1) A huge ramp up of QOF workload
It is a safe bet that the Government’s will impose the most wide-ranging QOF changes since the framework was introduced from April.
The changes will see funding for the organisational domain removed, a raft of new work introduced, upper thresholds hiked to reflect the performance of the top 25% of practices – including to 100% in some cases – and a change in the way QOF payments are calculated.
The changes have been described as ‘unworkable’ by the GPC, which has suggested that practices evaluate carefully whether the additional workload is worth pursuing.
Dr Peter Swinyard, chair of the Family Doctors Association, said that the changes will be ‘extremely difficult for GPs to cope with.’
He said: ‘Money is being taken away from the QOF organisation domain for things we have previously been paid for doing, and we need the money. Tightening of targets and incorporation of new QOF work will be difficult to cope with at a time when we’re at burnout. The wheels really are squeaking.’
He added that the threshold hikes are ‘worrying’ and could mean practices decide not to try to gain the points for some indicators: ‘If you set a threshold too high people will say “It’s not worth trying for it”. They’ll say “We can get our blood pressures down to 140/90 but we can get them down to 120/90. Patients won’t take enough drugs because it makes them fall over.”’
2) Practices battling with online records and new IT systems
One of new health secretary’s four priorities is to bring ‘the technological revolution to the NHS’ and GP practices are at the forefront of his plans.
After initially laying out plans in their Information Strategy - a ten year framework on how to improve access to healthcare information - the DH have proposed a new DES worth £3,600 of former QOF funding per practice - to come into effect from next year to implement the changes.
It will require practices to offer patients the ability to book appointments, order prescriptions and receive some test results online. From 2014/15, GPs will also have to make further test results available online, provide secure electronic communication within the practice and offer online access to medical records.
It also plans to introduce a DES incentivising ‘remote monitoring’ of patients from April, that will mark the start of the rollout of the Government’s cherished ‘3million lives’ telehealth initiative.
Dr Paul Cundy, chair of the GPC’s IT subcommittee predicted GPs would experience a ‘tsunami of irrelevant electronic communications’ that would prove difficult for practices to cope with.
He said: ‘GPs will receive communications from the sharply elbowed worried-well e-Twitterati at the first sign of a snivel, any ache or minimal disturbance of their physiognomy.
‘With any luck we may end up doubling the worldwide internet traffic,’ he quipped.
Dr Cundy also said that DH plans to expand patient choice of providers on Choose and Book and rollout telehealth were unlikely to have much of an impact.
‘Telehealth will pass - as most fashions - into the distant memory.’ he said.
3) Screening for signs of dementia
Dementia care is top priority at the Department of Health, after the Prime Minister issued his ‘challenge on dementia’ this year. The DH is under pressure to show that it is making progress on increasing dementia diagnosis rates and reducing antipsychotic prescribing in this group of patients.
Progress has been patchy so far, with plans to roll out a dementia diagnosis app being branded as ‘pie in the sky’ by the GPC, and antipsychotic prescribing rates coming down in dementia but not for a stubborn minority.
This is likely to change in 2013, with the Government proposing to fund a new dementia case-finding DES using cash released by retiring QOF organisational indicators.
GPs will have to assess all patients over 75 years, those aged over 60 years with CVD, stroke, peripheral vascular disease and diabetes, all patients with learning disabilities and long term neurological conditions such as Parkinson’s disease for the early signs of dementia.
The move has kick started a petition against the plans. Proposer Dr John Cosgrove, a GP in Birmingham, said the DES was not evidence-based and risked distracting GPs from other work.
He said: ‘Asking all patients over 75 if they are having problems with their memory is a screening test, however GPs are asked to do it. It needs to be properly evaluated.
‘I’m concerned about how it will affect the spread of resources in terms of GP time, memory clinics, and competition between patients with dementia for resources. The problem is going to grow and snowball over subsequent years.’
‘We need a political solution on how to meet the needs of our elderly population and this is just a distraction. Instead of focusing on diagnosis, we should be offering on the basis of need.’
4) GPs take on commissioning
Four months’ time will mark the beginning of the great CCG experiment in the NHS. Led by GPs, these groups will be responsible for spending the NHS’s £65bn commissioning budget.
Balanced precariously on their heads are the whole NHS reorganisation project, and the success of the biggest efficiency drive in the history of the NHS. They have a lot to prove.
Before then, the vast majority of them will have to be authorised, providing they can get past the complex web of requirements from the NHS Commissioning Board. With three-quarters of the first-wave being hit with conditions on their authorisation, this will be no mean task.
They also have to implement, sometimes unpopular, reorganisations of services and in the midst of private providers vying for a slice of the NHS cake. All this while negotiating a potential conflict of interest minefield - with one in five of their boards with financial interests in private healthcare providers.
Commissioning tsar Dr James Kingsland, a GP in Wallasey, warned CCGs have to tackle the ‘them and us’ feeling that is developing amongst grassroots GPs.
He said: ‘The priority has to be the engagement of the wider clinical community. CCGs must realise that the constituent practices are its members – not just the governing body.
‘I am still hearing too many practices saying “us and them” rather than the inclusive “we”. If CCGs get that right, everything else will follow; if they get that wrong, they’ll fall into the same trap as the PCTs.’
Dr Charles Alessi, NAPC chair, said CCGs should concentrate on addressing health inequalities.
He said: ‘We cannot have situations where parts of the CCG have significantly better outcomes than other parts of the CCG without action being taken.’
5) Continued squeeze on GP take-home pay
GPs have endured several years of pay freezes, and rising expenses, but 2013 will be the year where practice finances will be hit harder than ever.
GPs face additional expenses from revalidation and CQC, rising pension contributions, cuts to local enhanced services, increasing work imposed on them from secondary care and working harder than ever, just to stand still, under the contract for 2013/14.
Dr Ivan Camphor, medical secretary of Mid Mersey LMC, said: ‘It is just terrible and cannot be sustained in its present form.
‘The GPs I am speaking to are not prepared to engage in commissioning anymore. GPs certainly don’t want to engage with CQC registration.
‘Where are we going to pay for all this, how will we pay with a £30,000 pay cut, with £1,700 loss from MPIG, with CQC registration [fees]. The list goes on and on and on.’
‘How are we going to do this? With what resources? And people want us to be open on Saturdays and Sundays. We may as well give up. It is not the end of general practice, it is the end of the NHS.’
GPC deputy chair Dr Richard Vautrey agreed that further ‘efficiency savings’ were untenable in primary care.
He said: ‘The expectation from The Treasury is that general practice has to achieve 4% efficiency savings in the same way as hospitals are doing, without any real understanding of the impact that has on practices.
‘Practices have already delivered far greater efficiency savings than 4% by coping with the increasing shift of work from secondary care, by coping with the increase in consultation rates for our patients.’
6) Widening divide between UK nations
When Dr Alan McDevitt was named chair of the Scottish GPC in the summer of 2012, he spoke out in favour of protecting a UK-wide GP contract.
But just a few months later, after UK-wide talks broke down and the Department of Health in London threatened to impose a deal in England he found himself in a situation where he had to make a choice.
He chose Scottish GPs and is in the midst of negotiating a contract deal for GPs in Scotland that will safeguard practices from a number of the features of the deal that GPs are facing in England.
He said: ‘I would have liked to see a deal negotiated at UK level. That was the process I was involved with, with the UK negotiators. When that failed, an opportunity arose whereby in Scotland we could attempt to keep a level of stability within general practice.’
Notably, the Scottish Government has listened to the GPC argument that QOF is now core funding for GP practices and agreed to move the funding for the abolished organisational domain into core funding.
Dr McDevitt said: ‘That is one of the fundamental differences. The Scottish Government has listened to the argument that there needs to be some stability in order to retain the level of services to patients.’
In Wales and Northern Ireland, the situation on the GP contract remains somewhere in-between, with Welsh GPC leader Dr David Bailey and Northern Ireland’s Dr Tom Black still in talks with their respective governments, but with an imposition looming on the horizon.
Dr Bailey said: ‘Tom and I are still talking to our governments but it looks unlikely that we will reach negotiated deals.
‘Regardless of the outcome, regrettably from April we will have a wider difference between the four countries than we have had.
‘The drivers of this divide are mainly in England because of the Government’s wish to bring in marketisation of health services. General practice in the UK should be the same whether you are in John O’Groats or Land’s End and it is unfortunate that the UK Government is acting to split things up.’
7) More time spent on useless paperwork
But 2013 marks the year when GPs will be faced with preparing for both. Most GPs will receive the date of their revalidation appraisal next year, and registration with CQC will complete.
Dr Tim Morton, chairman of Norfolk and Waveney LMC, said that revalidation and CQC inspections may be a good idea in principle, but they are an unwelcome burden as GPs struggle to cope with all the other pressures on them.
He said ‘By themselves they are OK, the problem is we have them both coming at the same time.’
Dr Morton, who is getting revalidated in August, said it took him 50 hours over weekends and evenings to do the necessary work to prepare for revalidation.
Dr Barry Moyse, assistant secretary to Somerset LMC, hopes that GPs will just see the paperwork as simply as ‘just a next step’ and ‘just another thing they have to do’.
But Dr Moyse said he was worried about the lack of clarity over remediation: ‘If you are going to say to people they can’t work you need to have schemes in place that address the problem. I don’t think it’s very clear at the moment.’
8) Controversy over the payment of quality premium to GPs
It is not a Nostradamus prediction to say there will be controversy over the payment of the quality premium to GPs in 2013, considering the first shots have already been fired.
The premium will be given to CCGs who meet targets on mortality rates, reducing avoidable hospital admissions and passing the ‘friends and family test’, as well as some local indicators.
The NHS Commissioning Board is expected to confirm any day now that the premium will be worth around £5 per patient, which the CCG can spend how it likes, including passing it on to practices.
Not surprisingly, the Daily Mail has given its view of the issue already, suggesting that practices will receive £30,000 – the average payment based on the £5 figure – for ‘doing their job’. There is also the indication that this will lead to a conflict of interest for CCG leaders – who will be able to pass the premium onto their members, which includes their own practices.
Dr Richard Vautrey, a GPC negotiator, says: ‘The Daily Mail article is the start of it. The public are bemused about what the quality premium is. They can see a conflict of interest, which affects the doctor-patient relationship.
‘Our fear is that CCGs will put pressure on local practices to achieve targets and stay within budget in order to get the premium. This could lead to patients feeling they are not being referred or prescribed medication just so that the practice can receive payments.’
9) Increased rationing of services
The QIPP challenge is only half-way through, and more financial pain is set to be visited on the NHS in 2013.
A survey done by Pulse in the autumn found that GPs were already feeling the effects of rationed services. Two-thirds of the 237 respondents said that rationing had adversely affected primary care while three-quarters said it had damaged their relationship with some of their patients.
Dr Michael Ingram, a GP in Hertfordshire, predicted next year would be a ‘perfect storm’ for the NHS.
He said: ‘Next year will have the excitement of disinvestment in general practice, high workloads, and an unwanted and complex reorganisation. It’s all the elements of a perfect storm.’
Despite the challenges, Dr Ingram said he hoped GPs would become more united. He said: ‘I hope that there will be a unification of GPs to deal with the issues.’