Nationalising General Practice
Paul Williams MP, writing in the Guardian on May 8th, states (quite rightly) that some GPs are open to the idea of being salaried employees of the NHS. He may also be right that directing doctors to work in under-served areas might be easier in a salaried service. But before the NHS spends a lot of money on this, News from Nowhere advises it to ask some difficult questions.
Demand is increasing in General Practice, but demand for what? General practice is a black box, we don’t know much about what goes on inside it. We certainly don’t know how much demand is supplier – induced, in the form of defensive practice (following up people when not necessary) or of NHS activities of unproven value (health checks, assessments of frailty, pursuit of dementia diagnosis targets). Ironically general practice has better IT systems than in NHS hospitals but hospitals supply better activity data. A prudent government might re-establish the regular analysis of GP activity, using already existing data capture methods, to inform NHS decision-making. In the meantime it could reduce some workload pressures by shifting money from supplier-induced demand tasks to core funding.
If one in ten GPs are in contact with 60 or more patients a day, as claimed – “double the safe limit” – the NHS might ask who established the safe limit, based on what evidence. Are nine in ten doctors not working at this intensity? If so, how do they achieve a lower workload? Is the risk to patient safety a wise theme to develop when calling for more money? As a patient told that my GP may not work safely, should I not by-pass him or her and head off to A&E, where there may be safer doctors? Doctors declaring themselves unsafe and in need of rescue might draw the attention of the General Medical Council, or of the Care Quality Commission, to their practices. Will this help reduce their stress?
Are GPs really the “heart” of their communities, and do they really “support patients through every stage of their lives”? This sounds like pastoral work, which can be very stressful, but these immodest claims do not sound authentic to News from Nowhere. Are GPs the gateway to the NHS, or would gate-opener be a better description given the rise in referrals to specialist services, across the board?
General practices have had to compete for resources – funding streams, personnel – with growing specialist services, and so far they have lost. How might the NHS divert funds from burgeoning hospitals to community-based services, when any proposed change in hospitals is perceived as evidence of evil intent towards the NHS? Nationalisation of general practice is unlikely to solve this problem, but when the only tool available is a hammer, all problems look like nails.
Baroness Dido Harding is in trouble. She is in charge of concocting the NHS’ workforce plan. The Health Service Journal (Anabelle Collins 26/4/19) reported her as saying that the NHS had been “asking the wrong question”, by trying to plan the number of professionals for particular specialties, and instead needed to combine workforce decisions with operational and financial planning.
She added: “It is a huge mistake to think you can divorce the most important asset you have from operational and financial performance, and we have been making that mistake nationally as well as locally……I don’t know how many cardiologists we will need in Scunthorpe in 10 years’ time. I am absolutely certain if you asked the project team in Whitehall to work the answer out, we would get the answer wrong.” She is adamant that workforce planning should be devolved to Trusts and emerging organisations, as News from Nowhere also advocates.
The responses in the HSJ discussion forum ranged from the offensive (dumb aristocrat) to the appreciative (..spot on!). An anonymous comment about paying doctors in the US Health Maintenance Organisation ‘Kaiser Permanente’ caught NfN’s eye. Here it is, in full.
The NHS is way overdue a rejig of consultant salaries and working practices. A lot of consultants put in way above what they are paid but equally a lot of consultants tolerate very low productivity in their NHS practice which they would not in their private practice. The question is – what is the relative worth of different craft groups, and how can the system adapt to change?
At Kaiser they have a graded system of pay, and there is no private work outside this. For doctors a 9-5 GP salary with no on call is the basic unit of currency. Hospital doctors generally get 1.5 – 2x GP salary with weighting for out of hours work / hard-pressed like Emergency Medicine (consultants work 24/7 at all hospitals). Procedural specialists get 2-3x GP salary with the top earners being orthopaedics / neurology / cardiac / ophthalmology reflecting their greater earning potential. No one gets more than 3x the basic GP salary. For every position they have 10 applicants, and selection is very careful based on team behaviours and potential to the organisation. No primadonnas!
No primadonnas? What utopia is this? An American one, where super-specialists brazenly walk tall.
Picking and choosing.
Commissioning is a tough game. At the end of April Virgin Care pulled out of a contract with East Staffordshire CCG after failing to obtain extra funding agreement with the commissioner (HSJ Rebecca Thomas 30/4/19). Virgin Care was contracted to provide community services under a prime provider agreement in 2015, worth £270m over seven years. Under the contract, the CCG outsourced its responsibility for commissioning and integrating services for patients with long-term health conditions and for frail, older people. The CCG said the prime provider model required Virgin Care to absorb expected increases in demand and costs over the seven years of the deal. Virgin argued it would have had to subsidise the contract by more than £1m, and after 18 months of negotiations withdrew from the commissioning element of the contract.
It could be worse in Staffordshire. At least the provider is not suing the CCG, as it is in Nottingham. Circle Nottingham and Rushcliffe Clinical Commissioning Group are in a legal battle after the CCG decided to take management of Nottingham Treatment Centre away from Circle after 11 years, and give the 5 year contract to Nottingham University Hospitals Trust instead. Circle asserts that the quality of services at the centre is at risk following a “flawed” procurement process (HSJ Nick Harding 1/5/19). There are winners and (bad) losers in the NHS market, it seems.
Skin in the game
Birmingham Women’s and Children’s Foundation Trust is refusing all new referrals to its paediatric dermatology service due to “severe capacity” problems (HSJ Rebecca Thomas 3/5/19). This is due to a lack of consultants and a growing backlog of both new and follow-up appointments. GPs in Birmingham and Solihull have been advised to refer patients to the local community dermatology service. It looks as if GP referrals to the tertiary dermatology service have overwhelmed it and it is trying to divert demand towards secondary-level community services.
As one respondent said: “Many Trusts are struggling to provide dermatology services and the shortage of consultant dermatologists has been felt at the front line for years. Despite this training numbers have not been substantially increased and many trainees choose to leave after training to work exclusively in private practice which is a huge and lucrative market”.