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Survival of the fittest for GPs as new DH ratings model takes off

A Pulse investigation finds NHS chiefs have acted quickly to introduce new ratings and competition for GPs. By Gareth Iacobucci reports.

By Gareth Iacobucci

A Pulse investigation finds NHS chiefs have acted quickly to introduce new ratings and competition for GPs. By Gareth Iacobucci reports.

Of all the Government policy documents that pile up on the doorsteps of PCTs and eventually filter down to GPs, this was the one you had to read.

That was the advice from LMCs after publication of Improving GP services back in January.

It might not sound like much, but the consensus was that in its pages lay a new, and potentially frightening, future for general practice.

The document starts encouragingly enough, by proclaiming that patients have a personal bond with their GP that is unique in the health service.

But for all that vote of confidence, it goes on to demand a sweeping series of measures to improve standards, ramp up competition and, of course, save the Government and embattled PCTs money.

So almost six months later, how far are NHS managers following their new commissioning bible – and how is its guidance beginning to impinge on the work of GPs?

Among the key recommendations were twice-yearly contractual reviews, measures to allow patients to switch practices more easily and recommendations for generating competition by further use of the private sector.

And central to all of this was the desire for all PCTs to bring in a system of so-called balanced scorecards, meaning GPs and other providers will get rated on an array of indicators including QOF data, GP patient survey results, prescribing figures and quality of premises-with all details to be made public.

It's a rating system that should, in theory, allow the performance of a variety of providers to be quickly compared by managers – and indeed patients – aiding decisions about who to commission and what contracts to cancel.

Just last week, Pulse revealed that a national balanced scorecard is now under development, with the management consultant firm McKinsey playing a central role.

And in any case, PCTs have avoided their usual habit of delays, missed deadlines and inefficiencies on a grand scale. Local managers appear to have taken to the task of implementing scorecard systems with relish.

A Pulse survey of 30 PCTs shows more than four out of five either have already brought in balanced scorecards for GPs or plan to do so this year, among them

NHS Peterborough, Wolverhampton City PCT and NHS West Essex.

Balanced scorecards were first trialed in Tower Hamlets in 2006, but the Government wants to make them a central plank of GP contract-management nationally.

McKinsey is developing 85 different quality indicators to assess practice performance, and as if that wasn't enough, PCTs are to be free to add their own.

Dr Richard Vautrey, GPC deputy chair, sees trouble ahead.

‘It's the same problems we've seen with hospital scoring arrangements,' he says.

‘Hospitals can be classed as poor or fair or good on the basis of very suspect information. Hospitals that often provide excellent services can be rated poorly.

‘The other problem is you don't then add any context around the information that these balanced scorecards create, so you don't know whether a practices at the bottom of the league table is actually one of the best-performing practices because of the difficulties of the population that they serve.'

Nearly 60% of the trusts in Pulse's survey have also been setting about conducting contractual reviews, involving both PMS and GMS GPs.

NHS North East Essex says it has scheduled a formal programme of PMS/GMS contractual reviews from next month, while NHS Stockport says reviews that last year were carried out at a ‘targeted number of practices' would this year be extended to all its GP practices.

Dr Tony Stanton, joint chief executive of Londonwide LMCs, claims PCTs in London have stepped up their contractual reviews in the past few months and warns that GPs will have to be prepared for more of the same.

‘There's been a renewed vigour in contractual reviews,' he says. ‘We've given guidance to all our practices on what they need to do to be secure and hold on to their contracts, including being patient friendly, having good premises and well-trained staff.'

Dr Stanton says the Darzi tendering processes for GP-led health centres has acted as ‘a wake-up call' to practices, and reckons GPs are beginning to realise what they have to do in order to survive in ‘the market'.

‘The DH wishes to stimulate the market. If practices haven't upped their standards, they're going to find it very difficult when PCTs come round to check on them.'

There is one obvious driver for PCTs. Under the Government's World Class Commissioning strategy, managers realise there will be hell to pay if they get it wrong. Two PCT chief executives at trusts with a weak first-year performance in WCC have already left their posts.

Very high on the priority list for PCTs is the business of ramping up competition.

David Stout, director of the PCT network for the NHS Confederation, says PCTs will fear being ‘shown up' as ‘weak commissioners'

The various measures being brought in are also giving NHS managers hitherto undreamt of control over GPs. The DH has given PCTs directions to tackle the feeling in Westminster that GP services are outdated because they are not adequately exposed to the usual law of the jungle faced by other businesses.

The Government, the Government in waiting and the CBI all sing from the same hymn sheet on this one.

As Nottinghamshire LMC puts it, in a stark warning to its members, ‘only the fittest and most efficient providers will survive under the new regime'.

The WCC document makes it clear that to get round not having enough ‘direct influence' on GPs, PCTs should not hesitate to encourage private providers to step in.

Here too the Government is demanding more. A brutally titled new document ‘Necessity – not nicety' makes clear that trusts will be expected to make huge efficiency savings in the services they commission, by increasing their procurement skills and making greater use of the private and third sectors.

Mark Britnell, the author and the Department of Health's director of commissioning and system management says: ‘Now, more than ever is the moment to create a new commercial operating model which will address past deficiencies.'

The WCC document set out the DH's view that there were ‘underdeveloped systems and incentives to promote choice and competition'.

The unfairness of the GP funding system meant money did ‘not fully follow the patient if they switched practice'.

It also lamented the lack of competing practices that patients could register with and the absence of comparative information for patients.

What with balanced scorecards – which will be published for the public - and plans for NHS Choices to provide restaurant-style ratings on practices, that criticism could soon be a thing of the past.

Mr Britnell's new model will unleash commercial support units for each SHA.

‘The landscape for commercial and procurement activity in the NHS and DH has developed in a piecemeal fashion and no longer provides optimal benefits for providers, commissioners, patients or the taxpayer,' he says.

Considering Pulse's investigation this week, showing the amount trusts have spend on external consultants has almost tripled in the past three years, it will be interesting to see whether the taxpaper ends up a winner of a loser from inviting still more.

PCTs have already spent up to £200,000 tendering for GP-led health centres over the last year, but the DH has made it clear that it wants more.

It wants more competition, more contract management, more ratings and more choice. This is one document that could bring some life-changing experiences for many GPs.


What is government trying to do?
The Government's World Class Commissioning scheme is aiming to improve PCTs' patchy commissioning skills to drive up standards and bring efficiency savings. Trusts have so far come up short in some areas, particularly in meeting the Government's desire to stimulate competition.

What will GPs face?
The DH blueprint asks trusts to kick-start a twice-yearly cycle of contractual reviews for GP practices, to begin either this year or next. It urges them to develop school report-style ‘balanced scorecards' of performance, to measure practices' performance and achieve desired commissioning targets.

What are balanced scorecards?
Balanced Scorecards were initially used in the business world as a performance-management tool. Tower Hamlets PCT was the first to develop them for general practice back in 2006. The model is now being widely adopted elsewhere, using data from the QOF, GP patient survey results and data on prescribing, referrals and premises.

NHS bosses have moved fast to set up a new ratings scheme for GP surgeries

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