#WeNeedToTalkAboutJeremy

No one I know has any confidence that the 10 point plan developed by NHS England, Health Education England (HEE), the General Practitioners Committee (GPC) and the Royal College of General Practitioners (RCGP) in order to address primary care workforce issues in January 2015 has any chance of making a significant impact. I thought it might be worth exploring why.

The current crisis is down to too many GPs saying it's all too much, that although the job in principle is extremely worthwhile, the pressures mean increasing numbers just don't want to do it.

A way of assessing this is to look at willingness to do the job at different workloads as pay varies. If pay is high and workload manageable people will feel better about doing the job; if it is too low people may feel the job is not worth doing whatever other worthwhile elements or job satisfaction it offers.

A Commons Briefing Paper shows that between 2005 and 2013 real terms pay for GPs has dropped 22% from £137,108 to £107,331. 

The number of FTE GPs in the same period has gone from 29,248 to 32,075. However the estimated annual number of consultations has escalated from (my estimate) 267m to 340m over the same period. The workload (in consultations pa per GP) has therefore gone from 9,134 to 10,600, a 16% increase.

You will notice both measures are going in the wrong direction, meaning that the job in 2005 was 48% more worth doing than in 2013 when this is expressed as the change in Pay/Workload ratio. (Some may query my choice of 2005 as the baseline but bear in mind this was where we were after a solution to the last GP crisis was enacted and generally folk felt the crisis was resolved at that point and so this seems to me to be the most appropriate point to choose for a baseline.)

We can get a handle on the crisis by considering how pay and workload affect the proportion willing to do the job. 

Each line represents willingness to do the job for the same workload at different pay levels, with say 10% increases in workload between lines A through D. As the work stress increases there will come a point where the stress levels are such that willingness to do the job drops away rapidly as in C. In the most extreme cases where the job causes illness, work may become impossible and willingness drops out very rapidly as in D. I suspect that over the last 10 years we have moved from X to Y as real terms pay has dropped and workload shifted up a gear.

 My contention is that our current level of workload means pay vs willingness is not a linear relationship but has a steep slope, if not a cliff. I think there is good reason to think we are now at point Y on the curve C. This is very precarious for two reasons. Firstly, further drops in real pay, without a change in workload will continue to push us down the steep part of curve C. (Bear in mind GPs are generally very capable individuals who can and do switch to other parts of the economy or other economies.)
But this is not the worst thing that could happen. I suspect that secondly, like fissile material at critical mass, further increases in workload could trigger a chain reaction where loss of more GPs pushes up the workload for the remainder suddenly flicking us down vertically from Y onto curve D, in which large numbers just walk as the job becomes non-doable at that or any price. This disaster would be difficult and expensive to recover from! I think the level of anxiety in GP land at present reflects an intuition that this could happen.
So the solution to the crisis relies on finding ways to push us back up the curves to higher levels of willingness to do the job. (To be sure pay and workload are not the only reasons for doing the job as others have stressed (www.whyGP) which is why on curve A people with means would do the job voluntarily but these factors only shift the curve to the left, they don't change its shape at higher workloads: however fantastic you think General Practice is there is always a point when the stress of the job will make you unwilling to work. What makes this crisis such an issue is that the curve is likely to be already left-shifted by the intrinsic value of the job and the values of the profession compared with other jobs and yet we are still at Y.) My view is that reducing workload rather than increasing pay is likely to be more effective and you can see that from the shape of the curves - going from Y vertically to curve B is more efficient than a pay increase in getting people to stay, if I am right. The main determinant of workload is list size and so for an effective solution practices must be given the right to unilaterally close lists to contain workload, NHSE should commission to cope with the overflow and pay must not drop any further in real terms.

We are now in a position to understand why folk might be sceptical about the 10 point plan which fails to address the above adequately.
I will cover the points in turn

1 Promoting general practice 
This is a marketing campaign setting out the positive aspects of General Practice.

This will clearly make no difference to the Pay/Workload issue. It is possible that it might shift the curve to the left by convincing some to be more willing to do the job for the same degree of stress (but the curve is probably already as left shifted as it can go for the reasons listed above). This does rely on pulling the wool over many eyes in an age of social media, and them discounting their experience and the experience of the more experienced, which seems rather unlikely.

2 Improving the breadth of training 

HEE will work with partners to resource an additional year of post CCT training to candidates seeking to work in geographies, where it is hard to recruit trainees. 

This does nothing to shift the curve or address Pay/Workload once the doctor gets into General Practice and may increase work stress generally by taking a cohort out of full service delivery for a year.

3 Training Hubs  

NHS England will invest in the development of pilot training hubs, where groups of GP practices can offer inter-professional training to primary care staff, extending the skills base within general practice and developing a workforce which can meet the challenge of new ways of working.

This too will have no effect on the curves. New ways of working are likely to increase work stress at least in the transition (note there is no mention of transition funding), risking pushing us further down the slippery slope.

4 Targeted support

NHS England will work with the BMA GP Committee and the RCGP to explore a time-limited incentive scheme to offer additional financial support to GP trainees committed to working in specific areas for 3 years.

Once in a post after three years the Pay/Workload ratio is unchanged once the real work starts. Significant golden handshakes have not been very successful for post CCT GPs which rather suggests it is unlikely they will work for GPRs.

5 Investment in retainer schemes

NHS England will review the use of current retainer schemes and invest in a new national scheme, making sure it meets the needs of both GPs and practices. 

The Pay/Workload ratio is unchanged.

6 Improving the training capacity in general practice

The Government’s recent announcement that there will be an extra £1 billion for investment in new primary care infrastructure will enable increased training capacity and a more positive experience for medical students and foundation year doctors within general practice.  More broadly, NHS England will work with the BMA's GPs committee and the RCGP on the strategic direction of the primary care estate.

A nicer building does little to change the willingness to do the job. Current experience with GPR recruitment is not picking up despite the publicised investment and my City has several shiny underused buildings.

7 Incentives to remain in practice

NHS England and partners will conduct a detailed review to identify the most effective measures to encourage experienced GPs to remain within practice. Options may include a funded mentorship scheme, opportunities to develop a portfolio career towards the end of your working life, and a clearer range of career pathways.

The options suggested specifically do not address the Pay/Workload ratio. The options might decrease stress for the individual doctor but will increase stress on others as their contribution is reduced. This might help prevent things being worse than they would be otherwise but won't reverse the slide.

8 New ways of working

NHS England, HEE and others will work together to identify key workforce initiatives that are known to support general practice - including e.g. physician associates, medical assistants, clinical pharmacists, advanced practitioners (including nursing staff), healthcare assistants and care navigators.

Now this might work - but can only do so if it reduces the GP workload without decreasing pay, thus increasing the willingness to work. Unfortunately the recently released information on the Pharmacist Scheme where practices pay an increasing proportion of Pharmacist time means this is highly unlikely to happen.

9 Easy return to practice 
HEE and NHS England will publish a new induction and returner scheme.

See 2

10 Targeted investment in returners

NHS England will make available additional investment to attract GPs back into practice, increasing over time.   Targeted at the areas of greatest need, the scheme will offer resources to help with both the costs of returning and the cost of employing these staff.

Now this might work if they turn out to be serious in meeting the cost of employing these staff on a permanent basis but the numbers are not likely to be high. 

What is striking is there is absolutely no mention of pay or workload which are key to the willingness of GPs to do the job. They just don't want to talk about this Elephant.

So what will change the situation?

In order to increase general willingness to do the job workload has to be reduced. This will push us back up a curve.

I suspect too that it is this cooperation with such ineffective proposals that has contributed to a loss of confidence of a growing number of GPs in their representative bodies.

I'm afraid there really is no way out of this without increased investment in the primary care workforce (as well as buildings) which could be achieved within the NHS budget by stopping activity with poor evidence and diverting those resources. NHS Health Checks are a good place to start.

None of the current proposals reliably move us back up from Y to X and the GP contract is not set to change in a way that will address this.

Pay is set to continue it's downward drift and nothing significant is being offered to relieve the workload. Consequently the situation is set to worsen still, driving the profession down either a steeper cliff or to implosion. If JH does not realise this he is incompetent, if he does but does nothing he is either impotent or malicious - whatever #WeNeedToTalkAboutJeremy and the petition for a no confidence vote is entirely appropriate.

A plan comes together

Don't you love it when you can deliver healthcare with an efficiency and quality even the 'A' Team would struggle to match?

My patient booked an appointment on line to see me about their thumb. He/she put in the free text 'I think I need an injection. :-( '

This text appeared on my screen under their appointment booking so I had the needles / steroid ready on arrival. Yes -  typical osteoarthritis of the 1st carpo-metacarpal joint. I did the injection clean into what can be a small joint to get into. My patient went away happy and left me with the feeling of a job well done.

Appointment on-line booking time by patient three minutes.
Consultation time eight minutes.
Reception time 0.
Admin time 0.
Medical record coding time 0 (part of my 8 minutes)
Invoice processing time 0.
Insurance assessment time 0.
Patient wait 0 (first appointment of session)
Time to claim minor operation fee 0 (integrated into our EPR)

I challenge you to find another healthcare system within Pluto's orbit that could come anywhere close to diagnosing and treating this condition from a standing start in 11 minutes total. Compared to the NHS most other systems would still be in the blocks by the time we'd finished the race and completed our third lap of honour.

Private medicine? You are having a laugh - 15 minutes to complete the first tranche of bloody paperwork!

So how do we do it?
No denying it, the technology is great and primary care IT like this is world class.

But here is a formula to note
Technology + Continuity = Quality + Efficiency

This could not have worked without continuity.

I had previously injected this patient's plantar fasciitis about 7 years ago and it worked a treat. So they knew I did injections and so knew to book with me.  They also knew my injections were 'ok' - reading on NHS Choices that someone else thinks you inject ok is not the same as knowing it (almost literally!) in your bones. It means patient anxiety pre-injection is minimal and I can get on with the procedure quickly without lots of explanation, consent forms, reassurance or medico-legal worry. All this makes the procedure itself less painful by eliminating nocebo effects.

An APMS contract (NB NHS England) could not have delivered this as with 5 year contracts it's highly unlikely the same doctor would still be around. This is only possible under GMS or PMS which NHSE very, very stupidly is not actively newly commissioning.

Technology alone could not have delivered this because technology cannot manufacture the trust that comes from long term personal care.

So Mr Hunt if you have a 25 year vision, make long term personal continuity part of the plan and stop wrecking GMS/PMS!

Stop blathering on about technology - I've been using computers in General Practice since 1989. I got it 26 years ago! We all get it in GP land, that's why we lead the planet.

You can have it all but only if you get and promote continuity of personal care...

New deal

You know that dissonance when as a GP when you encounter someone who turns out to be psychotic and they are saying things that are borderline possible but don't quite add up, you know how you have to seek independent witnesses to be sure - well that's how I feel whenever Jeremy Hunt (JH) speaks. He has just enough traction on reality to be almost credible, if your antennae weren't already twitching wildly. Of course there is no psychosis here just a deliberate skirting around the presentation of truth, as opposed to the mis-perception of it you get in mental illness. Sometimes the patient can be so near reality you begin to question your own grasp on things.

That is why on reading the New Deal speech I had to go back to evidence.

Much of the speech has already disintegrated of course - 5k GPs is now a maximum (but no minimum stated!), the 82% of not a lot and what seemed to be new money that wasn't. Then there is the oft-repeated semi-lie that the CommonWealth Fund voted our NHS number one last year - well yes but they always forget to mention that fact that this assessment was based mainly on data from 2011 and some from 2011-13. For some reason they don't claim that our number one status is (was?) actually the outcome of 10 years of Labour investment in the NHS - funny that.

And in a cracking self-contradiction JH goes on to say 'We rank best in the world for having a regular doctor who co-ordinates care' and subsequently berates Labour with another of his oft repeated misrepresentations for undermining 'the personal relationship with patients by scrapping named GPs'. So they undermined that relationship did they and seven years later we're still top for having a regular doctor? Does anyone read this before putting it out there? It's embarrassingly bad.

Reflecting on this speech is a bit like picking up a carefully crafted sandcastle in your hands - it just falls apart.

But what of this obsession with 7 day working in primary care?

I wondered if there was an evidence base. The Conservative Manifesto 2015 pg 40 (the main vector of the contagion) announces it under the subtitle 'We will make the NHS more convenient for you'. Nothing about reduced A+E attendance or measurably improved outcomes - nothing to suggest anything other than convenience - which as an aspiration is fair enough, but nothing to indicate it is actually needed.

An MP's Briefing Paper and PM's post election speech had no evidence either, apart from the generous reassurance that doctors weren't actually all going to have to work 7 days each week.

Then we get to the New Deal Speech where there are signs that JH is scrabbling around for something a bit more than the 'convenience' of the Manifesto, in belated recognition that actually yes there really does need to be a need, given the circumstances.

'The role and purpose of 7 day primary care is about much more than convenience – it is about making sure precious hospital capacity is kept clear for those who really need it. We have clear evidence from Imperial College London that a lack of access to GPs at weekends results in increases in urgent hospital admissions.'

At last a mention of something I can hold on to - alas no actual reference is given. A bit like my paranoid patient who says someone told him the neighbours were spying on him but then can't tell you who. Nor can Prof Majeed who co-authored some relevant papers but he kindly confirmed on Twitter 3 papers I had also found from Imperial that JH might be referring to.

The problem is none are about 7 day working or weekends specifically and only one is about hospital admissions... of children.

More dissonance.

One shows an association between patient reported difficulty accessing appointments 2 weekdays in advance when they rang in ordinary surgery hours and self referral to A+E followed by discharge (ie not admission). It concludes that better access might result in less self referred A+E attendances (maximum effect size possible I calculate is a 1% reduction in A+E attendance) but the effect is dwarfed by the effects of deprivation which are 4 times greater, which the paper does acknowledge. The evidence would suggest therefore that for maximum benefit we should be resourcing deprived area practices with more appointments in weekdays in usual hours to reduce A+E attendance (but the direct beneficiaries would probably not be Tory voters!). Oh yes that was what our PMS funding (now cut!) was for.

Another makes a rather speculative guess at the proportion of A+E attendances that were preceded by someone not being able to get a GP appointment at a time that suited them, based on the GP Patient survey. This again is an argument for resourcing in hours care properly as the Patient Survey was on patients who rang their practice in hours who presumably were looking for appointments in hours. It tells us nothing about routine GP access at weekends or emergency admissions.

This is consistent with the finding that there is a lack of demand for weekend appointments by many of the PM Challenge Fund pilots.

The last paper, which if you compare the original abstract which contains no mention of GP out-of -hours, with its summary, which does, bears the hallmark of being sexed up. But at least it looked at emergency admissions ..er in children even if it cannot draw any meaningful conclusions about 7 day working. The authors themselves say 'we cannot infer causation' and the fact that the increase in admissions was seen in chronic conditions but not infectious ones led the authors to conclude that the study 'may indicate an adverse impact of financial incentive schemes focusing on chronic conditions in adults' rather than it being due to a problem with GP out of hours availability. 

Even the RCGP felt the need to issue a press release.

So the evidence JH seems to be referring to for 7 day working is ..well ..NOT evidence... unless he can come up with a paper Imperial College themselves don't know they have written!

Well at least it's not me that's losing the plot.

So it seems that JH is systematically misrepresenting evidence for political gain, again. So given I already work 45-50hrs per week, some already at weekends (work email, research coding, GP trainee eportfolio, appraisal, reading CCG documents, private study etc), can find no evidence of benefit from 7 day working, would have to pay a high premium on medical defence cover, face hitting LTA and pension charges, won't be seeing my patients (yes 'real clinical responsibility' is about continuity over access), won't see friends and family and like any GP my age who has read the runes has made sure I don't need the money, will I be working weekends mainly for the convenience of Jeremy Hunt?

Mending primary care

So we know not for profit OOH is favoured by patients and that APMS practices on average deliver poorer quality care. So the evidence gives us something we should be moving towards (don't hold your breath!) - not for profit OOH and conventional primary care contracts but with an improved cost base from economies of scale while retaining an emphasis on optimising the access/continuity balance.

We desperately need to improve recruitment of GPs and nurses into a context where many work not just very hard but suicidally hard in a wholly unsustainable way. Working even harder is therefore not an option, so just paying more to do more won't work. Nor will back to work schemes without enough wanting to come back, golden hellos or unrepresentative assertions of rosiness without concrete action.

We have to get back to a non-punishing daily routine. I can still remember the only time I had a decent lunch-break in the last 4 years, which was on 16/5/2014. It was 45' long and I actually went home later in a better mood than I started the day for the first time in ages. I was still at work for 10 hours but was only actually working for 9 of them. This and better must become a daily experience if we are to attract folk.

A growing problem is that progressively more clinical and organisational responsibility is being carried by fewer and fewer shoulders. The financial and medico-legal risk run by many partners is no longer sustainable and also contributes to burn-out and early retirement. Further, the more people for whom an individual partner is carrying ultimate responsibility for, the less they are able to keep tabs on what is going on and the greater the anxiety. GPs face the doubly stressful work situation of both loss of control of their work and of control of clinical risk. We have to get back to a more even distribution.

And it is essential to guarantee any improvement going forward. No one is going to come into a profession when they think we will be back here again in 10 years when we have been here at least twice in the last 12.

Getting back to sensible working will happen because the current situation, ironically for health workers, is incompatible with their health and so will not last. The only real question is whether it's with or without a public health disaster en route. More of the same will collapse primary care as we know it and our NHS values along with it. Everyone has a limit and many of us could just walk away right now, taking experience and the training skills to produce the next generation with us, further depleting input at the bottom. Practices could tumble like dominoes as one takes out the next; some areas could be left with no primary care to speak of. The whole thing might be privatised and serious numbers of people would lose the right to primary healthcare as it becomes unaffordable as medical time is priced out of their reach.

This will eventually be OK for doctors though as price will limit activity and lunch times will be restored. Most GPs oppose this form of privatisation because they know only too well how badly large numbers of people will be affected. We could move to a US fiasco and public health and inequality go into reverse and still the overall costs escalate. Even if replaced by a comprehensive insurance system it will still be more expensive and very many will lose the kind of access to care they currently enjoy.

It's probably not too late for a more civilised route but I still have yet to see anything tangible. So what needs to happen?

Things that might help a bit or not at all are:-

Defining GP workload to limit demand. There was much talk about this around the 2003 contract negotiations and it was attempted but failed miserably. The role of the GP is constantly evolving and so as soon as you try to define it, it is out of date. It would require continuous re-working and is not worth the endless wrangling. And as we have discovered since 2003 'new resource for new work' just doesn't work.

Payment for activity. The main reason for cost effectiveness in the NHS is that doctors are NOT paid for activity; you end up with healthcare activity regardless of whether it is needed and this drives up costs. This will seriously damage NHS cost-effectiveness.

Co-payments for primary care appointments. This directly contradicts a core NHS value and discriminates against those most in need. The transaction costs are counter-productive anyway.

Cavalry. In the form of Physician Assistants or Nurse Practitioners. As effective as these can be there is no evidence they are cheaper over all and the jury is still out on the safety question when more serious disease presents and there aren't enough anyway. They increase the burden of clinical responsibility on the GP supervising (as if they have time!) their work.

Salaried Service. Many see the only hope is in a fully salaried GP service as they think the loss of autonomy will be compensated for by a contract that will have to offer acceptable working patterns. Personally, I think it is simply unaffordable in the current climate and will ultimately stifle innovation and patient advocacy, which is becoming ever more important as secondary care services return to 1990's waiting times.

So what will help?

We need a mechanism that is going to guarantee adequate, properly focussed funding of primary care and sensible work intensity. What is obvious is that no government can be trusted with this, otherwise we wouldn't be in this mess. We need a system where there is a powerful legal incentive for politicians to ensure that viable primary care continues, by containing demand and adequate resourcing. The current system provides neither.

Practices must be given absolute discretion over their list sizes. (I was pleased to see this passed as a motion at this years LMC conference and is a restriction that would be sensible to enshrine in law, Mr Osborne). By all means the practices should give warning they are about to cease taking on registrations and there should be some limitations eg they should close for a minimum of three months. It will focus minds properly on commissioning primary care if local politicians are faced with the realistic possibility of angry patients unable to register with a doctor. Currently, struggling practices are seen by NHSE primarily as the other local practices' problem when it comes to making up any deficiency in supply but not their own. Er, contractually it's not other practices' problem and nor should it be, the other patients are not registered and should not be automatically assigned. It's NHSE's (or jointly CCGs) responsibility, although practices may be willing to help, if able. The current system leads to lazy (non-)commissioning; it has to change.

The beauty of the above change is we do not need to worry about what a GP job is as the mechanism will cope with whatever it is, depending on the collective experience of coal face practitioners about a suitable list size.

Practice funding must reflect actual practice co-morbidity (NOT just age)

The current funding system actively discriminates against practices providing quality services that patients appreciate. How so? In an area where patients perceive a differential in quality between practices and vote with their feet, inevitably the high service users are the ones that switch practices. They take with them a higher than average workload but only an average capitation fee. Thus the 'good' practice becomes less profitable (greater workload per remuneration) and the 'poor' one more profitable. ie exactly the opposite outcome the patient choice agenda was supposed to achieve. In this inefficient application of NHS resource, it over-stresses popular practices while over-funding the less popular. Doh! (Current funding mechanisms do not take account of actual morbidity distribution between practices but smear an average deprivation factor over a geographical area.)

Evidence of this can be seen from QoF 2012 prevalence data from my patch of Leicester.

The coefficient of variation here is a measure of the variation of the disease prevalence distributions between seven practices serving the same geographical area of Leicester. There is, for example, a seven fold variation in the recorded prevalence of depressive illness between the practices, with the same pattern of variation for the other disease areas. Notice that there is much greater variation between practices for mental health / neurological conditions than for cardiovascular ones. As any GP will tell you the demand on GP time and emotional energy for the former is much greater than the latter.(1,2) We know also for example that depression associated with diabetes in the same patient is more time consuming for primary care than diabetes and depression in separate patients. The same is not true for hypertension and diabetes. (3). This variation, for reasons I haven't got space to go into here, is almost certainly down to prevalence variation reflecting patient choice / transfer rather than coding variation between practices.

A new funding mechanism based on actual practice multi-morbidity, assessed annually, is essential if meaningful competition and innovation is to be driven in primary care.

There must be more intelligent analysis of doctor behaviour. In exchange for discretion on list size GPs need to be willing to handle greater scrutiny over the areas that generate much secondary care cost, especially referral behaviour. Current initiatives such as the Unplanned Admissions DES simply don't work, but there are better ways.

For example there is a completely untapped seam of data which may give useful insights and potential savings here, as well as function as a useful educational resource. This is to audit GP referrals adjusted for the case load and case mix which form the background to this.

Years ago now we were struck by a 28 fold variation between different doctors in the crude count of their gynaecology referrals in our practice. I decided to adjust these referral rates by looking at the background of all consultations for gynaecology problems from which these referrals were drawn and adjusting for case load / mix and age. When you adjust for these factors the variation disappeared (moving from variation well outside 3 sigma to well within)!

Analysis of other areas such as neurology showed that less experienced GPs referred more patients for vague symptoms than experienced ones, offering an immediate educational and cost saving opportunity, that was not otherwise apparent.

I have been unable to repeat this work in SystmOne because incredibly despite 25 years of GP computing it is still impossible to create a list of all consultations by GP classified by the problem encountered even though our GPs have been recording every consultation properly!

The Doctors & Dentists Review Body (DDRB) recommendations must always be implemented fully by government with more than just a gentleman's (ha, ha) agreement to do so. Successive governments have shown themselves to be entirely untrustworthy on this. The DDRB in recent years has become a joke and ought to be experiencing some kind of existential crisis given the degree it is ignored by government. The deal that we don't take industrial action but DDRB recommendations are implemented must be restored by legal instrument and MPs must be obliged to take other peoples' review bodies as seriously as they apparently take their own.

The above combination should be able to ensure that workload is controlled at the practice level, remunerated according to need and funded adequately nationally. Importantly it will oblige engagement by reluctant politicians in an ongoing discussion about our NHS and what we want it for.

The main obstacle will have to be an acknowledgement of the repeated failure to manage primary care properly. It will be messy as I suspect a lot of practices will cease to take new registrations but the alternative will be much messier. It will cost because practices will have to be paid the same to do less to bring workload levels back from the suicidal. But it will cost less, be more equitable and a lot less messy than the alternative.

1. The workload of GPs: consultations of patients with psychological and somatic problems compared
Else M Zantinge, Peter FM Verhaak, Jan J Kerssens, Jozien M Bensing
British Journal of General Practice, vol. 55 no. 517 609-614, PubMed 16105369

2. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study
Chris Salisbury, Leigh Johnson, Sarah Purdy, Jose M Valderas, Alan A Montgomery
British Journal of General Practice, vol. 61 no. 582 e12-e21, PubMed 21401985

3. Implications of comorbidity for primary care costs in the UK: a retrospective observational study
Samuel L Brilleman, Sarah Purdy, Chris Salisbury, Frank Windmeijer, Hugh Gravelle, Sandra Hollinghurst
British Journal of General Practice, vol. 63 no. 609 e274-e282, PubMed 23540484

Vulnerable?

"The best test of a civilised society is the way in which it treats its most vulnerable and weakest members."

Mahatma Gandhi

With David Cameron saying he is going to revitalise the concept of the One Nation Tory (I really hope he succeeds), he's going to need some tools for the job. One good place to start is to focus on the most vulnerable. This is all very well but by their nature the vulnerable are often so because they can be hard to spot. Those exploiting or creating vulnerability are hardly going to advertise the fact and the vulnerable themselves generally struggle to stand out or even recognise their condition.

A civilised society is one therefore that takes a more pro-active role. Given that primary care seems to be held up as the solution to most of society's ills we're not going to be able to escape this responsibility. So what to do?

Much has been made of the need for the NHS to keep up with new technology. However the focus too often is on the gadgets and remote monitoring of tele-health where the benefits so far have not proven that exciting; largely, it seems to me, because when you are ill the last thing you want to do is faff around with more gadgets. I'm sure this will change but in the meantime the NHS has to hand something pretty special in Western medicine - an abundant source of rich, comprehensive, well-structured data. Our USP, which, in any more NHS re-organisations, must be preserved, lies mainly in the fact that the data describes geographically oriented, list-based primary care. Theoretically, we know a lot about local populations, unlike health systems without this local focus. It is this we need to exploit to prove how civilised we are.

Working in a practice serving a deprived population at Saffron Group we are only too aware that the context of someone's illness is key to recovery and vulnerability. We like to think of ourselves as family doctors but too often we aren't fully aware of this context, even in patients we think we know well. The irony is that often this data is available in other household members' records; we usually don't have time to hunt for it so its presence just passes us by. This is a lost opportunity for our patients.

But what if we moved our unit of analysis away from the individual patient? What if we moved our unit of analysis to the household?

We decided to use our IT skills to bring primary care data together at the household level. The tool we have developed consolidates a huge range of data from our clinical system and presents it by household. The tool contains a search engine to analyse it and a viewer of the output. This means you can search for a huge range of possible combinations of diagnosis and vulnerability. You can view the whole household in one go with vulnerabilities such as domestic violence, dementia, being a carer etc highlighted, which we are hoping will bring new insights to our practise, with vulnerable people as the beneficiaries. This is our first attempt and we are making it available for others to use free of charge at www.ukaguzi.com/VH.htm. Read more here.

The Household search tool and Household explorer

With the increased collaboration between health and social care this could become a powerful force for good. We have only just begun to explore its possibilities such as using it to view the whole household in our child safeguarding meetings. We hope this can develop into a wider open NHS collaboration. Please acknowledge us if you do any work based on this and if someone else decides to make money out of the idea or the system suppliers adopt it, remember where you saw it first. Sadly, as it is entirely voluntary we cannot provide support for the use of the tool. We hope you find it useful.

Rational regulation - where I get touchy about no-touch taps

Let me start with a quotation from easily the most useful medical textbook I have ever read - one that has actually helped me save lives,

(Speaking of operating in a developing country) 'In an emergency you may even have to operate by the light of a hurricane lantern. The light will attract insects, and these will fall into the wound, but even so they are unlikely to influence the patients' recovery'

The point being made here depends upon the concept of marginal risk reduction. Using surgery as the example there are a number of ways you progressively reduce the risk to the patient.

Firstly, choose your cases carefully.

Not opening an abdomen that doesn't need opening is always going to be safer. Of all the potential cases for laparotomy, 40% may not need surgery.

Pre-op: have a check-list - 15% risk further reduction

Good anaesthetic technique - 15% more, say

When you operate use sterile equipment - that's another 15% risk reduction

Use good surgical techniques - handle tissues gently and you have another 10%

Sterile gloves 2%, experienced assistant 2% and so on.

Each addition gives a marginal risk reduction which is subject to the law of diminishing returns.

So what if a moth falls in the wound (desirable if it doesn't of course and believe me fly screens are much more useful in Africa than here) but it only has a minor impact on outcome when all the rest is in place.

Using single use instruments will reduce risk further, but by nothing like as much as sterility. Similarly different scrub techniques of longer duration and newer antiseptics and laminar air flow and hotter water and plastic floors and de-cluttering and no touch taps all will help but, in ordinary primary care minor procedures, not detectably so when the rest is in place.

It is at these margins when already high levels of safety are in operation that I start to question the regulatory regimes. For new builds or major renovation, no problem; but when the margin of potential further benefit is small the risk of generating harm by perturbing an existing system becomes significant. If the process of implementing a regulation carries a greater risk than the potential marginal risk reduction it could bring, it is stupid to implement the regulation. 

Let me relate the story of my tap.

At 5am on 28/4/2014 I was called to the surgery by our cleaners as one of 4 new automated taps, only changed to meet CQC regulations and done 3 days earlier, had flooded my consulting room, the corridor and part of a neighbouring room with over 30l of water, rendering it smelly and unusable for over a week. We had to employ a specialist cleaning company to make my room habitable again. Prior to this my single lever mono basin mixer tap had functioned for over 20 years (actually 7,390 days) without flooding, Legionnaires Disease or any attributable infection in well over 1000 minor procedures carried out in my office. The introduction of a new tap would appear to be at least 615 times (7,390 / [3x4]) more likely to cause an incident that damages patient care than the old tap in usual operation! As one of our lovely-wiser-than-CQC cleaners put it, 'If it ain't broke...'

In order to be sure of overall patient benefit from changing a system, the ongoing risk to patients from the old system must be greater than the risk to patients from the new system plus the risk to patients from the process of change-over. However, from our experience, it would seem that the maximum absolute risk reduction achievable by changing taps (which equals the absolute risk to patient care from the old taps) is likely well over 600 times smaller than the risk attributable to the process of changing the taps.

Should CQC have required that we only change taps at the end of their operational lives (ie when we have to incur the risk of change)? I wondered if CQC risk-assessed the implementation of their regulations by balancing achievable marginal risk reduction against the risk of system change. I asked Prof Steve Field at the RCGP Conference 2014 but I don't think he really 'got' the question and possibly I didn't ask it very clearly, so I still don't know. I didn't find anything on the CQC website on this.

Now maybe we were just exceptionally unlucky in having the only incident in the installation of at least 2,400 (4 x 600) taps or maybe my old tap was actually far more dangerous than direct observation suggests but it seems very unlikely.

This may seem a trivial example, but if it is generalisable there is a real chance that systematic damage is being done up and down the country in CQC's name. Tick box regulation: 'Have you got this new super tap Y/N?' is simple but at best simplistically naive and if it has not accounted for marginal risk properly, at worst it is negligent.

However, the risks are not confined to direct service delivery; there are opportunity costs and unquantifiable risks (but increasingly real as the GP recruitment crisis unfolds) such as the negative effect over-regulation might have on morale. We had to spend practice resource on these changes and as the marginal risk reduction is tiny then the benefit/cost ratio is also and may have been a lot smaller than say spending the money on increased staff. To spend on improperly assessed regulatory requirements is to waste NHS resource.

I would be grateful if CQC could reassure us that it routinely assesses the risk to patient care resulting from the process of implementation of its regulatory requirements and only insists on implementation where the overall risk is shown to be lower. 

Taking exception

Over recent years there has been a growing trend to use the UK General Practitioner (GP) Quality and Outcomes Framework* (QoF) exception reporting rates as a quality measure or standard. For example, in Leicester, one entry requirement for the Primary Care Diabetes (Enhanced) Service (a scheme to reward more specialised community diabetes care) is:-

The specification requires the provider(s) to (show):

• Evidence of QoF low exception reporting ( less than 10% )

In the annual quality review of our practice the overall exception reporting rate is routinely reported as a quality measure, comparing it with the Clinical Commissioning Group (CCG) average, but with no explanation of what this actually is supposed to indicate.

This marks an unwelcome development as I believe it betrays a misunderstanding of the topic. This blog is about why.

For the uninitiated some explanation of the system is necessary. QoF payment is based on points scored in a range of disease areas for achieving certain quality standards. The number of points available for each area such as for how well blood pressure (BP) is controlled is fixed. The actual point score for a practice is calculated from the proportion where the audit criterion was achieved at the year end of a defined percentage range of eligible patients within which points are counted. So if the points available are 10 for this disease area and the point scoring range is 50-90%, if 70% of eligible patients meet the audit criterion, say of good BP control, 5 points (10 x (70-50)/(90-50) are scored.

So for the above QoF area a practice scores nothing if it does less than half the work and nothing more if it meets the QoF criterion in over 90% of those potentially eligible.

So where does exception reporting come in? The key is in the phrase 'eligible patient'. Individual patients who might be suitable for assessment of care in each QoF disease area can be deemed ineligible and exception reported. There are various valid reasons for this. Eg a person with a poorly controlled BP not meeting the target value required may also be suffering from a terminal cancer, in which case worrying about their degree of BP control is hardly relevant. Such a person could be exception reported as 'unsuitable'. Someone else may just refuse to be followed up making it impossible to meet the care standard which can be exception reported as 'informed dissent'. These patients are then not counted when it comes to assessing points.

The rationale for this is to level the playing field between practices, as the number of patients in these groups is going to vary year on year and by population served and to avoid inappropriate treatment.

So why the fuss about exception reports above?

Suppose you have two practices with 100 patients each who are potentially eligible for a particular QOF indicator. Just before the year end one has met the criterion in 83 patients and another in 89. Both are a little short of the maximum 90% target. In the first practice there are 8 patients who could be legitimately excepted, an 8% exception reporting rate. The practice excepts them, achieving 83/92 or 90.2% and thus gets the maximum number of points available for that area.

In the second they except two, a 2% exception reporting rate, achieving 89/98 or 90.8%. The rub is this, both get the same maximum QoF points but the second practice has treated 6 more patients to target. So you can see why having a low exception report rate might be seen as a 'good thing' but does a low rate actually indicate a better quality of care?

Supposing in the two practices the maximum number of patients that could reasonably be excepted was 8 and 2 respectively. In this case the first practice failed to treat 9 (=92-83) to target of the patients it could have treated, as did the second (=98-89). So despite a fourfold variation in exception reporting rates they under-treat the same number of people. (The first has treated 6 more people to target but only because it was easier to do so; exception reported patients are frequently more complex or less compliant and so it is perfectly reasonable that they both get maximum QoF points in this area, despite the variation in exception reporting rate.)

But supposing both practices could have excluded 8 patients, then the second practice is performing better, it just didn't need to report as many to get maximum points, because once you have achieved maximum points there is no point in taking exception reporting further. The problem is you cannot know this just by looking at exception reporting rates; you need to know the number who could have been exception reported, and this latter figure is never assessed in QoF.

The point is both practices have at least met their contractual obligations to the same degree but that one might be over-performing, if its exception reporting rate could have been higher. So on their own exception reporting rates tell you nothing about quality of care.

One might argue that despite this, downward pressure on exception reporting will help keep coverage rates up. However, it cannot be assumed that this is necessarily a good thing as it may result in over-treatment which itself carries hazards we are increasingly aware of.

A better strategy to keep treatment rates high would be to increase the top of the QoF target range and this is what has happened as QoF had gone on. But even this may not be wise given the dis-benefits are bound to increase and as the above figures show the potential improvements are marginal.

In our example suppose you had to hit 95% to get maximum points. Our first practice would indeed have to boost performance from 83 to 88 patients as it could except no more; our second, if it could except more, could except 7 to achieve the 95% target. It's exception reporting rate will have jumped over threefold to 7% in response to the 90 to 95% change in top target range but its quality of care is no different; it's just making real its over-performance under the old 90% target. On its own exception reporting cannot be used to meaningfully compare practices or to assess a single practice over time when the target range or audit criteria have changed.

So the message is exception reporting is not a meaningful quality measure unless you also know the maximum potential exception reporting rate for each indicator in each practice. So please Area Teams and CCGs stop using it as such!

Maybe the worry is that some practices over-exception report merely to hit QoF targets and that patients for whom a care standard is appropriate are being denied it by being wrongly exception reported. If this is happening then this is a probity issue, not a quality of care one. CCGs, by all means query outliers in exception reporting rates and do some post payment verification. All practices should be recording reasons on the exception codes to justify them. But please drop the uninterpretable exception reporting rates from your quality dashboards and service specifications.

* a quality incentive scheme still responsible for a significant but shrinking proportion of GP remuneration where payments are made depending on the points scored

The Anatomy Of A Drug Error

I made a serious drug error last year. There, I said it - confession is good for the soul. Fortunately, no one was harmed but this was the first time in 23 years as a GP that I got it that badly wrong. The story is worth telling in detail as it contains important lessons for me, my practice and the wider NHS.

In a nutshell I prescribed an antibiotic (No, that wasn't the sin – there was a genuine indication!) to a frail patient in a care home whose records unambiguously contained a correctly coded allergy to that drug. The drug was prescribed, dispensed and the full course given before the error came to light. Had the patient had a significant reaction, in his/her frail state, it could easily have caused death or hospital admission.

All doctors have a mental script they rehearse when prescribing to stop this from occurring. My checkpoints for a home visit are as follows:

1) Check the patient print-out I carry where allergies are recorded on the front page

2) Ask myself, ‘Are there any other reasons, drug interactions or co-morbidities, which would contraindicate this drug?’

3) Ask the patient, ‘Are you allergic to anything?’

4) Ask the carer or relative, ‘Are they allergic to anything?’

5) On writing the visit up back at the practice, prescribe the drug on the clinical system, without printing the already handwritten prescription, as this will alert me automatically to drug errors as part of the process

6) Trust the dispensing chemist, who often has drug reactions recorded on their system, to alert me if they are aware of a problem

7) Trust the care home administering the drug will check the drug against their records and alert me if there is a problem

This has served me well for 23 years and only once before have I got to stage 5 and had to back-peddle to prevent a drug being given wrongly.

So, to the anatomy...

In August 2013, as a result of growing pressure from an increasing list in too small a building, we made an application to close our list to new registrations. In making the application one of the reasons I gave to NHSE was 

‘Increased stress on doctors raising the risk of adverse patient events’

And I concluded the application with 

‘We believe that, without a change, continuing to increase the pressure on our building by increasing our list size and continuing to the increase the pressure on individual staff because of our recruitment difficulties will necessarily result in patient harm at some future point. We are obliged to avoid this and raise the issue with the LAT and CCG. We believe our proposal is reasonable and timely.’

I quoted the relevant GMC guidance, for good measure.

It took NHSE four months (much longer than the contracted time for response) to reject our request concluding that,

‘there was adequate GP to patient ratio provision available at the practice to manage the current demand’

helpfully adding, despite our pointing out how over-stretched we were, that

‘The practice could also consider exploring seven day working as a way of managing the current demand’

We were obliged to struggle on. On 8/3/14, after a particularly bad day on call, I emailed my partners, describing my day, flagging it as a significant event for my appraisal discussion in July and suggesting that we apply for a list closure again, concluding:-

‘I don't think I did any harm y'day but the safety margins are becoming uncomfortably narrow which might be tolerable for old hands but carries a bigger risk for GPRs and less experience salarieds’

There was a general reluctance to re-apply because it was felt there would be little point, given such a negative response first time around. Nevertheless we started re-drafting an application.

In August 2014 I experienced one of the busiest days I have known in general practice. I worked from 7:45am, foot continuously on the accelerator, until after 6:30pm with no break for coffee or lunch or tea. I probably managed to pass urine once. For the first time in 22 years I was unable to complete the work I needed to do that day before being late for our Partnership meeting that evening. It was a 13.5 hour day and I cycled home exhausted. I slept fitfully and woke early, my mind racing with the events of the previous day and thoughts for the coming one, as I was to lead a meeting that afternoon to discuss federation plans with several local practices.

The fateful visit occurred later the same day, at the end of another full-on morning with no break and no lunch, with only a few minutes to get back to the surgery to lead the meeting. The patient, who I knew well, was acutely ill and needed a prescription. In my rush at checkpoint 1), I missed the drug allergy on my patient printout. I can’t remember whether I checked and just missed it or whether I just didn't check. I thought I knew the patient so skipped through checkpoint 2). The patient has dementia so no point in checkpoint 3).  I wasn’t the only person having a busy day, the carer got called away to someone else mid-consultation and so checkpoint 4) was omitted too. For some reason checkpoints 6) and 7) also failed to kick in.

I rushed back to people waiting for me and the meeting went well. Then with my mind buzzing I set about catching up with all the tasks and letters and path results that had come in that morning and afternoon and the work I had been unable to complete the previous day. I wrote up the visit and went through checkpoint 5). The computer warned me about the drug interaction but I flicked through ignoring it along with all the other non-clinically relevant warnings that come up.

A week later I was reviewing the patient’s notes for some reason and to my horror realised what had happened. I printed out the visit slip – yes the allergy was there. I tried re-issuing the drug – yes the computer did warn me. The really scary thing is that despite being a conscientious GP for 22 years, despite predicting that something like this would happen (though not to me!) and despite teaching safe prescribing habits to GP registrars for 15 years, I did not realise what was happening at the time. I was just overloaded and hitting me so I'm more careful in future isn't necessarily going to help.

We reviewed the event as a practice and we have made the visit printout even clearer and have heightened awareness but if I have another 48 hours like that I don’t think I can guarantee it won’t happen again. The only way I can avoid it is by being able to control my workload to within what I know after 22 years’ experience is safe. I had already asked for that and was refused, against my better judgement.

This all occurred a week after we had again applied for a list closure at the end of July 2014, with a pretty much identical document. We did not hold out much hope as if NHSE were consistent they would have to respond in the same way as the first time.

This time they granted our request!

I was itching to see how they would explain this volte face in the formal response. The application was identical, their response the opposite. In the event whether to hide their total inconsistency or because organisational dementia prevented its recognition, the letter merely detailed the rules and our duties concerning list closure, without any explanation of the decision.

I have no confidence in our area team. They failed to listen to my concerns first time round which was at least partly responsible for me nearly killing someone and then behaved wholly inconsistently without explanation.

Since the list closure things have been a bit better and I have no further incidents to report. But in four weeks we have to open the list again and nothing fundamental has changed. We've looked at hot-desking and made significant changes to the appointment system and phone system which will help.

Much is made of learning from the airline industry in making the NHS safer. However, NHSE, DoH and the government are not credible in this matter. The current contractual arrangements mean that there is no point beyond which a GP cannot be pushed and NHSE is quite intent to keep on pushing. This is in stark contrast to flight crew safety rules which 

‘recognize the universality of factors that lead to fatigue in most individuals and regulates these factors to ensure that flight crew members in passenger operations do not accumulate dangerous amounts of fatigue.  Fatigue threatens aviation safety because it increases the risk of pilot error...’

If only the GMS/PMS contract was as sensible.

So what is the solution to the current situation where resignation from one’s livelihood is the only reliable way to escape an intolerable safety risk? Well one thing that would help is giving GPs absolute discretion about list closure. We could have avoided the above near miss, which convinced me that Area Teams are not competent to make such decisions as they are susceptible to political pressure. It is absurd that GPs are trusted to decide on the patient with chest pain in front of them and on commissioning for populations but are denied the ability to decide on a safe workload in their own practices. The requirement to go cap in hand to Area Teams to get a list closure has contributed to the serial de-funding of primary care by allowing them to pretend there is adequate GP coverage. Politically, of course, it would cause major embarrassment as practices closed lists up and down the country but this is a crucial safety governor and would oblige proper resourcing and commissioning of primary care to save political face, which is the right way round.

And if no solution is forthcoming, General Practice will have crossed, by NHSE’s action, from ‘if’ serious patient harm occurs to ‘when’ but it will be the GP who is hung out to dry. I find myself asking a question I never dreamt I’d ask, ‘Is it ethical to be a GP?’ Should I continue to work within this system, knowing there is a real chance of inadvertently harming a patient, when it deliberately and incompetently denies me the means to minimise that risk?

So how long do I continue to push my luck? If I do err again and someone is harmed whether I appear before a coroner’s or civil or a criminal court, or the GMC or the Health Ombudsman or the CCG Performance Committee or CQC or the latest ‘Safety’ Agency, I’ll produce this blog as evidence for the defence, M’lud.

Be clear on cancer!

Be clear on cancer. Well my patient was: 'Three weeks of heartburn? See your doctor', so they did.
I wish I was that clear!
No risk factors, no drinking, no smoking.
No red flags, no vomiting; eating, swallowing and appetite fine.  Put on a bit of weight. Typical mild but annoying symptoms on lying and bending, eased by a simple antacid. And on examination no nodes, no lumps, no anaemia, looks as well as I've ever seen them. No sign of cancer at all.
And when you dig a bit: well yes I've always been a bit prone to it, so not just three weeks, but worse in last year since starting the aspirin for the silent ischaemic heart disease based on the abnormal ECG and since stopping the PPI (anti-stomach acid drug) you gave to cover the NSAID (gut-rotting anti-inflammatory drug) course for the arthritis flare.
But there you have it, the big C genie is out of bottle or is it ogre out of his lair: could it be cancer? Well it might be and really only your age is against you but weight gain, aspirin and medication changes are actually much more likely causes.
Be clear on cancer: your GP estimates your risk at less than 2% given the above but a) he might be wrong and the risk is actually higher and b) if he isn't you could still be in the 2% anyway (you might have asymptomatic cancer and your symptoms are coincidentally due to the weight, aspirin and medication changes and I'm about to blow your luck - he said with a smile on his face)!
You always cheer me up, doctor!
It's called explaining risk to the patient - you are 98% OK. OK?
Oh... so you're not 100% sure....
Be clear on cancer because your GP is not wholly non-anxious about his conclusion about the best course of action here and saying 'You're the Doc' is not much help when I ask 'What do you think?'
Am I mistakenly colluding with your desire to avoid endoscopy to your disadvantage, or are you just being nice to me in my uncertainty, giving me an excuse not to refer?
And if we refer you all something else will have to go - causing longer waiting times for the 2% who do turn out to have cancer whose prognosis will worsen as a result.
So we're clear on (symptoms that have <5% chance of) cancer, just unclear on what to do about it.
Decision! Stop aspirin (and increase your heart attack risk - he smiles again) and restart a PPI and I'll review you in two weeks.
It'll either be another totally unsung, well-judged piece of risk management that saves enough cash to allow the NHS to fight another day, avoids delaying the diagnosis of those we hope will be less fortunate than you and avoids your small endoscopy associated risk and your inevitable anxiety or I'll be thrown to the dogs as another cancer-missing-GP. Watch this space!

Well that was two weeks ago and on telephone review (What it is to be an early adopter of new technology!) my patient is absolutely fine. Will now stop PPI and see. Still no certainty of course - I've either slightly saved the NHS from financial self-harm from a miss-targeted ad campaign or I've missed a cancer and covered up the symptoms - useless GPs...
As a Reader in the good old C of E I could go on a funeral course and then I could legally bury my mistakes. Mmm better not mention that to my appraiser.

PMS Slash: A Postscript

We met with our local area team reps about the so called ‘Review’.

Seems the spreadsheet was not as misleading, as some of the compensatory money for our PMS slash comes from others’ loss of MPIG being re-injected into global sum; so as beneficiaries of others’ worse misfortune we apparently should be grateful. There was no answer to my charge that the rest of it was misleading. But there were more reasons to be grateful that the practice which I have spent 22 years of my life building was about to be destabilised. At least there was a locally agreed transition arrangement and we might be able to get the money back through (an as yet an unspecified means of) reinvestment: MPIG practices had no such luck. Which do you prefer; at least a chance of avoiding death or disability by annual cuts over 6 years or instant limb amputation?

And the pain management service we have provided since 2002, currently at double the number of patients we're contracted for? As I predicted they had no idea, none at all, at just what they were about to 'review' out of existence. And they saw my point re our growth element to address inequalities but... 

The last drops of goodwill and trust are thus squandered. But it's worse than that. I now know that there is no point in trying to create innovation within NHS structures because future iterations of these sociopathic, demented entities will capriciously squish it. Reality is: 'cynically take advantage where you can, realising it may be transient'. This is absolutely not the lesson needed at this critical juncture and is completely at odds with the stated aims of the review. The positive words about PMS in the announcement of the review are entirely contradicted by NHSE's behaviour, at least locally. A proper PMS review was never done and there was never the least intention of doing so. They had concluded that they could get away with giving practices a Hobson's choice and effectively bully them into GMS contracts.

In the end the meeting was not about 'reviewing' anything (well we knew that really), this was a done deal; they were there to tick the 'Met with practice' box. The localism that PMS was supposed to be is revealed as a lie; so what does that tell us of what the centre really thinks of that other manifestation of localism, CCGs? A quantitative easing in the NHS with the currency of contempt?

They had nothing to offer and displayed the body language to match; minimal eye contact, except as demanded by a measured politeness, and a kind of corporate weariness. (Please this is not a personal criticism; the cogs in a bulldozer are just that.) It became clear why.

In 6 weeks it's no longer their problem. That's when co-commissioning kicks in. If you, like me, thought the 'co' participle implied joint working, that was in no way the impression conveyed. But in line with the above experience, we can no longer assume that what's said relates to what will be. There was an unmistakable sense of signing off of responsibility which was to land squarely onto CCGs. So folks the commissioning of most secondary healthcare and now primary care rests with an organisation of which I am obliged to be a member and thus accept responsibility for, despite having no control at all over the amount of funding (unlike local councils) and with ineffective representation. If secondary care fails it's GP commissioning failure and soon the same is true of primary care. The sting is ready, the denouement awaits the election result.

At the same time as passing primary care commissioning to CCGs NHSE has acted in a way that curtails their freedom of action by ensuring most PMS return to GMS. The centre will continue to control the agenda as they.have for the last 10 years. This charade 'review' wasn't about saving money or cost effectiveness but about retaining central power over core GP contracts. CCGs are denied the option to fund GP contracts properly via PMS. They can only repeat the history of the IOS Red Book failure in the form of damaging short term LES proliferation/fragmentation. The bung to CCGs to accept this has been paid for by PMS practices. In my practice the losers will be people in pain and the disadvantaged, as well as increasingly demoralised partners.

I genuinely do try to adopt St Maureen's positive spirit and I'd love to report something good but it's so, so hard when I find my every cynical thought backed up by evidence that that very path has already been laid. It's like seeing a patient where you immediately think 'cancer' and where, to your growing horror, every red flag symptom you ask about turns out positive. I wonder if I'm paranoid but if I am, then, at the very least, there has been massive communication failure by NHSE to GPs. I didn't get the impression they cared a jot.

The challenge now is to carry on even though we know we can't trust anyone outside our organisation. To judge from comments at the end of Pulse articles many already have decided it's no longer a challenge for them. Not long until Good Friday.

Apocalypse in a bus shelter

And I saw a creature with whirring wings hovering in the sky. And with six wings it hung over the bus shelter and spied the shelter with a camera eye. And I was in the eye and on the roof there were big blue letters in the colour of the UN and the letters were ‘NHS’. And I rejoiced greatly that, so visible from the sky, it would be protected.

Then I saw a hilux pick-up driving to the shelter and, not black, as I feared, but a blue creature and its yellow cur came from the truck. And like reapers, but with sledgehammers for scythes, they raised them to the glass of the shelter.

And I cried out 'But you have no mandate for this! Where is your authority?' And the wise watchers exclaimed, 'This must not happen to the shelter of the people!' And the creatures pretended to pause and then swung into the shelter anyway. In slo-mo the single, crystal glass shattered into millions of sparkling shards. And I despaired at the shards but the vultures rejoiced.

Woe to the shelter of the people!

And as I watched ant workers came from the ground and tried to carry the shards and piece them together. And I wept and wept for the workers. Who will help repair the shards? And I thought I saw one like a son of man walking among the bus stands. Wail for the shelter, its damage seems too great.

And as I looked, podiums were established; there was a red and a yellow and a blue and one that looked like a fag-end soaked in stale beer. And there was a green and there wasn't a green one. And those who perched on the podiums and their minions fought with words and SoMe.

And I heard a voice, the voice of the people, with ire, like the roar of the sea, and the voice said, ‘Stop pissing around! This is a bus shelter not a pantomime; people are going to die!’

News Flash: PMS slash

Our drug budget is overspent. (We'll ignore for the moment the fact that our disease prevalences are greater than the CCG average in nearly all disease areas from COPD to depression and our SMR is 40% greater than CCG average and that drug budget setting makes no meaningful adjustment for this major morbidity differential.) What should we do?

Well what about a drugs review? Simple, we calculate how much we are overspent, work out what the cost equivalent is for some high volume drug and just remove that drug from everyone's repeat prescription - and the patient? Well... Review over: we are now in budget! Someone else will have to sort out the patient at their next medication review.

Er no - we'd be shot and justifiably.

But this is exactly what NHSE have done in the PMS review. I naively imagined that a PMS review would be like a patient medication review: sit down, discuss progress and agree options. And after all such a review is hardly unreasonable. But no, in Leicestershire we got a badly worded email containing errors and an incomprehensible spreadsheet, sent out on 30th December 2014. We were told we had 30 days to decide our financial futures and were left to calculate our own PMS losses! Someone was meeting an internal deadline, methinks.

We're still not really sure what we lose. Less of a review, more of a slash. Bizarrely the spreadsheet also attempted to conceal the extent of the loss by projecting a compensating increase in income through an unexplained assumption of list and global sum growth while completely failing to account for the inevitable increases in costs! As such it seemed like a deceit, an NHS version of PPI miss-selling. Using the spreadsheet felt like a curious form of self harm.  They have no staff to do anything else I guess, hence, a wrecking ball.

Despite NHSE saying reviews should be at individual practice level to my knowledge we have had no such discussion. The 5YFV promised a New Deal for GP and this appears to be an early instalment... 

We'll leave the crass, unprofessional and uncaring way in which this was delivered as some more serious reflections may get lost in the shell-shock and anger. The PMS premium (the difference between core GMS and PMS baseline) is to be removed from PMS practices' funding (albeit with some transition arrangements locally). That's it, no review practice by practice, no consideration, as thoughtless a procedure as me stopping a drug en masse to get my drug spend down.

Just how unthinking can be seen by asking 'Why the PMS premium in the first place?' PMS contracts functions were twofold: firstly as an contribution to the late 1990s attempt to break up what was perceived as the GP monopoly on primary care and secondly as an attempt to create practices better moulded to deliver services to particular populations. To qualify for PMS funding, practices lost the security of the GMS contract in return for funding over core GMS to deliver additional services which GMS did not cover and which met locally agreed priorities.

So what is the message this across-the-board, unconsidered slash giving? That these PMS contracts, the negotiations, the investment, the planning and subsequent delivery and annual review were all essentially meaningless, even fraudulent, even though the stated aims of the review and the raison d'etre of PMS are essentially identical. All this work can be dispensed with by an Excel formula.

Now no one likes money being taken off them and I realise that some GPs harbour hard feelings toward PMS practices who they feel have been favoured (though they can't claim inequality of opportunity when PMS started). But please read on: this affects us all and many of the MPIG arguments are analogous.

There are immediate practical implications for a PMS practice like ours which will damage patient care. Our PMS bid had two components. One of our service developments was to provide an acupuncture and primary care pain management service for our patients, as well as those from local practices; given that chronic pain is known to be commoner in deprived populations. On the back of this our practice now supports local meetings of acupuncturists and complements our local pain service by up-skilling local GPs. This now faces amputation by the NHSE barber surgeons and they almost certainly don't even know they are doing it. How could they, without talking to us: the courtesy any decent GP would afford their patient?

In recognition too of the fact that deprived populations have higher age adjusted morbidity and consultation frequency at all ages apart from the very elderly, we received some PMS income which was invested in salaried GP time to address that health inequality of access unmet by core GMS, as well as developing better access for mental health, improved LARC, staff training and chronic disease management. This money continues to be well spent: we are in the top 10% for patients recommending the practice on the national patient survey, we are key members of an innovative sexual health scheme (the only surviving project from practice based commissioning locally), have some of the highest mental illness prevalences in the city (patients voting with their feet) and have been very active in diabetes research and in improving primary access to diabetes care. We have expanded our GP training capacity. We have maintained quality despite the erosion of PMS growth value over the years resulting in static partner pay for over 7 years but will struggle to continue if the cuts go through. The irony is that the money freed up by PMS reviews is supposed to be used to address health inequality. In our case it already is but this literally mindless process won't even recognise the fact. We will have to go through another (as yet unspecified) process which will necessarily be similar to the PMS negotiations but with no guarantee we will end where we are now! 'Idiocy' as a descriptor doesn't come close.

It also has deeply damaging implications for future service development. Any trust and confidence I had in the system of negotiating with PCOs in good faith is now wrecked. I used to think working with PCOs was like working with people with dementia; the organisational memory eroded with personnel churn and then vanished with each re-disorganisation; hugely frustrating but liveable with. But now it feels like working with someone with dementia on top of a sociopathic personality disorder.

Goodwill, which used to flow comfortably, now requires active anger suppression and serious moral effort: distrust, loss of respect and suspicion now colour my attitudes to such organisations as a whole (despite enjoying cordial relations with the individuals involved). Given this experience, am I likely to want engage in a PMS-like service development discussion again? Permanent damage is being done to the fabric of trust that underlies innovation in primary care. The sort of commitments 5YFV needs cannot be built on contractual relationships alone.

The NHSE has a huge amount of bridge building to win back the profession's confidence. I see little actual sign of that at present, 5YFV notwithstanding. NHSE has announced £10m to recruit and retain GPs; it would be more effective not to further demoralise practices by taking money away from teams that have a proven track record. Destabilising a key training practice in a city facing huge recruitment issues does seem particularly obtuse. NHSE's mission is 'high quality care for all', so it is ironic that I must report being driven to regard NHSE itself as currently the biggest threat to the quality of what I do.