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Is the Government's contract deal good for patients?

Primary care tsar Dr David Colin-Thome says extended hours are essential to meet the needs of six-and-a-half million patients unhappy with their access to a GP. But LMC chair Dr Andrew Mimnagh argues it is unethical to take money from care of the sick to provide care for the worried well.

Primary care tsar Dr David Colin-Thome says extended hours are essential to meet the needs of six-and-a-half million patients unhappy with their access to a GP. But LMC chair Dr Andrew Mimnagh argues it is unethical to take money from care of the sick to provide care for the worried well.



Yes

Nye Bevan believed ‘the family doctor is in many ways the most important person in the service'. Sixty years later, that still holds true and universal access to GPs is still vitally important.

Lord Darzi is leading a review of the NHS, looking at how services and care can – and should – be improved to respond to 21st century challenges.

It will look at how to deliver world-class primary and community services that focus on promoting health, preventing illness, caring for individual patients and often their whole families, and systematically managing their long-term conditions.

In the short term, we have looked carefully at how best to reuse a limited number of out-of-date indicators in the QOF. We took the view to use these resources to strengthen the focus on patient experience – because we see this as an important part of the high-quality services GPs offer.

There is an enormous range of good clinical practice that GPs need to continue to deliver, including – but by no means restricted to – areas such as heart disease and osteoporosis.

It is simply not possible to have individual financial incentives for GPs covering every aspect of good clinical care – or every aspect of good patient experience.

We decided it should be a priority to improve patient access to the skills and aptitudes of their GPs. We believe this can be significantly enhanced through extended opening hours.

The GP contract of 2004 brought huge benefits to healthcare, primary care, GPs and, most importantly, patients.

But four years on, we must ensure that the contract continues to evolve to meet new challenges.

The GP patient survey, conducted last year, showed that although most patients were pleased with the care offered by GPs and their staff, 16% of people were unhappy with the opening hours of their practice – that means nearly six-and-a-half million unsatisfisfied patients.

Inequalities in access

They want access at times that are convenient for them – at the weekend, in the evening or early in the morning.

Figures show that young working men and some members of black and minority ethnic communities are more likely than average to express concern about access to GP services. We have a duty to ensure that access to healthcare does not create inequities for particular groups in society.

Our proposal is for an extra three hours opening a week for the average practice, to be funded through better use of the non-clinical resources within the current contract that are currently being spent on access and choice.

In addition, practices would see an extra £100m of investment in general practice, which equates to £12,000 more for the average practice.

If practices offer extra appointments at more convenient opening times, they will receive funds of nearly £3 per patient, equating to about £18,000 for a typical practice.

But if practices are unwilling to provide extended hours they will see their income reduced. The proposal is consistent with our view that extra income for practices should be linked to improving services for patients.

We believe this deal is a good one for patients. Patients cannot benefit from the high-quality care that GPs provide if they cannot access the service.

In addition, we are committed to working with the profession to support longer-term ways of improving quality and access to GP services.

I hope GPs will back these proposals.

Our shared aim is to improve the quality of care for patients. By giving more people better access to their family doctor, we will address this and be well on our way to making the NHS world class.


No

The fundamental flaw with the extended hours plan is simple.

Under the negotiated terms of the GMS contract, the QOF placed a premium on the evidence-based management of chronic disease, while also throwing in a few points for political footballs.

But the new impositions are funded not only from the disposable political points but from those that would have been of real use to clinical care. It is inequitable to remove money from care of the sick to provide care of the well.

The majority of the 1,000 points in the QOF are focused on evidence-based best practice and aim to remunerate the effort of becoming familiar with a disease area, reimburse the expense of any necessary equipment or consumables and provide cash for support staff to oversee the provision of care by community colleagues or secondary care specialists.

How it was done or who did it was not generally specified – GPs were paid to see it got done, not necessarily do it. This has caused a few tensions, with consultants and practice nurses alike claiming ‘we do the work, the GP gets the cash'.

Nonetheless, and indisputably, the standard of care has risen in those areas where GPs were remunerated. Conversely, clinical standards have not risen in areas that were not incentivised by the QOF. I say this a statement of fact, rather than of criticism.

Given the effectiveness of clinical targets for improving care, it's unsurprising that further changes to the QOF were under discussion.

The QOF was not designed to be static. A rolling QOF programme can maintain standards for less cash per indicator, while introducing new standards that continue to drive up global quality.


No interest in quality

Now let us consider the areas rejected to make way for extended hours. The Government apparently wasn't interested in the planned new indicator for use of ß-blockers in heart failure, even though a Healthcare Commission report last week found only 39% of patients are getting the drugs.

Maybe ministers consider preserving an elderly population who are drawing their pensions is not in the Treasury's interest.

The Government is also ignoring the evidence on the treatment of osteoporosis and fractures, regardless that its profound effect on the health of the individual ultimately saves health and social services money by preserving independence and reducing traumatic orthopaedic operations and rehabilitation.

It needs investment now to gain a deferred and enduring financial benefit, but perhaps the Government fears it may not be around to see the results.

But it is the exclusion of peripheral arterial disease that challenges the Government on the most fundamental basis.

Having promised to reduce the mortality of cardiovascular disease by 2012, it finds its focus on coronary heart disease and stroke paying dividends via the QOF, as last week's NSF report showed.

But these are only parts of the atherothrombotic disease spectrum – and failure to provide points for peripheral arterial disease propagates a profound health inequality.

If you have symptomatic peripheral arterial disease complicating cardiovascular disease, you are 1.8 times more likely to die than if you have both stroke and ischemic heart disease together.

It is possible that peripheral arterial disease marks particularly extensive atherothrombotic disease – but the fact remains that patients with the condition receive less intensive cardiovascular treatment than those with ischaemic heart disease or stroke.

The omission of these clinical areas from the QOF in favour of incentives for extended hours appears to value re-election ahead of the enduring health of the nation. I wonder if the electorate will forgive him; the medical profession and bereaved relatives will not.

And yes, ministers question our professionalism in pointing out that we could do all this clinical work regardless of the QOF. But the paradox is that these proposals place a further restriction on the major impediment to this goal – our available time.

Dr David Colin Thome

National director for primary care. Dr David Colin Thome Dr Andrew Mimnagh

Chair of Sefton LMC and a member of the Target PAD group Dr Andrew Mimnagh

We must ensure that the contract continues to evolve to meet new challenges.

It is the exclusion of peripheral arterial disease from the QOF that challenges the Government on the most fundamental basis.

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