1 A reduction in box-ticking – but not in workload
Health secretary Jeremy Hunt hailed the 2014 contract deal in England as removing the ‘micro-management’ of the Labour years, but whether the cull of almost 40% of the QOF indicators will really achieve this remains to be seen.
GPs are likely to welcome being freed from the onerous Quality and Productivity domain, but this will be replaced with the equally bureaucratic unplanned admissions DES.
The process measures removed from the QOF are likely to enable GPs to focus more on patients, rather than paperwork, in consultations. But the harder-to-achieve, more process-orientated indicators remain in the framework.
Dr Nigel Watson, chief executive of Wessex LMCs and a GP in the New Forest, says: ‘The new contract gets rid of some of the hassle factor but nobody’s kidding us that we’re going to have loads of spare time this year to get things done.
‘It just signals the start of a reduced tick-box, re-professionalised general practice.’
What this means for your practice:
Don’t expect any time on the golf course, but the shift away from pen-pushing to patient care will be welcome.
2 More intrusive CQC regulation
New chief inspector of general practice Professor Steve Field promises the new CQC inspection regime will not be a ‘witch hunt’, but given the history of the regulator, GPs could be forgiven for reserving judgment.
Professor Field promises more GPs on inspection visits and says he expects the number of practices with serious issues to be ‘very small’. But GPs are entitled to worry that the four Ofsted-style ratings they will receive from the CQC – and have to publish in their waiting room – will be overly simplistic. Who wants to register with a practice ‘needing improvement’?
For GPC chair Dr Chaand Nagpaul, this is one of the major fears for 2014. He says: ‘I’m very worried about the spectre of inappropriate scrutiny and the effect that will have on practices. If the CQC ratings result in a simplistic league-table approach to general practice, it will undo a lot of the good work we’ve done. The last thing we need is more turgid bureaucracy and yet more performance management of GPs.’
Dr Bob Morley, executive secretary of Birmingham LMC, puts it more simply: ‘People are baying for blood and the CQC will have to provide some.’
What this means for your practice:
The march of the CQC inspectors will continue. Be afraid, very afraid.
3 GPs are pitched headlong into the new ‘marketised’ NHS
This is the year when the full impact of competition regulations will be felt – with all LESs to be reviewed by CCGs and local authorities and recommissioned where appropriate as ‘community service contracts’.
Practice boundaries will be removed from October, with those that wish to able to register patients from outside their existing catchment areas.
GPs will also feel the full force of Monitor as it continues its investigations into the primary care market, ensuring a ‘fair playing field’ for independent providers.
Dr Morley says enhanced services are very much on his radar this year: ‘This is one of the big issues for 2014. GPs will have to face the realities of the commercial world with services they’ve historically been paid to provide.
‘Public health enhanced services, especially, are likely to go to procurement. For example, in our area there’s a single sexual health contract, currently provided by practices, that could be opened up to bidders. This could have a big impact.’
But Dr Charles Alessi, chair of NHS Clinical Commissioners, says competition is a fact of life: ‘If managed sensitively, competition can be a good thing.’
What this means for your practice:
GPs will have to fight for the services they have historically been paid to provide – it will not be pretty.
Known unknown of 2014: removing practice boundaries
This controversial initiative was agreed as part of the 2014 contract deal in England and will fulfil the Government’s long-standing promise of giving patients more choice. But will they take advantage of it?
The pilots trialling the abolition of boundaries were largely ignored by patients and practices, but the Government is hoping that by allowing patients to ask to be registered at any practice they choose, they can begin to impose market forces on GPs.
Former RCGP chair Professor Clare Gerada is sceptical. She says practices already offer flexibility, and that removing boundaries will mean CCGs will struggle to commission services for their local population.
She says: ‘Removing boundaries is wrong. It removes the relationship between the GP and their local community.’
Dr Michelle Drage, chief executive of Londonwide LMCs, sees the policy as an example of political window-dressing: ‘The evidence from the pilots was unclear. Most patients won’t be interested.’
But Dr Charles Alessi, chair of NHS Clinical Commissioners, cautiously welcomes the move: ‘This will change the 1960s model we’ve been stuck in and is a step in the right direction.’
4 English GP ‘flight’ becomes a serious national issue
As English GPs look enviously at working conditions in other UK nations and overseas, the phenomenon of GP ‘flight’ is likely to become a national concern.
Pulse revealed in July that requests to the GMC for certificates used to move abroad were accelerating, with a 40% increase since 2008. This trend is set to continue.
The UK-wide GP contract is looking more fractured by the day, but the rapid marketisation of the NHS in England under the Health and Social Care Act could to lead to GPs seeking shelter in the comparatively calmer conditions of the devolved nations, or even further afield.
Dr Nagpaul says: ‘We have heard many reports of GPs in the early stages of their career choosing to move abroad, many to Australia. It is a barometer of the low morale and lack of motivation of UK general practice. GPs feel beleaguered, attacked from all sides and they don’t feel valued. The Government has to turn this around in 2014.’
What this means for your practice
Combined with more senior GPs increasingly seeking early retirement, this can only exacerbate the existing recruitment crisis.
5 GP bashing is tamed, but not eradicated
GPs have spent much of the past decade under ferocious attack from all sides over their pay as a result of the 2004 GP contract, despite the reality of successive falls in practice income. But health secretary Jeremy Hunt has led a change in rhetoric in recent months, insisting he is the ‘most pro-GP in 50 years’ and billing his general practice reforms as a ‘return to the family doctor’.
The 2014 GP contract deal paves the way for GPs’ net NHS earnings to be published from 2015/16 onwards.
Dr Watson says: ‘It will be extra workload for practices to work these out and publish them and they won’t look as high as many think. But that won’t stop the Daily Mail having a go.’
But Scottish GPC chair Dr Alan McDevitt is more hopeful. He says: ‘People are starting to realise again that they actually need us. Of course, many GPs are pushed to the edge now by workload, [but] they can cope with that as long as they’re not under attack too.’
What this means for your practice:
Don’t expect flowers from Fleet Street, but slightly more sympathetic treatment in the national media is not inconceivable.
6 Practices face growing pressure to open longer
The Prime Minister has already signalled he is keen for GPs to open later and at weekends, and pilots to test his ideas will begin this year.
CCG leaders are also beginning to realise that they need practices to help alleviate the growing pressure on emergency and urgent care services, while NHS England is likely to recommend longer opening hours at surgeries as part of its review of urgent care led by NHS medical director Sir Bruce Keogh.
Grassroots GPs remain strongly opposed to the idea, with a recent Pulse poll showing 85% think the £50m seven-day working pilot is not a good use of NHS resources, and just 9% in favour.
But GP leaders are less negative about the idea, partly because they see it as a way of demanding additional resources.
RCGP chair Dr Maureen Baker says public opinion may force longer opening hours. She says: ‘Patients express great satisfaction with GPs on the whole but there is increasing dissatisfaction with access – or at least that’s what politicians are hearing. And in a period when you’re coming up to an election, this becomes very important.
‘GP access will be under much scrutiny and this could either mean more pressure on GPs or result in better support for practices – perhaps through federations.’
But Dr McDevitt says other ways of extending access should be considered: ‘Access can be digital or take other forms as well.’
What this means for your practice:
GPs will have to open longer – the challenge will be to ensure there are adequate resources and GPs to staff the additional surgeries.
7 GPs receive patient complaints over use of their personal data
GPs may officially be the ‘data controller’ for their patients’ records, but they have had little say in the rollout of NHS England’s big care.data scheme, which aims to link up this data with hospital records and make it available beyond the NHS.
The Government’s growth strategy – published in 2012 – identified patient-level data as a priority area for boosting growth and soon afterwards, NHS England revealed it plans to sell access to data held by the Health and Social Care Information Centre to private companies and researchers for a nominal £1.
That suggestion ran into trouble as patient groups and the Information Commissioner realised the scale of what was being planned and NHS England was forced to agree to a full-scale public information campaign this month, with leaflets going to all households in England.
But patients have little time to opt out as the first data extractions will take place in March. Any patient data that is extracted will be anonymised – but not deleted if they opt out after that.
Dr Watson says: ‘There’s a general acceptance that we’ve got to get it done – care.data is a big piece of work that can’t be done at practice level. [But] NHS England needs to be explaining this to patients, not GPs.’
Dr Alessi says: ‘We need to be able to share data for the new system to work, and I fully support people opting out. However, I feel this hasn’t been really properly explained to patients yet.’
What this means for your practice:
Likely complaints from patients who missed the leaflet and weren’t aware their data was being shared across the NHS and potentially even with big business.
One to watch: Simon Stevens
Simon Stevens will have the most powerful job in the NHS from April, when he takes over as chief executive from Sir David Nicholson. He will have to cope with the fallout from Mid-Staffs and intense budgetary pressure on the whole system.
But the influence on primary care he will have remains to be seen. He was a special adviser to Prime Minister Tony Blair and an architect of the Government’s agenda for primary care via the 2000 NHS Plan.
He later became influential in US healthcare as executive vice-president of UnitedHealth Group, the nation’s largest health provider.
When UnitedHealth was planning a major move to run GP surgeries in the UK, he told Pulse that he supported the GP contract at the time and insisted GPs had nothing to fear from private companies.
But he has also been critical of GPs. He told Health Policy Insight in 2011 that CCGs needed to ‘get serious’ about improving the quality of primary care, but said this was a huge ask as GP commitment was needed for commissioning to work well.
GPC chair Dr Chaand Nagpaul is guardedly hopeful. He says: ‘He was only in the country for 36 hours recently and invited me to meet him, which I take as a good sign. I hope he’ll be a supporter of general practice and appreciate the logic and immense value of proper investment in GPs.’
Please note: This article was changed on the 02/01/14 to reflect that it was NHS England and not the Health and Social Care Information Centre who proposed to allow the NHSCIC to sell off access to patient data to private companies and researchers for a nominal £1.
