Saturday 29 November 2014

Outcomes AND activity based commissioning

Outcomes based commissioning is the way your healthcare will be funded tomorrow. It makes a lot of sense. Get all the medical staff together and pay them only is what they do makes a difference. That way, they can work out between them whose input is most valuable and when.

In truth, most health outcomes depend very little on medical science. Whether you take amoxicillin for your cough or simvastatin for your raised cholesterol isn’t going to make much difference compared to your 20 a day smoking habit and your household income.

So if we’re going to integrate, let’s amalgamate all budgets with the potential to benefit health. You’ll have a hard time finding a budget that does not. Let’s get all that money together and find the best way to help people live healthily for longer.

However, within that system, let us pay people for the work that they do. In particular, pay GPs for each consultation they undertake,

That way, if I as a GP spend time advising someone on their housing needs, I will be paid for my time. However, it is likely that it would be more cost effective for them to speak to their housing officer, and so the integrated system should do all it can to ensure that people in need of housing advice reach their housing officer first.

Similarly, someone understandably distressed after the breakdown of their long term relationship, might be encouraged to contact the psychological treatment service, Relate or perhaps a faith leader.

Even those with an problem likely to resolve without medical intervention, such as a viral illness, might be encouraged to take advice from a trusted family member or friend - or even the internet - and accept the small risk that the first diagnosis they receive might not with hindsight be 100% accurate. Within the context of either honesty or finite resources, this is in any case the only possible conclusion.

GPs might be nervous that their role be usurped by others. They need not. There is no shortage of dire medical need.

GPs might respond by requiring more consultation time for each condition. With modern IT, the solution to this is simple: cap funding to that appropriate for the anticipated consultation time for each new diagnosis.

In summary, outcome-based commissioning has the potential to drive integration only if components within each system are paid for their activity. Why base a person's livelihood on outcomes beyond their control?

General Practice: Selfridges or Tescos?

Where do you do your shopping? If you want a designer suit, I’d wager you’re more likely to go to seek a personal fitting from a high end department store on Oxford Street than to get it from a supermarket. However, if it’s a pair of socks or even a shirt you’re after, I’m guessing you’d make a best guess or take advice from your partner on the fitting, maybe even get a recommendation from a friend or internet review and pick it off the shelf when you next visit the supermarket. Otherwise, you run the risk of paying far too much for something bespoke that your washing machine will destroy.

When it comes to your health, if you fear you have cancer, you’re going to want swift, personalised, confidential and professional service and medical expertise. If, however, you have a snotty nose and a rotten cough, you’d probably be better off taking advice from your partner or even a trusted friend or internet site.

Since its inception, the NHS has provided, free of charge (at least at the point of use), the equivalent of a Selfridges personal shopper: personalised, confidential and professional access to medical expertise in the person of your GP for whatever medical needs - or none - that you might have. Just the job (in theory) if you’re worried you might have cancer or some other condition that, without medical treatment, might hasten your death.

Initially, good GPs were able to discourage people from consulting them about snotty noses and other conditions for which there was no effective medical prescription, simply by issuing simple reassurance rather than a prescription. However, even this has discouraged patients or those around them from giving simple reassurance (“you can’t be too careful”, “you can’t put a price [especially if someone else is paying] on health”).

Faced with problems which, quite frankly, were scarcely mentioned in medical school, many GPs succumb to the temptation to reach for the prescription pad: antibiotics (effective only against bacteria) for the viral illness, addictive sleeping tablets for insomniacs, scans and the false promise of surgical cure for back pain and now even cholesterol-lowering drugs for a longer life for anyone! The more enlightened GPs recognised that their patients’ real problems had no medical solution and set about as their patients’ medical advocates arguing on an individual basis for better housing, transport and even employment.

What is not to like! For no cost to users and no additional cost to tax payers, GPs now promise to address all life’s ills. Sadly, this is deceitful at best and, in reality, positively harmful, as it absolves sections of society with the ability to really make a difference - wise friends and family members, landlords, councils, employers and, most of all, government - of their responsibilities.

All this while our patients are living longer and therefore more likely to develop cancer and other conditions which sorely need medical intervention.

General Practice has therefore now reached the point where, with the resources of a single store on Oxford Street it is expected to deliver all the services of a national supermarket.

While general practice has largely simply absorbed this extra work, it has now reached the point where other sections of the NHS, such as A&E departments, have started to pick up this extra work. (In reality, thanks to general practice, very many A&E departments have seen no increase in demand, but have chosen not to contradict national statistics suggesting the opposite.) Quite reasonably, they refuse to take on such an open-ended commitment without additional resources.

The solution

The solution is simple: pay GPs for the work they do.

If as a result a Selfridges’ price tag for a Tescos' service seems too expensive, perhaps tax payers, government, council and local community will strain every sinew to see that a more suitable alternative is provided.

Can GPs please get back to fitting suits and let others go back to supplying socks, shirts and bread?

Please see my next post for a consideration of how this proposal might be incorporated into the current vogue, outcomes based commissioning.

This post was published on Huffington Post on 10 December 2014.

Sunday 23 November 2014

Notes from RCGP Council meeting 22 November 2014

This was my first RCGP Council meeting. Readers will be relieved to hear that I have been placed next to +Margaret Mccartney, who will therefore keep me honest!

Patient-Centred Care

In response to this independent inquiry published just that morning, I expressed my concern that it seemed to address needs relating to patients with long term conditions but risked overlooking the demands placed upon the health service by those without such needs. I cited Paul Little's observation from the James Mackenzie lecture the previous day that whilst it is laudable that 90% of respiratory illnesses are self-managed, the risks of reducing that proportion are enormous.

Outcome-based commissioning

I responded thus:
This proposal may make a lot of sense in the context of the management of chronic diseases such as hypertension and encouraging an integrated system. Equity of funding models between primary and secondary care is indeed attractive.
However, I have three main concerns:
1) My first relates generally to integration and the risk that GPs might become gatekeepers for access to all social care interventions. Given that GPs are already operating above capacity, we cannot afford to agree to take on new work, especially such a potentially large commitment and for which our primary training has scarcely prepared us. I would also worry about GPs' ability to determine social needs equitably.
It is therefore important that the development of such integration is led by GPs but consists of the incorporation of social and other workers into the primary healthcare team, rather than GPs taking on this work personally.
2) The most important variables in determining health outcomes - and hypertension resulting in stroke is a good example - are social: wealth, employment, education, social and family networks, cost and availability of food, tobacco, alcohol and drugs, planning, transport policy and architecture, to name but a few. The health system has no responsibility over these other than advisory, nor should it. Therefore, its ability to influence outcomes is greatly limited.
As such, it seems grossly unfair to base the livelihood of GPs and other healthcare professionals on measures over which they have limited influence. *this point was addressed by a previous speaker
3) Free access to GP means that we are consulted routinely about matters which are neither particularly medical, nor is addressing them likely to influence health outcomes in a tangible way. My ideal system would incentivise the healthcare system and society to share more of this work. An example of a service which has developed in spite of the current system is a chaplaincy service provided to patients of a practice in Birmingham.
I cannot see anything in outcomes-based commissioning which would achieve this. I wonder if actually activity-based fees to GPs for such work would be most appropriate. This will incentivise the development of other services which will be more cost-effective, less medicalising and will free up GP time.

RCGP draft position statement on obesity and malnutrition

Other speakers spoke powerfully against the medicalisation of the management of obesity.
Regarding the management of malnutrition, I made the point that whilst I was happy to offer dietary advice to my patients, I did not see why I as a GP should be involved in the prescription of food and other nutritional products, a task that dietician colleagues are well placed to fulfil.


I was pleased to learn that Council members are expected to adhere to the seven Nolan Principles of public life: selflessness, integrity, objectivity, accountability, openness, honesty and leadership. I will explore ways of supporting the observance of these principles, especially accountability and openness. Watch this space!

In the meantime, I have updated my declaration of interests on and would encourage all doctors to do likewise.

The Impact Report 2014 was presented at the AGM. More detail is available in the Annual Report and Accounts 2014. As RCGP is a charity, these will be published on the website of the Charity Commision. I would welcome any comments on these accounts.