Watson Esam | News | Big changes ahead for GPs - Part 3
The overall picture emerging is that the NHS is to be restructured as a bottom-up service to replace the present top-down one, with patients exercising control and choice over healthcare decisions and delivery.
The government’s White Paper “Equity and Excellence – Liberating the NHS” was published on 12 July with a statement to Parliament by Andrew Lansley, the Secretary of State for Health. It sets out in very clear terms where the coalition government wants the NHS to be by April 2013 and all stages in between. There are three aspects of the plans:
- De-layering of the bureaucracy of the NHS at all levels.
- Focus centred on clinical outcomes and patient outcomes, in place of a process-based one.
- GPs holding the central role in the commissioning of patient services with around 70% of the NHS budget in their hands.
1. De-layering of the bureaucracy
Strategic Health Authorities will be abolished in April 2013 with Primary Care Trusts following them shortly afterwards once the hand-over to local authorities of their public health function and to GPs of their other functions has been completed. Existing GP practice-based commissioning clusters will form a number of the new commissioning organisations. Indeed, the Secretary of State referred in his statement to Parliament to such consortia as being “ready to go”. They may be if they are large enough and sufficiently resourced to negotiate on an equal footing with those private sector providers which not only want to offer commissioned services but also to manage the whole commissioning process for GPs.
Many of the process-based functions which have been the hallmark of health policy in recent years are scheduled to disappear along with at least one third of the health sector quangos after a review of their usefulness.
All NHS Trusts will have to become Foundation Trusts within three years. Monitor, which currently regulates only Foundation Trusts will therefore have its role expanded as the financial regulator. It will also have the crucially important role of regulating competition between providers and of specifying maximum prices.
The Care Quality Commission’s (CQC) role of monitor and inspector of standards will be expanded and refocused. It will extend to all healthcare whether privately or publically funded.
Together, CQC and Monitor will licence providers, with power to de-licence and fine for breaches. Monitor will also be given similar powers to other sector regulators to enable it enforce market competition.
A new NHS Commissioning Board will be formed to regulate the commissioning process and assist GP commissioning consortia in managing their roles. It will also be required to ensure patient involvement in medical decisions.
2. Focus on clinical and patient outcomes
The Qualification and Outcomes Framework (QOF) has proved beneficial for GPs. But it became a bone of contention for the last government which recast it every year on the basis of changed clinical priorities – but also with the aim of clawing back money from GPs. This will now be reinvented and a new commissioning outcomes framework will focus on clinical outcomes and patient-reported outcomes in place of the top-down box-ticking exercise that currently exists. GPs, patient groups and others will be consulted on the development of the new national outcome goals.
So that patients are enabled to make informed decisions about their treatment, detailed and wide-ranging information is to be made available not only to healthcare professionals but also to patients. This is to include performance information about hospitals for the relevant type of treatment or operation. The government will want to be very careful that, in so doing, it does not replicate the present accounting-driven hospital management system, when the new fundamentals are that it is to be clinician-led and patient-driven.
Since the emphasis is on patients sharing in the decision-making and outcomes are to be measured not only clinically but also by patients’ own evaluation of their experience, the use of Patient-Reported Outcome Measures (PROMS) is to be expanded. This will also inform future decision-making at local and national levels in the NHS.
A concern has already been raised by GPs that it will be invidious for them to impose rations on the availability of treatments for their patients: one can envisage frictions with other members of a consortium or within a practice if a GP or practice uses a disproportionate amount of the budget. It is not yet clear exactly how this will work out. But there is just a hint that the government may be willing to restrict treatments where an illness or condition is self-imposed by a patient: the White Paper recognises that, with increased choice comes an obligation for patients to “accept responsibility for the choices they make … and the implications for their lifestyle”. (para 2.18) This could have far-reaching implications for a population which is not only ageing (presumably not regarded as a fault in itself) but increasingly obese – where there is a considerable groundswell of opinion in favour of restrictions on publically-funded NHS treatment.
3. GP commissioning role
GPs are to have a huge chunk of the NHS budget - £80bn - for commissioning services for their patients. Fundholding by GPs was introduced by the Conservative Government in 1991 and then abolished by the Labour Government in 1998 shortly after it came to office. It had been criticised on the basis that it created a 2-tier system for patients according to whether or not their GP practice held funds. Practice based commissioning was introduced by the last Labour Government but faced the criticism that it failed to transfer any real responsibility to GPs.
The government has stated that it has learnt from the past and will avoid those mistakes. So it will transfer both funds and responsibility. GP commissioning consortia will be established from April 2012 for all GPs without the ability to opt-out. They will receive formal transfer of power and responsibility for commissioning in April 2013.
GP practices which are not already in a consortium will be compelled to join forces with an existing one or form a new one with others. There is no opt-out and GPs will have to have joined up. The process starts in April next year with shadow existence for consortia. They will be formally established in April 2012 before commissioning starting in April 2013. This could prove interesting in terms of implementation because it will involve GP practices joining with other GPs who may already be, or may later become, their competitors - freedom for patients to choose their GP is a central feature of the reforms.
How will this issue will be resolved? The idea of patient choice involving their being able freely to move around different practices may be illusory in reality – especially when most practices already provide patients with the option of seeing a doctor of their choice at the practice. If there is any significant patient migration, it is likely to occur in the smaller or sole practitioner practices. All recent governments have been happy to encourage the amalgamation of smaller practices on the basis that they have economies of scale and there is a consequential saving in central administration. Paradoxically, it may also operate to restrict patient choice.
Clearly GPs will not be allowed to enter into reciprocal restrictive covenants to prevent them from taking on each others’ patients. But perhaps new GP consortia will be permitted to impose a restriction on their members preventing them from actively seek new patients by, for example, advertising or mailshots. This would permit them to adopt a passive approach to the registration of new, unsolicited patients. Unsolicited advertising – otherwise known as junk mail – should not be mistaken for opening markets to competition by providers. Nor should it be assumed that aggressive patient poaching has anything to do with patient-centred outcomes.
Conclusions
From some of the early criticisms levelled at the White Paper, including those even before its publication, one might be forgiven for thinking that GPs wanted neither money nor responsibility, but rather just to be left alone with their services contract with the PCT.
That is incorrect. GPs have long had plenty of complaints about the present system: for example, that their own patient agenda and that of the PCTs bore little resemblance to each other; that the tokenism of their representation on the PCTs was insulting and illustrated the general attitude of PCTs to GPs; that PCTs actively encouraged patients to pursue complaints about GPs (albeit on the diktat of the Department of Health); and a general frustration at the PCTs’ lack of responsiveness to the needs and priorities of general practice.
On the other hand, life has not been easy for the PCTs: they have always had to play pig-in-the-middle between GPs on the one hand and the Strategic Health Authorities and the Department of Health on the other, frequently getting the blame, but not the resources to resolve issues - as in the political football otherwise known as “Out of Hours”.
As various groups with vested interests in maintaining the status quo try to ambush the plans, there is no doubt that the only real game in town for the government is getting the GPs on side in sufficient numbers to push through the changes. The Royal College of General Practitioners has already given a favourable initial reaction to the proposals – before they were published! No doubt the RCGP was one of the first calls made by Andrew Lansley after the general election.
What will it take for GPs to support the new proposals? We suggest the following:
1. The de-layering of administration to include the Department of Health itself and an assurance that the administration and monitoring functions which do remain will not repeat the mistaken micro-management of the past. Left to its own devices, there is a natural tendency for administration to grow. Separation of the “What” (government’s role) and “How” (clinicians’ role), (White Paper paragraph 1.5) will in practice be very difficult to demarcate.
2. The de-cluttering of all politically correct agendas – i.e. those which are not strictly clinical in the narrower sense.
3. Ensuring that the Care Quality Commission, which is to have oversight of all standards, and Monitor, which will have financial oversight, both of which are to expand, do not merely replicate the abolished organisations.
4. Practical assistance and guidance from the proposed NHS Commissioning Board to guide GPs in the formation of consortia and the commissioning function itself, so that they are in the driving seat, rather than becoming mere “employees” of the private sector companies which are now gearing up at top speed to control the market – that would hardly result in a clinician-led let alone a patient-led service.
5. Additional, or at least more flexible, patient consultation times: this will be crucial if GPs are to be able to implement patient choices with more enthusiasm that Choose and Book. This should be achievable depending on how remuneration for GPs is structured together with a contribution from the savings made in bureaucracy. It means more GPs will be needed.
If the government can deliver on these it will have secured its main ally.
For prompt advice and assistance please contact Guy Lachlan on 0114 275 3350 or email guy.lachlan@watson-esam.co.uk.
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