Sunday 28 June 2015

A further blueprint for primary care

I was interested to hear Jeremy Hunt announce on Radio 4 his intention to review the terms and conditions of GPs. I feel this is overdue. Much has been written about the crisis of recruitment and expectation faced by GPs, who, being the most efficient part of the NHS (90% of NHS work done by primary care for less than 8% of the total funding), are most able to drive some of the £22bn efficiency savings demanded by 2020.
Being a GP in the UK is a uniquely fulfilling occupation. However, the frustrations and challenges are beginning to threaten a truly rewarding career. So what might bring general practice back to being an awesome career choice?
In mulling it over, I considered if I were to be in charge of the nation’s health policy and legislation, what would reduce the frustrations and safeguard the viability of general practice? From a conversations with colleagues emerged the following ideas.
Idea 1. Produce and continuously monitor the activity levels of GPs –  both demand and access.
This would allow for effective planning rather than rhetoric. RCGP has called for this in its blueprint for the new deal for GP in England.
Idea 2. Increase remuneration and supply of GPs to enable them to have smaller patient lists to be able to maintain that activity level.
In the past 5 years activity has increased by over 40 million consultations per year over the past 4 years. However primary care has seen a similar period reduction in funding from 11% to about 8% of the NHS annual budget. In short a ~13% increase in work for a ~28% reduction in funding.
Idea 3. Make changes to control activity:
3.1. Allow only the prescription of prescription-only (POM) item on NHS prescriptions
3.1.1 Prohibit pharmacists from selling treatments without a prescription (“over the counter”) at a higher price than with a private prescription
3.1.2 Re-evaluate the current criteria for ‘free’ prescription entitlement especially with regards to chronic health conditions.
3.1.3 Create a national formulary for use by the NHS.
A significant portion of resources both in terms of finance and time can be spent on prescribing issues with significant variation in geography, practice and ethos. Standardising and making these efforts more equitable would solidify the aims of treatment in line with the ethos of fair treatment for all. Additionally a national formulary may help to prevent stock sourcing issues currently facing many GPs, pharmacist and subsequently patients.
3.2. Forbid priority to be given on the basis of a referral from NHS staff for any service or treatment not agreed with GPC
3.3. Forbid advising people to consult their GP except if they are ill, believe themselves to be unwell, or for any reason agreed by GPC
3.4. Contract separately medical treatment of those with no illness
GPs are primarily contracted to treat the ill and those who believe themselves to be unwell. However, there is currently nothing to stop anyone publicly advising people to attend their GP for any one of a variety of reasons, whether that be the treatment of self-limiting conditions, cosmetic concerns, the prescription of drugs to the well, marginally to extend life expectancy (statins) or even the prescription of boilers. These may or may not be worthwhile, but undertaking this work without adequate resources distracts GPs from those who need them most – the ill.
3.5. Allow GPs only to consult in approved premises except when treating those who are housebound and in the terminal phase of an illness.
Home visits and community based resources are both a privilege and a finite resource. They are not a right for convenience particularly with increasing workload pressures and reducing resources. Contractual changes as above would support clinicians offering equitable and appropriate care as already functioning in some areas such as South Staffordshire LMC visiting guidelines.
3.6 Remove fitness certification from the GP role.
It is important to provide equitable treatment of patients by appropriately trained clinicians. GPs have a fundamental conflict of interest when it comes to fitness certification. Their duty is to act in the best interests of their patients. This makes it both difficult and uncommon for a GP to challenge a patient’s belief that they are medically not fit for work. Pilots for this are already underway. Remove this duty and free up GP time whilst opening up the possibility of a fairer assessment process.
Idea 4. Instead of capitation-based funding, offer activity-based funding to those GPs with a minimum list size determined on the basis of predicted need.
Currently general medical services (contract on how primary care is offered) is enumerated at an average of £136 per patient per year- less than a standard Sky TV package. This funding model needs an evaluation given the significant increase in health needs by an ageing population with more chronic disease issues. Many acknowledge the historical advantage of capitation funding in giving GPs an incentive to provide only necessary treatment. However, GPs have now completely lost control of demand. Activity-based funding would give an incentive to every taxpayer to encourage fair use of GP services. Indeed LMC Conference on 22 May 2015 passed a motion supporting exactly this change.
Idea 5. Allow GPs to be covered by Crown Indemnity/ reimbursement of indemnity.
A growing issue pushing many GPs away from working particularly in out of hours services and deprived areas is the rapidly increasing costs of indemnity cover. Incorporating crown Indemnity or establishing a way to reduce costs (something even outstanding CQC banding can not help with) would facilitate more GPs not being priced out of working in such valuable areas. Precedent may be set with the incoming primary and acute care systems (PACS) as suggested by the Five Year Forward View. The LMC Conference voted for this proposal on 22 May 2015.
Idea 6. Amalgamate the GMC speciality and GP registers.
This would allow GPs to be recognised for sub-specialising and aid GPs to be viewed as equitable in status as specialist consultants as their training currently allows. This may help to address some of the issues noted in the recent BMA survey (see below) which Government policy changes will not.
Fig.1. GP trainees’ responses when asked why they didn’t choose general practice as their specialty. (BMJ Careers 2015)
Idea 7. Exclude General Practice from the NHS.
A severe idea with growing support. General Practice as a gatekeeper is central to the NHS. However, unless the GP contract is adjusted to include the ideas suggested above, General Practice and possibly also the NHS will fail. British GPs have unique skills in managing risk pragmatically across an extraordinarily broad range of medical conditions and may have no choice but to reserve these skills for fee-paying patients and health insurers.
These are ideas which may or may not resonate with your own thoughts and obviously vary with severity as well as risks and benefits. I am not saying these all have to happen or that they are all miracles that will save both healthcare or the speciality that is general practice. However we are always asked to bring ideas to light and many of these have the possibility of significant impact at a time where the NHS and general practice are in crisis.

First published with Dr H Gandhi (+Dr Gandalf) on 23 May 2015 at eGPlearning. I note that the +Conservatives government has paid scant attention to any advice offered by GPs in their New Deal for General Practice.

Mental illness, General Practice and the GMC

+Clare Gerada tells +BBC News that levels of mental illness in GPs has become disproportionately high in recent years as a result of the unprecedented pressure they have been put under.

It is tragic that so many GPs are so unwell. This must change.

However, this also highlights the problem of stigma of mental illness among doctors. While doctors have a duty to shop to the GMC their doctor patients and unwell colleagues, stigma will persist.

I would suggest that duty should be confined only to those whom one is a current clinical colleague of.

CQC response to call for emergency measures

At least the quango that is the +Care Quality Commission has sufficient insight to be "disappointed" after the democratically accountable +Royal College of General Practitioners and +The BMA call for emergency measures (RCGP, BMA).

That insight seems so far to be rather limited. After visiting 1,100 practices, it is quite extra-ordinary that CQC thinks its approach would not be burdensome for a "well-managed" practice.

I trust Steve Field will now lead them through serious and soul-searching reflection.

It is time for our regulators to question the effectivenes of their apparently hostile stance and encouragement of burdensome bureaucracy and to ask themselves how they were allowed to get so carried away.

Colluding to collapse General Practice just might not be the best way to reduce variation in quality!

Saturday 20 June 2015

Notes from RCGP Council meeting 20 June 2015

The agenda for today's meeting was packed, including, I am pleased to say, a paper on transparency which I wrote with +Jonathan Leach and +Kirsty Baldwin.

#OpenRCGP discussion paper:
Balancing transparency with information security

"First of all, I would like to thank my co-authors Jonathan Leach and Kirsty Baldwin for their invaluable input, and also Officers and staff, including Paul Rees, for their enthusiastic encouragement.

"I have been receiving Council papers for over 10 years. Throughout that time, I and colleagues have had some uncertainty about how confidential individual College documents are, and therefore a frustration that we did not feel free to share them with other members.

"There are some practical details to be worked out. We are looking for feedback from Council on our proposals to allow us to continue developing these proposals

"Our proposals therefore form two main strands:
  • clarity as to exactly how confidential individual documents should be
    • reduce the risk of unwitting leaks
    • and minimise unnecessary restriction
    • this builds on good practice by groups such as the Trustee Board and the Planning and Resources Committee
  • publication of Council documents
    • moving from a position of sharing with members only what we are obliged to share, to sharing with members as much as possible so as to improve engagement and foster a sense of ownership commensurate with their membership fees
    • builds on the decision at the Council meeting in February 2015 to publish minutes
    • as part of this, our 3rd proposal is for a staff observer to Tweet from Council
      • builds on Council’s views on Social Media use during Council meetings aired in September
"We would be grateful for Council’s thoughts on these proposals.

My understanding of Council rules as they stand is that I am free only to disclose my comments, hence the one-sided nature of my notes here.

"New deal for General Practice"

Jeremy Hunt had set out what he described as a new deal for General Practice the day before. I have already analysed this announcement on these pages and found it wanting. I told Council that it contained neither anything new nor a deal and that I continued to be dismayed at his apparently fixed idea that healthcare is a commodity. Indeed, his assertion that he could not change consumer expectations was particularly disappointing and he is probably referring more to an unwillingness to risk losing votes by being honest with patients about what they might reasonably expect from the NHS.


I welcomed a paper on overdiagnosis from +Margaret Mccartney and +Julian Treadwell on behalf of the RCGP Overdiagnosis group. It proposes tests to be applied to every policy proposed by RCGP. I advised that these include a test of opportunity cost: i.e. if new work is proposed, what old work should GPs stop doing?

GP workload & fatigue

I welcomed a paper linking GP workload with patient safety. I warned that there is a fine line between making such a link and acknowledging that GP is relatively low risk, without fuelling further risk intolerance, which itself has been a major driver of pressure on GP services.

I warned that making a link to "missed and delayed diagnoses" implies a precision and urgency of diagnosis that is often not appropriate in General Practice and risks encouraging over-investigation, -diagnosis and -treatment. I recommended instead referring to "reduced quality of diagnosis" and "unacceptable delay in treatment."

Skill mix in General Practice and Primary Care

I warned that many members are nervous about proposals to increase the skill mix in General Practice. We must reassure them that we are the Royal College of General Practitioners and will put their interests first.

I advised that changing the name, remit or democratic processes of College would be a big decision and should only be considered after a full a careful consultation with the membership as a whole. Until then, the involvement of non-GPs in the democratic processes of College should be limited to observing.

Friday 19 June 2015

New deal for General Practice?

Today, Jeremy Hunt set out his new deal for general practice that he started work on amid much fanfare only one month ago. GPs struggling to cope with the burdens of increased demand and accelerating retirements had been awaiting this eagerly. RCGP had published its Blueprint for General Practice, setting out what General Practice urgently needs. How much of this has been heeded?


This was presented as a quid pro quo: in return for investing in General Practice, GPs are asked to:

Work 12 hours per day 7 days a week

An election manifesto commitment. Still no hint as to where the resources necessary for such a change will come from. Clearly the driver here is to reduce hospital workload: one might naively suppose that resources might accordingly be diverted from hospitals to General Practice.

Undertake social prescribing

Again, no suggestion as to how a service struggling to meet its current obligation might be able to undertake such an enormous new area of work. Closer integration of health and social services and their budgets has been suggested, but does it really make sense to use up more of the scarce resource that is the General Practitioner in this way?

Have a bigger role in Public Health

Might General Practice be expected to pick up the pieces of a Public Health service underfunded by Local Authorities? How is this to be resourced?

See publication of outcomes data

In spite of CQC's much-derided experience of publishing "Intelligent Monitoring" data (remember its description of GP practices "at risk"?!), Mr Hunt seems determined to continue this approach. How this could support a "change in culture – from name and shame to learning and peer review" is not clear, although such a change in culture is long overdue.

New commitments

So what new commitments has the Secretary of State for health made today?

£7.5m to Community Pharmacists

This will be diverted FROM  the Primary Care Infrastructure Fund set up to build new GP premises.

650 new GP training places

1,000 Physicians' Associates by 2020

Physicians' Associates had already been promised, but now we have a specific number. There remains debate as to exactly what their role should be.

4,000 practice nurses, district nurses and pharmacists

There is currently a surplus of pharmacists, so presumably these will form the bulk of this 4,000. RCGP and RPS are calling for finance from NHS England to support the introduction of practice-based pharmacists. There was no confirmation of such an arrangement in this speech.
Nurses are sorely needed, but Mr Hunt has said nothing today about how they might be recruited.

Clinical staffing data

Sure, this may help workforce planning. Why ever is this data not already available? What we really need, however, is detailed GP workload data. HSCIC even stopped collecting consultation rate data in 2008. The Nuffield Trust attempted to assess GP workload: it found consultation rates to be stable but hypothesised that "non-direct patient work", which it could not measure was taking up a disproportionate amount of GP time.

New ideas

There was just one new suggestion with no specifics:

Reduce bureacracy

Old commitments

£10m for struggling practices

It seems likely that this is not a new commitment, but part of the Primary Care Infrastructure Fund.

Clearly, within a national context, £10m does not buy a lot of GP time (ca. £1,000 per typical practice, £250 per GP or less than 20p per patient). However, if this is targeted sensibly, it could save a small number of practices (perhaps 40-100).

Extend GP training by one year in some areas

This something RCGP has been calling for nationally for some time. Unfortunately, this commitment is limited to certain areas and at least part of the extra year will be spend in hospital specialties, so General Practice will not immediately feel the benefit of an extra pair of hands.

Part-time working scheme to retain GPs close to retirement

More recycled ideas included:
  • 5,000 new doctors - an old promise. Where will they come from? That would require a doubling of GP training
  • A "pre-GP scheme" to encourage medical students to choose General Practice which has already been running for at least a year
  • A "marketing campaign" which RCGP has already started and apparently attracted 300 new recruits
  • A GP returner scheme which has so far attracted just 50 GPs
  • The £1bn Primary Care Infrastructure Fund - very welcome, but is a one-off fund for buildings, not GPs


In summary, Mr Hunt has a great deal on his wishlist, but will not provide General Practice with anything like the resources required to deliver it. Undoubtedly, some practices will succeed in some areas. Sadly, this may be at the expense of other practices and their patients. Yet another postcode lottery.
It is worrying that he is unable to be honest with the electorate that he is out of ideas to deliver on his over-ambitious promises. Is he really unable to "change consumer expectations of healthcare provision" or is he just unwilling to face the electoral consequences of promises he never expected to have to deliver on?