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Dr David Geddes: ‘QOF counts for around 17% of practice income, which is a large amount’

Please can you describe some of the objectives that NHS England will be working towards with regards to primary care?

‘The important element there is to recognise that we commission the primary care providers and services, but we will work very closely with CCGs and the local authorities to ensure we have primary care which steps into the remit of working to deliver an enhanced patient experience, challenged particularly by things like the inequality agendas and the outcomes issues there in terms of there being huge disparities between patient outcomes in certain areas or certain patient groups in particular.

‘That is a key priority for the NHS, and in order to create a primary care and community service to meet the demands of the big issues in terms of the demographic changes, which impacts significantly on the number of patients with long-term conditions and the types of long-term conditions, dementia being a particularly important one there, in terms of managing the impact that has on how we provide care and how we provide care particularly more in people’s homes or people’s communities and become less reliant on hospital services and secondary care services, so we get a better use of the NHS resources in total and we can provide more support for people in the community. That is one of the key themes in driving a lot of this forward.’

‘And in order to be able to do so there is a significant agenda in terms of reshaping primary care, so to your readers, and I am a GP myself, it feels as if we are busting at the seams at the moment in terms of being able to deliver a services to patients at the moment, to meet patients’ demand. We are meeting the demands of those needing acute care as well as the rising need for long-term condition care. A lot of this is challenging primary care in particular so that it feels as though we have got to the point where there has to be a significant shift in how we go about doing things. In order to provide the support we need to shift considerably the way that things are being done in primary care to make it more fit for the future.’

‘A lot of the kind of issues that we are exploring in NHS England, and we have partners such as for example Health Education England and the local LETBs, in terms of how we are going to start describing what we want primary care to offer going forward in the new world, and how we are going to make sure that primary care is sustainable and supports the desire to be able to provide care for people which is timely, appropriate and near to people’s homes. Those are the key themes that have been picked up in some of the discussions around NHS England and our partners.’


Professor Malcolm Grant announced at Pulse Live that there will be a consultation on primary care this year. Do you know when that is going to start?

‘The consultation has started in terms of how we are looking at doing things differently. CCGs alongside the area teams are already exploring what the challenges are for them in meeting the demands. So CCGs now are noticing significant challenges in terms of long-term conditions, the ageing population, and wanting now to be able to start looking at how primary care can do things differently to be able to provide that support going forward.’

‘We are talking very much about a strategy for NHS England and primary care strategy is a key element of that and we need to be able to articulate what NHS offers patients in primary care, and also recognising that it is really important that we have the local flavour, to give the CCGs and the area teams the opportunity to work together to make sure that the particular challenges that they are facing in their communities are being addressed. It is about getting those elements, it is a national offer, it is the national perspective alongside the localism which is important in order to make sure that CCGs in particular have an opportunity to be able to shape and create an environment for health services going forward.’


Will that be a public consultation?

‘Yes, so that is part of the national work from the national perspective and that is something which over the summer and autumn will be starting to take place and take shape. There is going to be local consultation and that will be happening at each Health and Wellbeing Boards in terms of informing CCGs and local area teams what to prioritise. So there will be opportunities for the public to be involved in describing how they want primary and community services to be shaped. They will be there from the outset via the Health and Wellbeing Boards in the way that has been built in through the health and care reforms, really.’


So GPs would also be asked to take part in that process?

‘Yes, GPs are in a perfect place to be able to, as a provider as a well as a commissioner, start to see what it is that will make a difference in terms of providing better care for their patients. So that is not just as a commissioner of secondary care, it is also recognising their key role in primary care, being able to make sure that primary care is seen to be able to work to overcoming barriers in terms of current levels of care and thinking more about opportunities that suit GPs in particular to be able to influence how that will go forward. The CCG Assembly in particular will be informing the primary care strategy going forward.’


Professor Malcolm Grant also said it could lead to changes to the GP contract.


What do you think might be some key things that could change?

‘I think we need to understand what is needed in terms of the barriers to creating that chance and I think we need some concerns amongst a wide range of stakeholders in fact that some of the current contract is not really aligned to what the outcomes need to be for the NHS. Some concerns are about QOF for example, whether there is a tick-box mentality to QOF that needs to be revised and looked at in terms of what we are wanting it to deliver in terms of some strategic outcomes. It is a refocus to move away from process and being able to commission on the basis of outcomes. That is aligned with how we look at commissioning for secondary care and primary care. So there is a shift away from some of the process measures into some of the outcomes measures. So the discussions that we will be developing and have already started will be with the CCGs, with area teams to identify what are the barriers to how we can be creative in primary care and how we can do things differently, and what from the GP contract perspective can we change in order to be able to bring about those benefits for patients. It will be about shifting away from process and to outcomes and we will be looking at trying to create opportunities for access, patient acceptance really, patient feedback regarding primary care experiences.’

Some of the feedback that we have, from academics and stakeholders, is that QOF has too much money attached to it. Is that something that you might look at changing?

Yes. I think we have to recognise that QOF has played a part in achieving quite a lot over the years but it may not necessarily be the vehicle by which we continue to invest or to change clinical priorities. It is really an opportunity for us to work with NICE to be able to decide which of the QOF indicators are most useful and most evidence based and most likely to be able to produce that change. But I don’t think we are feeling that QOF is the sole mechanism by which we will commission or contract for these changes. So therefore there is recognition that maybe we need to be slightly more creative around how that can be commissioned in the future, and that may well be that we are less reliant on QOF, and feel that there are other ways in which we want to deliver some of that. So yes I think that, in many ways, QOF counts for around 17% of practice income which is of course a large amount and it may well be that we wish to look at having a different mechanism for commission for some of those enhanced areas of care without it having to be through the QOF process.’


So it would still be some kind of incentive system then but not necessarily within the QOF?

‘Yes. QOF is one mechanism but it is not the only mechanism so we want to explore those, and be quite creative in that.’


It comes as the Department of Health has announced a move towards health and care integration. From NHS England’s point of view, what are you doing about this and how do you think that might affect GPs?

‘The Health and Social Care Act now allows us to work much more closely with local authorities so that is already in part developing so that there will be some areas of primary care, general practice, which can be commissioned by local authorities and then there are other areas which can be developed between CCGs, area teams and local authority collaboration. So all of this is going to be picked up by Health and Wellbeing Boards in terms of how they will be leading priorities for the local areas and ensure they are delivering good outcomes. So that is where there is going to be a shift from necessarily thinking this has to be a primary care medical model into looking at more creative ways on some of the services in which primary medical care is in a position to be able to pick up some of the areas to be more integrated with local authorities. That is particularly important when looking at some of the challenges regarding the most vulnerable patients, the elderly and frail but also with mental health or learning difficulties. It is about how we as a community, not just a health community, tackle the inequality agenda and how we can better commission to lessen inequalities in outcomes which are still quite stark in the country.’


Will that also then impact GP contract changes, to remove barriers to integration?



There is also an ongoing review into MPIG and PMS and before when it has been looked at it has been looked at within the context of the GMS contract. Do you think that has changed now?

‘The view, the intention, is still to have the GMS contract.’


Will NHS England be honouring the discussions then that were held between the BMA and the Government before on how MPIG and PMS will change or is that passed to history now?

‘Well, NHS England is a different organisation. We are mindful of the discussions that have been held but we need to create the right environment for primary care commissioning and so the priorities for NHS England have to be patient outcomes and benefits. So it is not that we are constrained by earlier discussions but we do need to be having opportunity to discuss with the GPC in particular how we are going to take that forward. So it is not something on which at this stage we would be able to give great detail at all. But we are certainly mindful of those previous discussions that have existed.’


Have you started talking to the GPC on this already? There is the discussion on Carr-Hill as well.

‘In terms of where we have got to with the funding formula is not something that would be sitting within my directorate within NHS England so I wouldn’t want to say for definite one way or another.’


But it is the intention to have discussions with the GPC? Because Professor Grant also said he doesn’t want the contract to be negotiated every year with the GPC.

‘Yeah, yeah.’


Would it then be more of a long-term contract plan?

‘I think we would like to have some clear sort of space where you can recognise the, rather than having necessarily annual contract… there are areas of the contract that will no doubt have to be discussed, but we want to be able to agree a plan I suppose, going forward, and then see how that will evolve over a period of time. And there will be flexibilities that will be created so that the right solutions can be found for the area teams to work differently maybe. But actually we need to be able to find a flexible kind of contract which gives us that approach forwards, so we have that agreement really where we are headed. It will be part of a broad dialogue for the vision of what primary care will deliver in the future.’


So area teams and CCGs will be able to do more on a local level to address needs in their area?

‘There will still be a national contract but the area teams and CCGs will be able to commission on a local level in response to local demand. It is particularly important for CCGs to be able to have flexibility so they can understand how to commission primary care and community-based services in a way which will be responsive to inequality issues which are often quite confined to small groups. So there are some of the outcomes, if you like, that NHS England needs to articulate what the outcomes should be, a give a narrative for how we wish to bring things forward. There will be solutions and then local ways for how these can be delivered. Localism will mean CCGs will work collaboratively with the area teams on how the national contract will be applied.’


How will the Health and Wellbeing Boards fit into that?

‘The approach that your CCG and local area team takes will be based on what the Health and Wellbeing Boards sets out as being their priorities. It will be the Health and Wellbeing Boards’ responsibility to identify priorities. Let’s say for example it is concerned about care for the elderly and how local authorities manage to coordinate their care and support with health services. That could be CCG-commissioned services, i.e. secondary care, area team-commissioned services, i.e. primary care and local authority-commissioned services, i.e. community services which could be commissioned through a standard NHS contract as a wrap-around service which will be able to apply to providers of services.’


Obviously now GPs are working to the 2013/14 GP contract. Do you think there will be any changes already to the 2014/15 contract or are these things for later on?

‘I think it will be later than that. There is this question about what is most helpful, and starting to devise an approach to primary care looking at the outcomes rather than process side of things. So there will be discussions about to what extent we want to be adding flexibility to the 2014/15 contract but in essence it is the kind of thing that we want to be discussed now in order to be able to understand what the demand is and what is the scope for that.’


So there might be a few changes to this effect in the 2014/15 contract but all of it will take a lot longer to implement?

‘Yes, there will be short term things that may be quite easy to incorporate or there may be other things having a longer lead-in time. We will need the contract to be informed by the strategy, the primary care strategy, so it would be the wrong way around to have the primary care strategy being informed by what is available in the contract. So we are looking at being able to define a primary care strategy for NHS England by October/November time as part of the overall NHS strategy and we will want to be able to have that informing contractual changes going forward. So it should be that way around rather than making contract changes and then let’s see how the strategy fits around that.’


So there will still be contract negotiations with the GPC over the summer as per usual?

‘Yeah. Yeah.’


So there will be a strategy coming out in October/November. One for primary care… will it be other areas as well…

‘There will be an NHS strategy, which will cover quite a large area, which will evolve in the course of 2014/15. The primary care strategy we are in discussions over at the moment, because it may well be more the framework actually, but it is important to be able to create a framework for the local development for what needs to happen in local area teams and CCGs so it is about being able to describe where some of the strategic issues will lie and how we work towards trying to align them. So some of these things have a much longer time frame but it is about being able to start that conversation now to get as many people as possible to have input into the ways that this will be described towards the end of the year. The message is really that there is no pre-determined strategy by NHS England but that primary care offers the answer to so much of what the NHS struggles with at the moment and we need to have a broad conversation with a wide range of stakeholders, including the profession, including patients, including the providers, in order to make sure that where we are heading is right not just for the short and medium term but also for the long term.’


So this consultation will run over the summer? Will there be a document published?

‘I am not sure there will be a document at this state. It is much more of an open discussion.’

‘The discussion has started, begins now. It is about having a conversation with for example the CCGs through the CCG Assembly, having conversations with the public, having conversations with the profession, GPC, RCGP… I don’t think there is a plan to have some trumpeted fanfare launch of the beginning of the consultation.’


So far some of the feedback you have had from CCGs about solutions, what have you heard?

‘I think there is a willingness from CCGs to be able to align the workforce to help manage people with long term conditions more effectively, being able to recognise that some of the barriers to primary care innovation has often been about how we share information between practices. We want to see if we can create more of a responsive approach to testing out new ideas in primary care. Manchester is a good example of where they have brought together a lot of the profession with the area teams and the CCGs to start to describe what their vision for Greater Manchester is and how they want to be able to provide a service which is more future-proofed, in particular in terms of particularly long-term conditions and the elderly and the frail.’

‘The other things are recognising the issues of the workforce and their development, and the LETBs, feature quite a lot in these CCG and area team discussions.’


Will you also look at the GP workforce?

‘All workforce. In terms of primary care we are not just talking about GPs, nursing is a big issues, pharmacists, dentists. Is the current workforce being trained? Are we recruiting the right individuals for going into medicine? Are we training them in the right way to be able to be doctors of the future, working in the community? Or do we want to change that training culture in order to make sure that there is sufficient resource in primary care, so that we don’t articulate a strategy which we are then unable to deliver because we have the wrong workforce that are being trained in the wrong way.’

‘I think that is essential to make sure that we are aware of the changing workforce and the change in demographic in the workforce and how that impacts on capacity to be able to look at care where we need it. So we definitely need to be working with Health Education England in terms of anticipating and having a workforce strategy that is aligned with the NHS strategy, and indeed the primary care strategy going forward.’


What else would you add on this topic?

‘There is a lot of work to do. It is not like we are starting from a blank bit of paper. Clearly there is a huge amount of work that has been done over many years. It is important that we in NHS England learn from examples of good practice to see where things have gone well in order to inform us going forward. So although the changes brought about with the Health and Social Care Act have been fundamental, what we aren’t trying to do is start from scratch and throw out all the information and the knowledge that has been built up over the years. It is about being able to develop from good practice and working with the colleges for example, the RCGP, on how we want to deliver that and spread some of that information. In every area team these is some really good information about good practice but it is in pockets and we still are worried about the rather variable quality of primary care in different areas so what we need to do is to be far better at being able to create ways of sharing that practice, that innovation, and make sure that there is a rapid adoption of good practice in primary care. So those are some of the challenges that area teams, and indeed CCGs, have to work with.’


In terms of getting GPs on board with this, some GPs are under a lot of pressure, how do you get those GPs on board?

‘It is a critical issue, isn’t it? How do we make sure that… You’ve got to be realistic and understand the pressures in general practice that are there. They are real, they are really challenging jobs, and we have to make sure we are engaging with the clinical leaders how we can take things forward, but we need to be creating some head room and space for other doctors who are busy and who need to be supported in being able to provide a different sort of service. A service which is focus on preventative care, the outcomes not just for the individual patients but for the community which their practice is a part of, and that can be more of a fundamental shift for some practices compared to others. It is about how we align the support for those practices, how we get people to have the opportunity. It is far more rewarding to be able to work proactively and not just feel that you are being reactive, and patch people up when it is too late. This is proper medicine which people want to get engaged with so we need to create an environment so that people can engage in it and feel we aren’t overwhelmed by that sense of having to fire fight all the time.’