highlights from a vigorous debate

 

Richard Hoey (RH): The big rationale of the NHS reforms is that GPs are the best-placed people to make decisions about commissioning local services and funding priorities. Do you agree with that?

Dr Charles Alessi (CA) GPs are close to the patient, so an obvious place to start. But GPs are not the only people – everyone who cares for a patient has something to contribute, and co-operation is really what this is about.

Dr Clare Gerada (CG) I don't know, actually. I agree to a certain extent. It's right GPs should be involved in planning services, but it's not just us. And I hope we're not talking about rationing. All health professionals should be involved in decisions about rationing. I would hate it if it was just GPs.

Dr Richard Vautrey (RV) It has to be in partnership with the patient. If not, you just end up with GPs making decisions or rationing services out of tune with what the local community wants. You have to start discussions at a much earlier stage, so that people feel they have a degree of ownership and that their voices are heard.

Dr Helena McKeown (HM) I don't want to be doing rationing with an individual patient in my surgery because that's going to break down doctor-patient confidentiality and trust. That's my great fear, that patients will say: ‘Are you not doing that investigation because it costs, doctor?' So it's hugely important we have this discussion with our patients and local politicians, and decisions are made completely overtly.

Dr Michael Dixon (MD) We need to make decisions about priorities or rationing as a collective that involves commissioners and patients, so we are doing a minimum of rationing in the surgery. When we have to do that – and frankly, there will be times – the most important thing is the patient sees we have a choice only between an individual and the good of the population, and our own income doesn't enter the equation.

Part of redesigning the health service is going to be all patients and doctors seeing they have a role in making resources go as far as possible. That means sometimes the patient accepting something that might not be quite as good as the very best, but is far cheaper, for the good of the community. Otherwise, we are going to end up with a runaway, demand-led system.

 

RH Clinical commissioning groups have been charged with getting a handle on part of that demand, the demand for referrals. To what extent should CCGs be responsible for limiting referrals, and how much should they be allowed to performance-manage whether that happens?

CA I have got experience of referral management centres – I was one of the people who set up the first one in England. That was set up with the full buy-in of practices by a co-operative of GPs. Hence it was successful.

I have a real problem with where referral management systems are imposed by PCTs or CCGs, because they are not sensitive to the needs of individual populations. All the evidence shows if referral management takes place at the practice level, it's a rich learning experience, rather than simply saying: ‘Oh, you have referred three hips today, so you can't refer another hip.'

I mean, that is just so crass, it's beyond belief that people are trying to impose systems like that. I completely abhor systems like that.

RV The key is that referral management takes place at the practice level, not at a PCT or CCG or supra-regional level. In most practices now, clinicians will talk to each other about whether it's appropriate to refer a particular patient this way, or did you realise that this particular service exists?

This isn't about stopping patients from getting care, it's ensuring the patient gets the right care in the right place. There is a concern where we have seen inappropriate barriers being placed, or scores or whatever it is to try and limit referrals, because inevitably that's going to lead to problems.

There will be patients who fall foul of those situations, who don't get referred, or commissioners who feel they are under pressure, so their balance of risk changes in such a way that it adversely affects the patient.

CG We should stop calling it referral management – it's actually clinical care and making a decision using your professionalism, and that includes discussing it with your colleagues.

I worry about the term ‘referral management', because you immediately bring in a marketing word – it means to reduce costs. It is putting a stranger in the consulting room. Your referrals are read by a third party, such as a nurse, and in future a manager, because that's what we know happens overseas. It will be absolutely limiting – we have already seen that with caps being placed on referrals. At worst, it is going to be performance-managing GPs and possibly ousting them from the CCG because somebody has said we have two standard deviations from the mean and beyond that you are a bad clinician.

MD We spend half an hour every morning looking at referrals in the practice, and often obviate them by doing an X-ray or referring to another partner, and giving the patient a better service so they don't have to wait for ages to go to outpatients.

The retrospective approach, I think, can be useful too. We do it at our own CCG. We spent a Thursday afternoon two weeks ago looking at referrals of all the GPs in the CCG, and there were a number of variations.

CG Was that at the consent of the patient? That's what I worry about.

MD They're all anonymous. The whole point is, Clare, that there were enormous variations and some of the GPs were using far more resources than others. Unless you grab that bull by the horns, you end up with an NHS that's not only unequal but you can't actually pay for.

RH So you are worried about the confidentiality issues of referral data being shared across other practices?

HM It's part of the individual patient's trust of what goes on inside the consultation. Does your patient expect their referral to be discussed, not only across the practice, but across a large group of doctors who may include some nurses and managers? Were they asked about that?

We have an opportunity, if we have patient groups, to start raising these issues, but at the moment I don't believe my patients know this is going on.

RV I would be amazed if any CCGs were discussing individual cases of patients. What most groups would be doing is looking at referral statistics and not at individual cases. If they are, I would be extremely concerned.

CA I will give the example of my practice. Patients are informed ‘your case is one that is going to need some further discussion with colleagues'. Those are the terms that are used.

HM Some of my patients have been in an unfortunate enough position to have had very expensive hospital stays or procedures. Everybody in my community knows about them. They are easily identifiable.

CG There is a great deal of literature about variability of referral, and the more you know about a subject, the more likely you are to refer because the more likely you are to pick it up.

Very little is based around inappropriateness. You can have extremes, and that is a clinical governance issue which should be picked up within the practice or within the PCT. But the idea my referral for my hysterectomy will be discussed with a group of doctors, nurses and managers without my consent… and if you say it is anonymous, I dispute that because actually within a small community, you will know.

RV It would be interesting to ask patients about this, because when you put it alongside the Government's choice agenda, many patients actually like doctors who ask specialists for a further opinion.

It would be interesting when information is made more readily available, as was announced today – patients' perception might be that a practice that is doing too few referrals might not be a good-quality practice. The views of politicians and the Government may be completely at variance with what patients actually want.

CA What I'm talking about is the more difficult therapeutic problems that have always been discussed internally within the practice. I am not necessarily saying all referrals need to go through a management process. But referrals can also be harmful for patients, occasionally, as well as beneficial. There needs to be balance and professionalism, and we are very fortunate that we have both.

MD Richard, you talk about patient wants, but is it the right thing to do? We use hospitals more than any other developed country in the world, apart from the US. That's where the money that ought to be going to primary care is persistently going, even this year. There is a problem that needs sorting – you can't just run away from it.

CG You need to reference that claim, because that's not right.

 

RH We have to move on to another area where there's been tension between grassroots GPs and CCGs, and that is democracy. The GPC has been quite vocal that in a minority of CCGs boards have been set up without a full democratic process – is there a lack of legitimacy in some areas?

CG Those leading CCGs are those who were leading PECs, PCGs and in fundholding days were leading fundholding. It's the same faces. I have been told of some very undemocratic processes, and also some very good processes, so there's a mix. But

I would like to see membership of CCGs as people with the right competencies rather than tokenism – one woman, one man, one single-handed. This is serious stuff we are going to be engaging in, and I want to make sure that the right people are doing it.

RV CCGs will fail if they don't allow every GP to have a voice, not only in the democratic process – that's just the first step. If a CCG wants to develop care pathways, if they don't involve all GPs – indeed, all clinicians – it will fail. That means not just the principals, it means salaried GPs. It means locums who regularly work in that area. If you have got a lot of locums, your success or failure will depend on their referrals and prescribing.

RH We have looked into these accusations of a lack of democracy, but it's quite difficult to get to the bottom of. Do you know of specific areas where these problems are occurring?

RV We do. Practice partners will tell you because of the proposed quality premium, their practice income will be dependent on what the CCG achieves. So that's why some are saying it's just about partners. And within the bill, it talks about the practice unit.

I think there's a foundation below that, and it's the patients and the clinical community that aren't necessarily practice-linked. There are many salaried GPs, in out-of-hours organisations for instance, who make significant referral and prescribing decisions that aren't necessarily in tune with what the CCG is proposing. How do we engage them?

HM Well, we need to enable them. I come from quite a democratic CCG where we are actively seeking out doctors. But you have to go to the next step. So when you are reimbursing people's time, you can't reimburse someone who is a locum for work they haven't done, you actually have to give them a payment that is superannuable. That goes for locums and part-time doctors.

RH Are you suggesting some people can't afford to get involved because of lack of payment?

HM Absolutely.

CA I absolutely think you need a full democratic process across all GPs and others, because if the unit of currency is the practice, and the practice really wants to involve everybody in clinical commissioning, it will want to ensure everybody has a vote.

MD Ultimately there has to be an election. CCGs are membership organisations of GP practices. There shouldn't be any separation between them and GP practices. If practices don't like the leadership they have got, they can vote them out.

CG There is an accountability issue, though. If CCGs, in the worst-case scenario, go bankrupt, it is the partners who will be accountable. And if a practice over-uses its resources, it will be partners who will be responsible if it is ousted from the CCG. So while I absolutely agree with democracy… actually, if my practice is ousted because an out-of-hours doctor, who is not involved in my practice, is on a board, I would think hang on a minute, this is my practice.

 

RH One of CCGs' roles will be to commission community-based services, including LESs. The Government is proposing getting round conflict of interest by making GPs compete to provide LESs with the private sector under any qualified provider (AQP). How does the panel feel about that?

HM It was bound to happen. If you have got a set amount of money in your budget, do you go down to Waitrose or to Primark?

RV There's a real issue with fragmentation of care. If you have got more and more services doing little bits, and you salami-slice the contract, the risk is you get cherry-picking, so companies set themselves up just to do a particular element of care.

They choose the easiest patients, and leave the more vulnerable, the elderly, or those with more complex needs and let the NHS pick up those patients. And if you separate elements of care, you commodify a disease rather than treating people holistically.

The real strength of general practice is that GPs will deal with any of a patient's needs as they walk through the door – their diabetes, their asthma, the fact they are going through a divorce and maybe with their benefits claim. That's incredible value for money.

The risk is you end up with a situation where the GP says: ‘Oh, sorry Mrs Jones,

I can deal with three of those items, but for the fourth, unfortunately, you have got to go to the unit down the road because they are on a contract for that element of care.'

CG I absolutely agree with Richard. Remember, older patients can have seven or eight comorbidities. Are they going to be salami-sliced into each one of those?

General practice looks outwardly very simple, but actually it's so complex. People looking at our profession from outside, they think people can do it better, you can just chop it all off. But if we take all the LESs and the DESs and the NESs and the PESs and split them up, we have destabilised general practice.

MD This is the big debate, isn't it, between integration and competition. I think sometimes we speak with our own interests in not liking competition, but on other occasions, you don't want to fragment a service.

That's why it's so important to involve patients in decisions. Because if we are transparent, patients can say where they want an integrated service, like vaccinations in the practice, or where no, quite frankly, they don't care if they go to Tesco.

RH How does it matter what patients think if the Government's policy says a CCG has to open up something to competition?

MD I don't think it does say that. It sees any qualified provider as a much cleaner, looser, less bureaucratic system than opening up to tenders. But I can't see the Government wading in and telling CCGs what to do.

CA The way it was described [by the guidance document] is something I certainly couldn't support. It's up to us to ensure what we end up with is sensible for the local population rather than this.

But can I give you a somewhat different view of a way you can introduce AQP which is sensitive? There are cases – for instance, in mental health – where the voluntary sector performs valuable services. I would envisage AQP being introduced through a joint strategic needs assessment, in areas where clearly care needs to be improved.

MD That's right – the CCG must be sovereign, it can't be bullied.

HM But Monitor is going to be there to do precisely that.

MD If Monitor starts interfering with what CCGs think are the best commissioning decisions, we will walk away.

RV It sounds to me as if that interference is already happening. There was a departmental document a few months ago that gave a list of eight areas, and you must have AQP by the next year in those.

RH Michael Dixon and Charles Alessi, your respective organisations are generally positive about GP commissioning. Are you planning to lobby on this specific point of the commissioner choosing when to bring in AQP?

CA Absolutely. We are trying to ensure we have systems that are sensitive to the needs of the population. I mean, this is madness.

MD Totally. There are only a certain number of things you can redesign at once. If opening up to competition might improve a service, we will do so. But this can't become a rash of things for the sake of it.

 

RH Let's move onto the controversial quality premium. There is an argument that it needs to happen, to encourage practices to do what CCGs want, but there's also real concern it will get between GP and patient.

MD We are privileged – we are becoming public health doctors looking after the health of the population. It's fantastic. We are not just sitting in surgeries doing prescriptions and referrals...

CG Doing what I was trained to do and what I enjoy doing.

MD We are now able to do what our forebears desperately wanted to do, and were never allowed to do. But we must make sure no patient can ever see that personal interest is between their interest and the good of the greatest number in the population. That doesn't mean you can't pay people for working in CCGs. It doesn't mean you can't pay the CCG for offering better services. But you can't pay people to ration. You can't afford to have the Daily Mirror ever saying these doctors are doing it because they are pocketing more money.

RH The policy appears to be that you won't qualify for payment if you go over budget. Are you comfortable with that?

MD Yes. If the whole health service goes over budget, we don't have a health service. You can say it's an imperfect solution, but it's better than not having a health service.

HM I cannot believe, Michael, I can just sit here and watch you denigrate what I do, in writing prescriptions and listening to patients and practising holistic medicine.

MD I didn't denigrate you listening to your patients...

HM I could train as a public health official if I wanted to. I have been an elected member of a local authority and had a portfolio for transport. But what I do in my consultations is highly skilled and I am very very proud of it.

MD And I'm sure you are an excellent doctor. But there's never been an opportunity cost for the cost of our prescriptions and referrals. Which means we have never been able to prolong our consultations, we have never been encouraged to actually do our patients good, to heal them.

HM A lot of the budget one is not directly responsible for. At the moment we have this wonderful risk pooling-system called the NHS.

My own practice, which is incredibly low prescribing, is very much over budget through things that are totally unavoidable – accidents, babies born prematurely and so on. For me, the quality premium is a no-no – it's going to get right in between me and my patients. We have to say no.

CA A quality premium describes what it's supposed to be about – quality. Either quality of commissioning or quality of determining how best to deliver healthcare within a finite resource. Now, there could be cases where if there were a significant number of accidents – or an aircraft crash, for example – and it's clearly outside of your control, then I believe you should get that premium, yes. But if there is unexplained variation…

RH Are you saying there should be an appeals process?

CA Yes, there has to be a process that is robust.

RV There's lots that's bad about the health bill, lots that's dangerous, and the quality premium is one of the most dangerous things. This is going to lead to GPs regularly being on the front page of the Daily Mail. It's going to undermine a patient's confidence, whether it's real or just assumed.

The patient is no longer confident the GP is working solely on their behalf, but believes they have a mind to the money they are going to get. Patients will put two and two together and say: ‘You're giving prescribing or referral advice because you are going to get this money.' There's another big area, and that's health inequalities. CCGs in affluent areas, or because of the funding formula, will receive better funding and be able to live within their resources that bit easier. Those CCGs will get more, and those serving more deprived population less, or nothing at all. We are in a very tight financial situation within the NHS and if there is any money available – tied up in this quality premium – then fund it on a capitation basis to CCGs now.

RH My understanding of the GPC's position is that it would accept a quality premium only if it was paid a) just at the CCG level rather than to practices, and b) that it wasn't attached to staying within budget?

RV No, our position has been we are opposed to the quality premium as an idea. If the Government has to pursue it, there has to be a limit – a prevention of it going into practice's pockets. But I don't think there should be any extra funding. It should be handed out at a capitation level.

CG Those listening need to be absolutely clear about what is happening, and what will be occupying our minds for years to come – it will be about reducing activity, not about caring. It is an undermining of what we fundamentally do, which is to care for patients. There's an undermining of the fact that for 50, 60 years, the NHS has been designed so GPs have no perverse incentive for getting patients into the practice.

This issue about giving rewards for not having activity is the dark underbelly of health maintenance organisations. And it's not just that we will be given money, but we will actually be encouraged to divert referrals inappropriately, so patients do not have care that is appropriate for them.

RV Just imagine what's going to happen in March. PCTs for years have had problems leading up to the financial year-end. If a CCG's main income, and a practice's main income, is dependent upon hitting targets, what's going to happen to patients who need care, prescribing or referral towards the end of the financial year? The pressure on practices is going to become significant, and that will be a disaster.

MD These are fair warnings. But it comes back to whether CCGs are in control and whether practices are supporting them.

CG They won't be in control…

CA It depends on how this is paid to practices. If it's paid to practices to deliver a service for the population, I'm sure everybody would be in favour of that.

I would have difficulty if we are talking about a quality premium that starts to interfere with the doctor-patient relationship.

RH The policy involves CCGs getting to choose how to split up the money. Do you think that can work and not cause great tensions?

MD It could cause tensions, but that depends on the practices and CCG being at one in what they're trying to do. It could certainly cause improvements in services. Say a practice is referring three times the amount of other practices. Payment to that practice could look at the quality of care being offered – which may not be as good.

RH I'm not entirely clear – why is the quality premium so different from things like prescribing incentive schemes, which already exist?

CG Because they reward for adhering to best practice.

MD That's only in certain areas, Clare, some areas just have a blanket prescribing budget.

CG To be honest, I think prescribing incentive schemes have lost the plot. We are having to produce audits on so many drugs. But if you are saying, is it right to reward for prescribing appropriately? Yes, I think it probably is. Is it right to reward someone for not referring? I think that is wrong.

RV One of the other big differences is going to be the size of resource. The Government sees this as a way of controlling practices. And to do that, there needs to be a significant amount of resource made available to the CCG to make it attractive as a vehicle for performance-managing local practices.

 

RH We have a draft Government document which makes clear that initially we will have commissioning support hosted by the NHS Commissioning Board, as arms-length bodies under commercial terms, but over two or three years they will be spun off into entirely independent organisations working in a market. What does the panel feel about this?

HM There is the option of using local authorities, which have commissioning support functions. That could be a sensible alternative to avoid what worries me, which is the very large corporate management consultancies – there are about five of them – being set up so it's very difficult for us more ordinary mortals to compete.

If we get these corporates embedded in the middle of provision, the outcome will be commissioning in a health maintenance organisation way. If you put that alongside the personal health budget, you can see us not worrying about the end of the financial year as a practice, but someone with complex needs having spent the whole of their personal health budget.

MD I don't see any great plots in the guidance, which is draft and will be revised because of concerns expressed. Until 2013, clusters will have the monopoly position for commissioning support and CCGs should be able to decide which cluster they go to, so there is an element of the CCG being the consumer and not the victim. After 2013, they should be able to go wherever. My own guess is that a lot of CCGs will start taking commissioning support in-house.

RH But the document envisages there won't be much that is taken in-house because it argues CCGs are too small to be able to afford in-house commissioning support?

CG The only way out of this, and again I appeal to the leaders around this table to give some sensible advice, and to those setting these up, is you have to have CCGs that are large, that are very large…

RH How large?

CG One to five million population. That is the only way. Then you can start to have sensible people on your commissioning boards, then you can start to have a population base, you can start to be employing the right people. Do not believe it's going to be a happy ending if you subcontract all your commissioning support to what will be a large corporate organisation.

RV I agree with Clare. This is the area that will expose us to what's really going to happen. Those who are keen on clinical commissioning need to take this most seriously of all.

RH Do you also agree with her about the one to five million patients?

RV Absolutely. The reality is that CCGs, if they are serious about having any influence at all in the new world, need to coalesce into structures that are equivalent to the PCT clusters at the moment. Even PCTs were deemed to be too small by the centre.

RH You were saying 100,000 to 500,000 before. But you are saying, in response to this document, you now believe CCGs should be going for a million to five million.

RV If you're going to be commissioning against large foundation trusts, or large local authorities, you need to be a robust, big organisation – but small enough to actually achieve things. The way to achieve the capacity to be able to employ staff and be intelligent commissioners is to federate within the structure of an overarching CCG.

MD It's very Machiavellian to say they have to be one million or more.

CG Why is that Machiavellian? The smaller you are, the quicker you are going to go bankrupt.

MD You need to keep local sensitivities…

CA Both the NAPC and the alliance made very clear that CCGs need to be treated as adults – they need to have a choice. I have concerns about very large organisations conceptually, but I don't believe it is appropriate that it is up to anybody other than the CCGs to determine their own fate. It is up to them to decide how big they should be.

CG I am touched by the faith Mike and Charles have in our colleagues to run the health service – it is incredibly difficult to do. We need help, a sensible commissioning size and to concentrate on provider reform. What GPs do best is to get together as groups of practices, pull in the third sector and start sorting the big issues – end-of-life care, out-of-hours care.

RV I've already heard large providers talking to the Department of Health. The DH is saying you will be in conversation with the commissioning support organisations in the future, not with the CCGs. This is starting to happen, this is the agenda. The risk is CCGs will end up signing the cheques and getting the blame. But the decisions will be made for them by larger organisations.

 

RH Dr Michelle Drage, chief executive of Londonwide LMCs, has warned we're at the ‘cusp' of seeing sliding morale among enthusiasts. Is there a crisis of confidence among GP commissioners?

CA We are at a very sensitive time. If the coils of accountability keep on twirling at a rate faster than the unwinding of the coils of flexibility, we will lose heart. That is a real danger. There is another danger in the NHS Commissioning Board. This organisation is going to manage primary care – but where is the general practice within it? I have significant concerns.

RV If this reform is going to work it has to be clinically led from the top to the bottom. We have to ensure GPs are in a position to be able to make a difference. What we've seen in the health service over the last 10 or 15 years is that the top says jump and the bottom jumps. That's why we are in the reforms frenzy we're in at the moment because as soon as the reforms were announced, PCTs rushed and jumped to ensure they were doing things as quickly as possible without thinking of the consequences.

CG GPs are doing it because they are very biddable…

CA Absolutely patronising.

CG I'm sorry, I think they are. They do it because they think it's the right thing. We should be concentrating on putting GPs on the majority of the boards of clusters, capping their management costs, getting sensible GPs in, and I'm not even worried about the democratic process. The most important thing to me is general practice.

I love it. I've been a GP for 30 years, and I think it is the answer to the health service. We've got about five years, if these reforms go through, before general practice starts to unravel like it has done in other countries. The numbers coming will decrease, the pay will decrease, our professionalism will decrease, and those around this table are the only people that can protect our profession. Not because it's protectionism, but because it's the right thing – it's what makes the NHS fairer, safer, kinder and cheaper.

MD We're coming to a point of agreement. We are at the tipping point. If we are told we have to commission via AQP when we don't think it's right, given support for commissioning we don't want or clinical senates wrong-footing decisions, people will walk away.

HM We have to look at this not only from the perspective of us GPs and our colleagues, but from our patients' perspective. What happens if you are a patient in a CCG area that fails?

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