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The Health Bill: policy into practice

The Health Bill: policy into practice
31 March 2011

Chris Naylor: There are clearly big opportunities in GP commissioning. The idea of getting more clinical involvement into the commissioning process is something that needs to happen and has been a weakness in the existing system for a long time.

Chris Naylor: There are clearly big opportunities in GP commissioning. The idea of getting more clinical involvement into the commissioning process is something that needs to happen and has been a weakness in the existing system for a long time.

But there are various risks involved in this for GPs – as we've seen in America, where some of the medical groups and independent practitioner associations have taken on a budget. Some have been very successful and others have struggled and have faced severe financial difficulties. [If GP consortia take on financial risk] how are we going to manage that?

There's also potential reputational risks to GPs. There's the idea that part of a GP's payment is dependent on commissioning performance – the public could come to see that as GPs making a personal profit from withholding treatment or reducing referrals. And there's also the fact they're being given a more explicit role in the rationing of services. Will that have an effect on the GP/patient relationship?

There are challenges, too. First there is the challenge of building the consortia and making sure that they have all of the right skills that they need to be doing this job. They'll face a choice [in size and models].

Will GP consortia be able to tackle the big challenges that the NHS faces – increasing productivity and the need to reconfigure hospital services – in the absence of the system leadership that strategic health authorities currently provide?

And then there's the question of getting adequate representation from secondary care clinicians, other health professionals and patients and members of the public. I think that those are two areas on which the Bill could be stronger.
And, finally, some of the uncertainties: there's a lot that isn't specified in the Bill. It will be worked out either through secondary regulation or just by how leaders in the system choose to interpret their roles and take on the various powers that the Bill gives them. Foremost is the relationship between GP consortia and the NHS Commissioning Board. It remains to be seen exactly what that will look like. It could take on a mainly supportive character or there could be more of a managerial relationship there and perhaps we'll expect to see elements of both.

Victoria Vaughan: You're at the forefront of health policy development right now, James. Do you agree that there are major issues with the consortia?

James Kingsland: GP commissioning consortium for me at the moment is very much secondary. It's the old form and function. If we don't get the function right, the form is irrelevant.

I'm still shocked at how many people within the NHS, as well as the public, don't understand the basic structures of our health service: the fact that you access the NHS by registering with a general practice. If you're not registered with a general practice, in effect you're not entitled to 
NHS treatment. You might say its detail, but that is the 
basic process.

So what we're looking to do is make every general practice the best a patient can get. To do that we need to expand care, improve capability and capacity. And when a patient chooses to register with a general practice, you deliver a whole range of services and, yes, keep them out of hospital, use that particular sector for the high-tech complex, but low-volume activity, and the vast majority of their care is used within the community.

So I want to clarify that there's nothing strange about that. Every single government always looks on the NHS to invest and reform it, and the only difference is now we can't invest in it. Have we really reformed it? No, we've restructured it in the past. This is the first real opportunity to really reform it. And if we reform it by just talking about the structure and geography of GP commissioning consortia, we will fail spectacularly.

Victoria Vaughan: Rhiannon, can you tell us about how 
the Department is helping GPs get both the form and function right…

Rhiannon Williams: We're working hard to try and see how to make sure that we retain the NHS staff… But a key thing, too, is the relationship with the private sector. The private sector brings a huge amount of deep understanding of delivery for a lot of these services, and if you just look at things like the informatics that the private sector can bring to the table, it's much more deep-rooted than many of the services that the public sector has traditionally done. A lot of this is about getting the right relationships and getting people to work together towards delivering the right solution. So, at the moment, we're working with the private sector, with the NHS, to see how that will work in the future market.

Victoria Vaughan: Katherine, what do you see as private sector's role in all this?

Katherine Ward: One of the things that's exciting to me about this shift to GP led commissioning is… the culture of data-driven decision making. So I think from that perspective, focussing our attention on supporting GPs in this new role around using data is one element.

Another element is about using clinical evidence to drive best practice. Actually being more systematic about that, trying to drive out unwarranted variation, using clinical information to really inform groups of clinicians about different practices across a group. I think that level of peer regulation that you're going to potentially have when you've got a group of GPs who are all able to see data for the first time that matches and looks at their different practice and gets them to then ask questions about that is going to be very powerful.

And then the third area where we've been really supporting has been around delivery, around discipline and execution around actually getting stuff done, performance managing, measuring that and getting it to be changed and evaluated and really driving change forward.

Victoria Vaughan: We've got practising GPs in the room. I am interested to see if this policy is changing anything in practice for you right now?

Jeremy Gray: I think there are issues about GPs not being that involved and at the moment the incentives seem to be quite limited. There's no real connection between GPs referring or not referring and incentives. I would say that most of our partners, and our salaried staff, really do not see why they should not refer anything they want to, because there's no real pressure for them not to refer. Referring is a major cost centre.
So to get people to change their behaviour is going to be quite difficult and I don't see that we've got the tools there to do that at the moment. I think there are lots of interesting developments, but I don't know that the grassroots GP is totally engaged in the process from a commissioning point of view.

Kartik Modha: I don't think there's enough GP support behind the changes for even people to contemplate changing their practice. I mean, getting involved takes time and people who have got the time are inevitably people not seeing patients as much, and therefore it's hard to get what the patients want relayed into the changes made at a higher level.

I am a sessional GP and I have got time on my hands – I mean, I'm here! So why isn't the government getting people like us involved at an earlier stage when deciding how we're going to bring about these reforms in a way patients want the system to work?

I'm not sure of the experiences of other GPs here, but I've asked my own patients actually, because I knew I was going to come here, did they know about what's going on? The majority of my patients don't know there's anything happening. The ones that did – an IT programmer, 26 years old, said, 'If you're doing your commissioning, how will you have time to see patients?' That was her concern. And another patient, who is a diabetic, about 54-year-old Asian man, said, 'Well GPs will be making money by referring fewer patients' – an interesting choice of word; 'making money', not 'saving money'.

There will be a compromise in the relationship between a GP and their patient if you're putting money into the equation and I think primary care is most effective when that relationship is strong.

Dipak Kapacee: What is the vision here? I'm not sure what the vision is. From the GP point of view, it seems to be, let's make £20bn worth of savings, come what may.

We as GPs have considerable concerns about this, the changes that are coming through in the new Health Bill… the speed of reform, the scale of reform, the fact that it's financially driven and, at the same time, they're touting patient choice at every stage, but nobody mentions rationing. The 'corporatisation' of general practice – because essentially that's what consortia formation is, and GPs are really a cottage industry in many ways and getting GPs to work together is… often we say it's like herding cats. There are so many risks here.

Victoria Vaughan: We have skirted around the issue of risk and there's obviously risk on many levels, and I wonder, Peter, can you come in on this?

Peter Edwards: Looking at legal risks I think the most fundamental change that we see is that GPs involved in commissioning will be making public decisions and that is not something that they have done to date, so they will be subject to the full rigours of the law in terms of how they make those decisions and the consequences of those decisions. So information law will apply to them, and judicial review will apply to them.

And I think also there are potential risks about the management of staff. If some of these organisations are going to be relatively substantial, they're going to acquire a number of staff who are currently based in PCTs. Those staff, of course, come along with existing national terms and conditions, they come along with established trade union relationships, something again that GPs to date really haven't been exposed to and may take some time to come to terms with. So there are a number of things there that I think will require a mind shift from running a small business to being part of a major public body effectively.

James Clarke: I think there does exist an opportunity actually to improve upon some of the activities that were undertaken by PCTs in respect of commissioning, because GP consortia will have the accountable officer for the real personal accountability that would exist there as far as something like procurement is concerned. That's something that PCTs have often not done a terribly good or consistent job of.

And then if you combine that with the contract management that comes at the end of the procurement process, sometimes PCTs have been a little bit lily-livered about managing their contracts and have not actually used the remedies available to them, ie the performance remedies in respect of the various suppliers of clinical services that are commissioned, and so really the relationship between commissioner and provider right from the inception of a commissioning process, through the procurement process, to the end result of actually performance managing issues from, for example, a wide range of community providers, hasn't always actually worked as effectively as it could.

So with more accountability in consortia and more at a local level with greater patient involvement, it's an opportunity to do just that, and so that's how the legal process can be managed to improve quality.

Victoria Vaughan: Michelle, you've got something to say about accountability…

Michelle Drage: Let's look at this absolutely clearly from a London context. Ten per cent to 20% of the budget goes to GPs to do what GPs do now; 85% of the budget goes to our big foundational trusts, teaching hospitals, large public corporate organisations in London which, do, in effect, 15% of the work.
Where has it all gone wrong? Well, it's all gone wrong because it's been managed by the wrong people in the wrong place at the wrong time for 25 years. Now within that entity there are very good managers who have been spoilt badly by the lack of common sense in commissioning policy.

So there's a natural tendency to have an affinity with the secondary care sector. And in London, that is a very powerful sector. It's very politically powerful. We've seen hospitals survive when you would never have thought governments would listen, and they have. We've seen games being played that nobody could get away with other than those with vested interests. They include things like charging four times the tariff for the same work that could be done elsewhere, justifying it by all sorts of things to do with research and actually what it boils down to is protecting their own nest.

If I could do one thing, it wouldn't be to look at GPs' referrals and prescribing. It would be to send in the coding inspectorate to every trust in London and make sure they're coding things appropriately. None of that is happening at the moment through the current rush to pathfinder status. Let's just look at the landscape. Everyone's going to be a pathfinder by late spring. It's going to happen. And why is it happening so fast? Because it's been such rubbish until now, and actually someone has twigged up there in NHS HQ that it needs to change, and it needs to change rapidly.

Now, who are the best people to make change happen? Actually, GPs have a flight of foot, they make decisions quickly, they invest quickly, they disinvest quickly. That behaviour is alien to the rest of the NHS. And many of my GPs have forgotten that you can translate that flight of foot into the NHS, and have become so conditioned by the bad, slow, awful incompetence that is out there that we all collude with and tolerate because we have to make the system work, that they've actually become demotivated, disengaged.

And the one thing that will disengage them more is more microscopic management of what goes on in their practice. By all means have the peer group review, the supportive analysis that leads to perhaps investment decisions and service redesign, but what it really needs is that big focus on the big picture. And the risk here is that we'll create, as we have in London, at least 33 consortia somewhere down the line, maybe 66, maybe 120 all concerned with the grass in front of their own practice, allowing the big vested interest players free play. So that, for me, is what is the task at hand.

Now I don't think there's a huge amount of personal risk to the GPs. They can get some pretty quick wins over a fairly short period of time, which will stand them in good stead. And I think we need to get on with it, do it and stop whingeing about it.

James Kingsland: I think back to the White Paper of 2006, which first started to talk about out-of-hospital care and the then minister Lord Warner saying, 'This out of hospital care is instead of, not as well as'. We're not going to make the QIPP challenge of 15-20% of efficiency gains through losing NHS managers, workforce, prescribing activity or referral pattern changes. Ultimately the biggest savings come from closing buildings. And we've got to get into the debate…

At the moment, with respect to MPs, the MP who chains themselves to the hospital, saying, 'Don't close our hospital', has got to change their attitude to say, 'If this is not needed locally, if it is not part of the vision for delivery of care in our community [then]…'. I think that hospitals have got to recognise that sector reorganisation and beefing up the community has got to ultimately [result] in bits of hospitals or whole hospitals closing.

Victoria Vaughan: The reforms are supposed to take the politics out of the NHS by having the board there, and I just wondered if, James, you could come in and talk about this relationship with the board…

James Reynolds: I certainly think that over the next year or so it's going to adopt a supportive rather than overly managerial approach. Going forward there will be a duty on the consortia to assist the board in managing some of the primary care contracts. That's an interesting aspect of the bill at the moment, how will that actually work? Are consortia going to be responsible for managing GPs who are underperforming within the consortium? And on the other hand the board will be obliged to manage the consortia if they do not meet their financial and other targets. This could include dissolution. So it's going to be a balance. There's obviously a lot of pressure on the board to work with consortia to ensure that they are working and functioning effectively, but ultimately it will be the responsibility of the board to take formal action against the consortia if they're not meeting their financial and other targets.

James Kingsland: We've often looked at the NHS as an investor in failure organisations. And I think there's [a need  for] a mindset change so that that the failing service, if it's had support and investment, is ultimately closed. It might be the GP consortium that consistently fails or some of the constituent practices [which are] destabilising… are shown the exit door.
You can only manage a list if you are part of a GP commissioning consortium. Therefore, if you're not in a consortium, you're not in general practice anymore.

Peter Edwards: When we first read that in the bill, [many of us asked whether the issue of losing your ability to practise if you are removed from consortia] was an intended consequence or an unintended consequence. If it's an intended consequence there's a surprising lack of detail around the processes, because ostensibly this is a decision that impacts fundamentally on someone's ability to earn a living. And yet it's the decision of the commissioning board. What sort of process will that require? Will there be a right of appeal? What about human rights? There's all sorts of questions there. And, as I say, fundamentally, was that the intention?

Dipak Kapacee: I think that there is a feeling that regardless of the colour of the government that no government likes independent GP status. 'The GPs need to be managed, and this is a way of managing them…' The days of independent general practice are coming to an end and we are going to be managed, but without the government necessarily taking on the risks of the premises and everything else that goes with it.

The panel met on 2 March 2011. The above is an edited transcript and is not reported verbatim. For information on GP Business round tables: call 020 7214 0526 or email [email protected]



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