Tuesday, 27 January 2015

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.

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