For East and West Sussex LMCs
Dr Russell Brown
20 November 2014
The GPC held its latest last week. The latest official GPC news can be found at the BMA Communities web site and for constituents and LMC members is included with this report. Unlike last month, though the actual conversations are confidential, I am able to be considerably less discrete than last month. As a result, this report is almost diametrically opposite to last month’s in its length and, of course, its consequent interest value. No, really.
CQC and “Intelligent Monitoring”
As I am sure you are aware, the CQC published a frighteningly misleading data set about all practices in England, and classified them into 6 bands of concern. Band 6 practices are apparently least likely to be putting patients at risk, and band 1 practices most likely. Speaking as a partner in a Band 1 practice, which went through a CQC inspection less than 6 months ago where nothing of any meaningful significance was found and which will be going through another inspection in the next few weeks under the new regime, I was extremely angry that CQC had once again deliberately made statements which they must have known the press would leap upon with glee. My partners and practice manager were understandably upset. On the other hand, my patients were either totally disinterested in the CQC’s assessment or horrified that their practice was being pilloried in this way. I have written to my local paper, the Eastbourne Herald, about the matter. They haven’t published it yet, so it would appear the local press aren’t fussed either.
The 38 indicators chosen do not seem to reflect on the quality of care provided by practices as well as being out of date. GPC was consulted by CQC on the use of the indicators and opposed their use as overly simplistic, but as is normal the genuinely constructive comments made were completely ignored. CQC has once again proven itself unfit for purpose, even assuming that its purpose is definable, which I am doubtful of. You will of course recall that fees are increasing by 9%, which is fascinating given the organisation is not providing value for money by any stretch of even the most fevered imagination. The GPC chairman, Chaand Nagpaul, has written to both Prof Steve Field, that well-known friend to general practice, and the Jeremy Hunt, the Health Secretary, expressing our anger and dismay. We are actually fortunate locally that the LMC office has managed to establish such a constructive relationship with the local CQC office, meaning that, to a degree, pragmatism and common sense is being applied. If you are to be inspected, please notify the LMC office as soon as possible and feedback about your experiences.
NHS Five Year Forward View
The full report can be found here. Interestingly, much of this document seems to suggest a move in a direction which GPs might consider to be right, as it often focusses on many of the areas that GPC has been working on in the last couple of years, particularly the “Your GP Cares” campaign which calls for long term sustained investment in General Practice. This can be broadly categorised under funding, workforce and workload (where the document agrees we need to expand the workforce including nurses and other primary care staff) and empowering patients, moving towards more self care and support for carers. Patient access to information is a strong theme and fits with the recently published long term NHS IT strategy and recently concluded contract negotiations, as well as local schemes such as ROCI and the enhanced Summary Care Record.
However, whilst the document recognises the pressure general practice is under as well as the unhelpful focus on hospital care that has existed for the last decade, it does not provide all the solutions, which is perhaps helpful as it recognises that a “one-size-fits-all” approach is inappropriate. It is worth remembering that funding for hospitals has increased by over 40% in the last 10 years, whilst in general practice that figure is only about 10%, and that consultant numbers have increased at three times the rate of GPs. The document talks about breaking down barriers between primary and secondary care, between mental health and health and social care. Services need to be organised to support patients with multiple conditions, with locally delivered services, whilst recognising that specialist centres can produce better outcomes. The plan recognises that list based general practice is the foundation of the NHS and this will continue. It also recognises the pressure that general practices is currently under and that there needs to be a “new deal” for GPs. There is a commitment to invest more in primary care over the next 5 years whilst stabilising the core funding for general practice nationally over the next 2 years.
To this end, new models of care are proposed:
Multispeciality Community Providers (MCP) will offer a new option for groups of GPs to combine with nurses, other community specialists and perhaps mental health and social care to create an integrated out of hospital care organisation. There are some early versions of this around the country but as yet they have not moved to the next stage of employing hospital consultants, having admitting rights to hospital beds, running community hospitals or taking on delegated control of NHS budgets.
Primary and Acute Care Systems (PACS) – this model of vertical integration combines general practice and hospital services, similar to an accountable care organisation now developing in other countries including the USA. Many would question what would happen to a practice if their contract was held by a hospital. This option could provide a model for some that has something to offer but would need many safeguards to be put in place. I suspect this may work in urban, under-doctored areas but is going to be of no use at all in the countryside.
Additionally, urgent and emergency care will be redesigned and integrated between A&E Departments, GP out-of-hours services, urgent care centres, NHS 111 and ambulance services. There has been a great focus on the pressure A&E is under, with an additional £500m being given to hospitals over a 2 year period to help relieve the pressure, yet A&E sees 21 million patients a year compared to the 340 million seen in general practice (increased from 240 million in 2004 but general practice has not received additional funding for this increased demand). Urgent Care Centres refers I think to the emerging model of groups of practices working together in partnership with others such as community nurses, paramedics, social workers etc to cover a larger population than an individual practice. The current model does not work and there are perverse incentives in the system: if A&E is paid on the basis of each patient seen and critically ill patients are funded at the same level as minor injuries, what is the incentive for them to stop the minor injuries attending the hospital. This is an important initiative to reducing the workload on general practice as well as A&E.
It is worth considering that many of our younger, often sessional, colleagues are perhaps ambivalent about our independent contractor status. Succession planning is something that should be thought of early and frequently and the LMC office is happy to provide advice and support.
But change is coming. Are you and your practice willing and able to embrace this change and move to a more interdependent model with colleagues in other practices as a means to maintain your independence? I am also concerned that the persistent failure to change the focus of investment from hospitals to out-of-hospital settings will continue. Without that nettle being grasped firmly, I do not see how this plan can succeed.
The NHS England report “Next steps towards primary care co-commissioning” was launched on 10th November 2014 and can be found here. It outlines three models of co-commissioning, NHS England’s plans for resource allocations for CCGs, plans for developing and delivering a new framework on conflicts of interests and the timeline for approval and implementation. The LMC is holding events on co-commissioning this week. This idea should not be dismissed out of hand as, if resourced and used appropriately, co-commissioning may be a mechanism to deliver more resources into primary care. Of course, the entire concept is only necessary because of a botched major reconfiguration of the NHS which is funded inadequately.
The key features of the three models are described in the report in this table:
In my view, model C is a nightmare scenario for general practices. CCGs are membership organisations of GP practices. The conflicts of interest evident in model C are unbelievable, with a GP-led (apparently) organisation being responsible for the commissioning of general practice. How can we hold the board of our respective CCGs to account if they are responsible for decisions on investments into our practices? How is this process going to do anything other than create a wide-ranging postcode lottery of service provision? And that in turn risks significant repetitional damage to GPs, who may well be perceived by the public and the press as commissioning with their own self-interests at the fore-front of their minds. Disinvestment in and decommissioning of secondary care during service reconfigurations could inflame tensions between primary and secondary care, jeopardising service redesign and integration, with the perception of wide-ranging conflicts of interests paralysing the decision making processes and removing clinical input by devolving more and more decision making powers to lay members of boards.
In summary, I am not a fan and would urge you to consider extremely carefully the various options. CCGs will, no doubt, be canvassing their member practices for views on a way forward. It is vital that you engage with those processes.
The next GPC meeting is to be held on 18th December 2014.
I hope you have found this report helpful. Please feedback so that I can ensure my reports are useful.
Dr Russell Brown