Simon Stevens’ Five Year Forward View and the later GP Forward View were remarkable and insightful documents which set the tone for how the NHS could change and run well into the future. There was, however, an extremely large elephant in the room. Money. Cold, hard cash.
The Five Year Forward View demanded not only increased funding from central government, which has by and large been forthcoming, if slowly – but also some £23bn of ‘efficiency savings’. It is at the edge of credibility to think that this level of savings can ever be achieved in a service which has been looking at cost efficiencies for nearly two decades. There are no further operating efficiencies possible in general practice. Whatever system we use to replace the 2004 contract has to break the traditional ‘free at the point of use’ system. This will bring hate mail and Facebook vitriol down upon me but I can think of no other way of controlling demand. The idea of paying to see the doctor/nurse at the practice has been voted down at successive LMC Conferences but by decreasing margins.
But I suggest we think about plastic bags. Since a charge of 5p per bag was introduced, the use of plastic bags at supermarkets has reduced by 85%. I advocate a £5 charge to see any healthcare practitioner in the surgery and for electronic and phone consultations to remain free. The charge should be refundable for those on low incomes – France manages it, we can manage it. This measure alone will reduce front end demand.
There are no further operating efficiencies possible in general practice
Then we need to think about how we are paid. I have had a salutary year acting as practice manager as well as a clinician and I am astonished at the appalling and arcane claim systems, designed by no-one in particular and almost unusable. CQRS, the claims system for enhanced and other services and the reporting system for some activity, has had no single person in charge. Ever. And it shows. We need more of a block contract than an item of service. Admittedly the latter incentivises us to chase immunisations and so on but the time spent doing so may be better used with patients.
We all need to have the phones manned 8am to 6.30pm and the doors open most of that time. The cost of doing so is not much different if you are a rural practice of 1,500 patients and one GP or an urban practice with 15,000 patients and 10 GPs. So there needs to be a Basic Practice Allowance again (like the Red Book) to take this into account. Then we need a properly funded block contract (don’t say global sum!) to cover all the other things we do including many of the enhanced services – there should be opt outs with abatement of pay rather than item by item opt ins. We are not going to get rich on £25 an hour from patient fees (my solicitor charges £350). There will be accusations of gaming and calling back for unnecessary reviews, but this will tip the balance to more efficient phone and Skype and other electronic models.
The nature of our practices is perforce changing with the shortage of GPs and the remaining GPs are becoming more consultant in nature, with patients being seen initially by people of lesser training and the more complex coming to the GP for management. New payment models must recognise this and reward good practice – Excellence Awards, anyone?
We need to keep general practice at a human scale. I do not think that the path down which we are being forced of having ever larger practices is in the interest of patients or their medical attendants. Economic necessity does not always make for good patient care. The innovative and resourceful driving force that is general practice needs the nurturing and funding to allow it to blossom again before we all give up and allow ourselves to be taken over by conglomerates. Or is it too late already?
Dr Peter Swinyard is a GP in Swindon and is chair of the Family Doctor Association