Saturday, 6 June 2015

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

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