By Gareth Iacobucci
With the general election fast approaching, Pulse reporter By Gareth Iacobucci sat down with health secretary Andy Burnham to quiz him on scrapping practice boundaries, NHS cuts and whether GPs can expect a pay rise.
Scrapping practice boundaries
Has the Government crystallised how it plans to abolish practice boundaries, and if so, please can you explain how it proposes to take this forward?
I’m aware of the interest and in some places concerns about how it will be implemented. That’s why we’re consulting, we want to get it right. We think there is support for the principle, and the BMA have indicated support for the principle, but we accept that there are practical questions, particularly about home visits that come through. So, while we’re pushing on with the overall reform we want to carry people with us. So they are taking time to consult. It’s more on the practicalities.
If I may, I want to take a step back from the specifics of the policy, to set the broader context. For me, I think we’re about to enter a decade of really exciting change in primary care. It’s begun to an extent with some of the changes with the more modern multi-practice health centres, but the next decade will see really dynamic, and I think, the most exciting part of the system will be what’s happening in primary care with services coming out of hospital. I think the range and breadth and quality of what’s happening at local level will really change.
I also think there is the potential for the development of more specialist services at a local level, again, as services come out of hospital, as we look towards a future where there is more integration between secondary and primary care. Some of the most exciting change in the health service is happening in primary care right now. That will intensify over the coming decade.
So the choice policy is really part of that big picture, really giving people the chance to choose GP services, that most fit their needs. Not just around opening hours, although that’s an important part of it, but encouraging that whole culture in primary care. The choice issue is almost helping to stimulate that whole process of improvement. I think it is exciting. I know people often feel, ‘oh, what are they coming up with now’, I would encourage people to take a step back and think of it in that bigger picture.
Could the proposal be implemented by reforming the temporary residency scheme, as the GPC have suggested, or is this not radical enough?
My mind is fixed on the principle, that we should allow people to choose services that are best for them. But I am open-minded on the practicalities. I would want the GPC to put their suggestions on the table, and I think this should be a positive debate about solutions rather than people throwing up all kinds of problems. It’s a reform whose time has come, it’s what people expect.
The vast majority as we know are very happy with the practice they’ve got. I don’t think the majority of people would be affected by this change. But, if I go back to my own experience in my life, I grew up with a family doctor and practice. And then when you go away to university or work somewhere else, you still might like to keep that practice. I think that’s a healthy and proper thing, but obviously they may choose to move for work reasons, because it’s more convenient, or opening hours if they have a young family. All of those reasons are good reasons to do it. What I want to understand is, if someone chooses to go to a PCT out of area, they may have to accept they can’t get the same level of home visits.
So patients would be agreeing to a trade-off?
The document isn’t hard and fast on these issues. We want genuinely to debate the practicalities and that’s why we’re doing it as a consultation and not pushing straight on. We want to carry people with us. All ideas are welcome. We want to make this work without detracting from the overall direction of travel.
On practice boundaries, Dr Martin Breach asks: ‘If practice boundaries are to be abolished, what, if any, geographical limits will exist for patients who wish to register with a particular practice. Will it be possible for a patient to register if they live, for example, 10, 20, or 30 miles away if they so desire? Alternatively, will there be some commonsense restriction on the freedom of patients to be registered and if so how and by whom will this be applied?’
This is exactly the trade off that we will want to explore in the consultation. It could be that a person chooses a practice many miles away, and that the PCT might then have a residual responsibility with regard to home visits, and we’d have to have a payment mechanism that reflected that.
It might be that the practice itself says, to encourage people to choose, we will also provide home visits, as long as they’re not too far away. There are solutions here, and perhaps, these could be arrangements struck at a local level rather than dictated from here.
How long does the consultation last for?
It lasts for 12 weeks. It obviously carried through the election period, but as I understand it, I think the opposition have broadly committed to this direction of travel, so I don’t see there’s any great debate about the principal; it’s the practicalities on which people will have stronger views.
Is a kind of daytime out-of-hours system under consideration, whereby it might be that GPs relinquish responsibility for daytime home visits for patients who chose to register at practices far away from their home?
The consultation asks questions on those points. How best to get that balance right, and would the patient have to accept the trade off. If you go from a local practice you obviously could get home visits, so these are exactly the trade offs that the consultation is exploring. There are alternatives available, walk-in centres, GP-led health centres, so in different areas it will work out differently.
I would very much want to encourage local solutions rather than mandating it all from here, as long as we can establish some broad principles for how this should work. I think it wouldn’t necessarily work in the same way in all areas. I’m aware of a situation in St Helens, where a number of practices PBC consortia are collaborating on a daytime home visits service, which they all jointly commission in one service. That seems to be a sensible solution that works for those practices. That’s local solutions, not something we would want to override.
Dr John Pike is just one of many GPs who have asked about cuts. Your department has said that trusts who operate slash and burn cuts would be named and shamed. We have some recent examples which seem more like cuts than efficiency savings. For example, In NHS West Kent, the PCT says mental health services will be ‘provided at lower cost’ and that services are ‘likely to be reduced in some areas’. Similarly, NHS Sefton plans to cut hospital activity by 10% in the coming year, while, over a slightly longer period, it’s planning to cut primary care spend by some 10%. Will you name and shame trusts that are inappropriately cutting services?
PCTs on average, are getting 5% growth this year, and 5% next year. That is the essential context for the immediate future. I have guaranteed that for the 3 years after that, PCTs will at least receive inflation. So, for the 3 years looking out from here as we approach a new financial year, that is the financial outlook for every PCT in England. Now, it’s challenging, even though there’s growth next year. But, overall, budgets are not being cut.
However, PCTs will obviously have to create headroom so that they can carry on meeting the pressure and investing in the latest treatments. So, I would take issue with the term ‘cuts’. Mike is quite right to say that it’s about improving, it’s about creating the space for funds so that they can be reinvested elsewhere.
Of the two specific examples. With West Kent, I would expect commissioners to take a hard look at mental health. Mental Health has not had the tariff in the same way, so there may be parts of the country where commissioners can quite rightly say, ‘we are not satisfied we are getting the best possible value for money’ compared to other parts of the country. With regards to Sefton, it is essential that we cut hospital admissions in the coming period. That to me means better management of people with long term conditions in the community, better co-ordination of care between primary and secondary care and a much greater emphasis on prevention, and support in the home. Yes it will mean change, but that’s not always to be equated with crude cost-cutting. There’s a very big difference.
One of the big differences between us and the Tories, is that they committed to a moratorium on hospital reconfiguration. I just think that is not a sustainable position, and I think most GPs would probably acknowledge that. There is far more that can be done in the patient’s home and in general practice to cut unnecessary referrals to hospital. If we’re going into this coming period with no change to hospital services, I don’t believe that is credible, and that would take money out of primary care. My vision is the opposite.
It’s not the cutting hospital services per se, it’s the fact that, in some areas, they are also planning to cut primary care spend. How can those things exist together without it meaning cuts?
The system is going to have to be under pressure for efficiency, there’s no getting away from that. I’m not exempting anybody from the pretty tough efficiency requirements that everybody will face. But what I am indicating is that, if I am sitting back where I’m sitting in June, which I hope I will be, I would want, in any scenario, for there to be more activity in primary care, and an extension of services.
Let me give you an example. The headline commitment we will take into the election is that over five years, we will give patients a 1 week maximum wait for test results for suspected cancers. People might regard that cynically, but in fact, it’s been very carefully chosen, because it goes with the grain of what we believe should happen in general practice and primary care in the next period, which is an investment in the testing capacity and capability of primary care. GPs are empowered by that, so they can say to the patient, ‘actually, I’m not sure about these symptoms that you’ve got, I’m just going to send you down into the corridor or the next room to have a test’. For the GP’s point of view, that will help them give better care to their patients rather than referring them off for tests in secondary care. We think its both good for the patient but empowering for the GP.
I know we’re often portrayed as having a downer on GPs, nothing could be further from the truth. If I look at my own constituency, that is where the exciting stuff is happening. Lots of entrepreneurial, dynamic GPs with good ideas and they are making real changes to the quality of patient care. That’s what I want to see all over the country in the next five years. I’m incredibly passionate about general practice.
In our recent survey of almost 900 GPs, 80% felt they weren’t able to manage care for elderly people in care homes effectively. They put this down to factors such as a lack of time to carry out visits, a lack of access to elderly care psychologists, and a lack of specialist nurse provision. Are they any plans to support GPs more in care homes, and if so, what are they?
Certainly, more specialist nursing is very much on our agenda. And part of the whole drive I’ve been describing, I see specialist nursing playing a key part of that. So the GP’s access to specialist nursing is a very important part of that.
But more broadly, what you’re getting into is the whole question of the interface between health and social care. I’ve made this the defining issue of what I’ve been trying to do over the last year. Before the general election, I intend to bring forward a white paper on the reform of social care. I think it’s so long overdue that it can’t possibly be ignored any longer. I favour a future where we remove entirely the boundary between health and social care where we integrate support in a much deeper and more meaningful way. The proposals I will bring forward for a national care service will outline how we intend to do that.
I think the health service ultimately picks up the pressure if we fail on the social care side, so we have got to adopt a much more imaginative approach. Helping manage people’s needs in care homes would be a part of that. But our big drive will be around what we call re-enablement, where people are at a low point, after a fall or operation, or bereavement; we think we need to provide much more intensive support to help them return home. That will be a big part of our drive, we think there are probably too many people that end up in care homes prematurely. They could regain their independence in the community. So we understand the concerns being raised, and we would want to improve the co-ordination between health and social care.
GP pay deal
What does the Government plan to do if the DDRB recommends a higher award for GPs than its proposed 0.5% gross uplift? Does the Government have the financial capacity to adhere to a higher recommendation?
The public mood has changed considerably, and I would say rightly so, in terms of attitudes to senior pay in any profession. This is true of MPs as well. I think its time for everybody to reflect on the change in public attitude towards levels of pay at senior levels. We all have to show responsibility and restraint, particularly when the health service is entering a more difficult time.
However, that said, we also have to be fair to people who have commitments, and are obviously highly trained with long experience. Its not that we’ve uniquely targeted GPs. This was obviously an agreement across the Government in terms of senior pay, in local Government, in civil service, parliamentary pay, ministerial pay, GPs. We’ve made our submission to the DDRB, and we await to see their recommendations. But I think we all have to be cognisant of the public mood on senior pay.
The Deech Review
A major Government–commissioned review last October – carried out by Baroness Ruth Deech, called for PCTs to guarantee maternity pay for salaried posts in order to remove the current incentive for GP practices to offer women short-term contracts, and for women GPs to be given tax breaks to pay for childcare under the recommendations. We’ve heard nothing since then – can you commit to implementing these recommendations?
It’s obviously a very important issue to the Labour party. We have always placed a strong emphasis on these issues down the years. The make-up of the GP workforce has changed. We would very much want to work with the Deech recommendations to speed up change in this area. The equality bill will come into force soon and further strengthen the Government’s commitment in this area.
Following your pledge last year that the NHS was now the preferred provider, you’ve recently said this speech was misunderstood. Could you clarify exactly where you stand on this, and also, give an indication of when the guidance will be issued to trusts on this policy?
The guidance is coming quite soon, in the next few weeks. Let me make this absolutely clear. I believe that it matters to people who work within the NHS that they work for the NHS. Perhaps we haven’t recognised that enough at times. It motivates the NHS workforce, and that is an important allegiance and commitment that they’ve got. I also know that the NHS is about to enter a period of change and challenge, where searching questions will have to be asked about both under-performance in terms of quality, and about change to patient pathways. We will have to have change and challenge on lots of levels to make sure we can rise to the financial challenge that’s coming.
Now, for me, in the past, we’ve done the reform in the health service and not thought enough of all people. I take a very clear view about this. We have to understand people and have fair rules that help people through change, and rules that respect what matters to people who work within the NHS. I’m saying very clearly that NHS preferred provider means that people get a chance to change if there’s a challenge in respect of under-performance or if there needs to be service reconfiguration. Where it affects existing staff, doing existing jobs, and existing NHS services, they should get the chance and the space to change before you would ever go out to an open market tender. I would defend that position to the hilt because I believe it’s the right, fair and common sense position to hold.
It’s not that I have a downer on independent, private or voluntary sector provision in the NHS. All of that remains really important as part of the NHS and a wider family. But this preferred provider change is very important in terms of recognising that the NHS is entering a different era where it is not simply about adding new services. We have to look at changing existing services, and that’s the big difference. When we were adding on new capacity, it doesn’t affect of threaten anybody’s jobs. But when you are having to change the system to meet the new efficiency requirements, I think you need a fair set of ground rules that lets everybody know where they stand, and which recognises that working for the NHS matters to people.
I think this does differentiate me from Andrew Lansley, but it’s a differentiation I’m very happy to have. I’m not ambivalent or neutral about the NHS. I’m very pro-NHS provision. That doesn’t mean I’m against other forms of provision, I’m just simply saying, give them a fair set of rules. The other thing to say is, I expect there to be more challenge, not less, and if NHS provision doesn’t come up to the mark, then there is no excuses. We can’t tolerate poor provision just because it’s NHS provision. So it’s a fair process, fair rules to help everybody navigate the change that’s coming.
Health secretary Andy Burnham Health secretary Andy Burnham