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February 17, 2011

Welsh Institue of Health and Social Care Blog
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» Why GPs Should not Commission Specialist Health Services

Contrary to manifesto promises and most informed opinion, the UK government is imposing a radical, expensive and ideologically driven restructuring on the NHS in England.  The central feature is the proposed delegation of the £80 billion annual budget for hospital and specialist services to consortia of GPs.  Although these changes do not apply in Wales and the other devolved administrations, they will have serious repercussions across the UK. 

This policy is misguided for many reasons.  First, it reinforces the misconception that hospital and specialist services are the core of the NHS.  However, only ten per cent of GP consultations trigger referral to a Consultant. 

Primary care is internationally recognised as the essential foundation of any effective national health-care system.  UK primary care, in which GPs play a leading part,  is amongst the best.  However, it is still not good enough. 

Choosing a GP is the most important decision a patient has to make.  Unfortunately, there is no credible public information on which the quality of a GP practice can be judged.  Many GPs are excellent.  Others are unacceptably poor.   

GPs are independent contractors to the NHS, not employees.  They determine how they spend their time, including private interests.  This pragmatic arrangement has generally worked well since 1948.  A clinically independent and trusted GP is important for patients.  The drawbacks include professional isolation, variable quality and a tendency for some GPs to confuse their personal interests with those of their patients.

 Advancing technology has progressively enhanced the diagnostic and treatment capacity of primary care.  However,  many GPs have abdicated from services traditionally associated with the holistic ‘family doctor’.   These include maternity, some disabilities and chronic conditions, home visits, preventative services and mental health. 

Despite the introduction of ‘NHS Direct’, many patients, particularly in deprived areas, still find it difficult to access acceptable GP services.  This has not been helped by GP withdrawal from  ‘Out of Hours’ services.  This has led to clinical discontinuity and, in some cases, negligent incompetence by substitute doctors. 

Many such changes have occurred during successive renegotiation of the national GP contract.  GP remuneration is fundamentally based on ‘capitation’ (the number and types of patient on a GP’s list).  However, this principle has been gradually eroded by supplementary ‘ fee-for service’ payments.  It is difficult to avoid the impression that GPs continue to be paid more for doing less. 

GPs are trained in the convergent skills of diagnosis and treatment of individual patients.  They do not necessarily have the skills required for leadership, long-term planning and development of comprehensive services.  GP involvement with commissioning is not new.  ‘GP Fund-holding’ was introduced with the NHS ‘internal market’ by the Thatcher government in the 1990s.  Most GPs were not interested in the scheme which was expensive to run and brought marginal improvements.  GPs have continued to be intimately involved with commissioning in the English Primary Care Trusts which the government now intends to abolish. 

The fundamental problems lie in the perverse, financially orientated and divisive  incentives of the ‘internal market’.  English PCTs have consistently found it difficult to balance the interests of patients against the self interest of service providers, particularly GPs whose (frequently undeclared) business interests are not always congruent with the needs of patients. 

Conflicts of interest are likely to become even more significant in future.  Probity requires public money to be entrusted to a properly constituted and transparent statutory body which is elected, or otherwise selected to be broadly representative of local interests.  A consortium of independent contractors to the NHS cannot possibly constitute a valid authority, either for distributing public money or monitoring their own performance.  Such bodies must also harness the experience of all health professions, and valid representatives of patients and public. They must not be hostage to any particular professional group.

The government’s (under)estimate of the costs of this upheaval is £1.4 billion, during a time when public services are being decimated.  After experienced NHS managers have been sacked, GP Consortia will be obliged to employ commercial consultants to fill skill gaps.  This will further inflate management costs and diminish public accountability.

In future, in England, it will be possible for NHS services to be delivered by ‘any willing provider’.  GPs are the government’s stalking horse for further fragmentation and privatisation.  On past performance, GPs may not choose the best quality or most cost effective options. Longer term considerations (such as training) and less powerful interests (such as mental health) are likely to take a back seat. 

The budgets available to Consortia will be cash limited.  Demand will continue to rise.  Consortia will overspend.  Ministers will blame GPs for the inevitable unmet demands.  GPs will be obliged to ration services but the basis for their decisions may not be  transparent.  The relationship of trust between patients and GPs (which is currently untainted by financial considerations) is likely to be damaged. It is also likely that GP practices will progressively merge.  

International evidence unequivocally demonstrates that markets in health care increase costs, reduce quality, distort access, increase inequalities and diminish choice.  They corrupt professional practice with financial considerations and increase the incidence of inappropriate, dangerous and ineffective treatment.  A former member of the Thatcher cabinet aptly described the introduction of the NHS internal market as “a triumph of ideology over experience”. 

The NHS is one of the most equitable and cost cost-effective systems in the world.  If the government wants to improve it, it should commission a comprehensive assessment of health challenges and consider NHS achievements in comparison with other systems.  The UK faces dramatically increased prevalence of many complex, chronic and debilitating conditions.  Many are closely associated with longevity but several, such as stress, obesity, substance misuse, diabetes, heart disease, cancer, mental illness and accidents have links with the environment and personal behaviour.  None will be resolved by simplistic market ideology which damages professional cooperation and patient interests.  

Effective medical interventions require the sound foundation of competent, multidisciplinary primary care, underpinned by locally integrated, but nationally coordinated, secondary and tertiary specialist services.  An independent review of the adequacy and funding of the totality of primary care services would be a good place to begin evidence-based consideration of the future direction of the NHS. 

The blinkered commitment of UK politicians to market solutions for social problems threatens the very existence of the NHS.  There is a better way.  In Wales, the internal market has now been abolished.  Local Health Boards (the Welsh equivalent of PCTs) and NHS Trusts have been combined into single authorities which are now accountable for the integrated development of all local NHS services.  Community Health Councils have been strengthened.  Scotland is further down a similar path.  Both countries should be confident that their chosen route will prove more cost effective, equitable and true to the founding values of the NHS.

Written by David Hands, Visiting Professor in Health Policy and Management

February 22, 2010

Welsh Institue of Health and Social Care Blog
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» NHS Wales' Waiting Times: The Sustainability Challenge

In commenting on the latest figures, Edwina Hart, the Assembly’s Health and Social Services said: “this is a significant achievement, and one of which staff should be proud” and that “the priority now for the NHS must be to sustain these targets”.

While many will share these sentiments, we need to be cautious not to underestimate the challenge of maintaining our progress. A lot of money has been thrown at waiting times to fund a sterling effort to get where we are. From a political and public point of view, it was right to bring waiting times under control – the reputation of health policy and the effectiveness of the NHS was at stake.

But many working in the NHS have had concerns about this initiative distorting clinical priorities, applying short-term fixes, and paying over the odds. This is not to deny that innovation, improved efficiency, and best practice have also played a big part in the success. But there is a danger that the waiting time programme could be seen as one off event rather than a coherent strategy with underlying policies, systems and processes aimed at maintaining, acceptable and sustainable waiting times.

As with all publically funded services, the NHS is facing a decade of intense pressure on its funding. One way or another the health pound will be increasingly stretched. This not only challenges the maintenance of existing waiting times, but it underlines the fact that the range and infrastructure of today’s health services is unsustainable.

The local plans emanating from the Welsh Assembly Government’s 2006 strategy, Designed for Life, were not well received by the public, the authors would likely present them differently today. But their direction and themes remain essential if we are to provide sustainable health and social care services through the 21st century. To be fair, all this is writ large in the documents that led to the restructuring of the NHS in Wales, and the new Local Health Boards are clear about what they have to do. They must deliver a patient centred care approach, with patients able to exercise as much or as little influence over their care as they choose, except where strong evidence advises against it. They must also provide services that are efficient, effective, timely and safe in a health service that changes the balance of care into people’s homes and communities, and away from traditional hospital care. The implementation of Dr Chris Jones’ primary and community services strategic delivery programme will be the precursor of a major review of what hospitals do and where they are strategically placed. What is clear is, things cannot go on as they are.

Fortuitously, a byproduct of all this talk about the cutbacks in public money, citizens may be softened up for change, but with health and social care, we can’t take that for granted.

To put the service changes now envisaged in context, if you keep people out of hospital, then they won’t have to wait to go in!

Written by Mike Ponton, Senior Fellow, WIHSC