8 September 2015

A truly new deal for primary care


The primary care sector is operating at unprecedented levels. The statistic showing that 90% of total NHS patient contact is handled through general practice is well known, but more telling is the jump in estimated number of total annual consultations, which is 40 million since 2008.

It is not obvious, however, that all is well. The GP Patient Survey of 2014 indicates that majority of participants were satisfied with every measured parameter, which includes things like overall satisfaction, ease of securing an appointment or adequacy of the waiting time once at the surgery. But it is also true that every single result was a decrease from the previous year, which in turn was a decrease from the year before that, and so on. Satisfaction with waiting times fares by far the worst – 57.8%, or three in five patients, were “happy with the length of time they have to wait for their appointment”. The figure stood at 58.8% in December 2013, and at 60.5% in December 2012.

As for the doctors, the picture is even bleaker. A look at the current GP workforce profile reveals that about a third are over 50, with many planning early retirement. A recent survey carried out by ComRes revealed that a majority of participants are likely to retire before 65. Even more are switching to part-time hours, as the recent Migration Advisory Committee report confirmed. Medical graduates increasingly shun general practice, largely as a result of worse remuneration and work/life balance prospects compared to few years ago. The raft of panicky schemes aimed at boosting traineeship uptake is so far receiving little praise, with many places still going unfilled.

The problem is undoubtedly that of morale. With budgets stretched in every direction partners have no choice but to keep cutting their incomes, but equally important is rising administrative workload, rising costs of indemnity as discontent grows and constant political pressure fuelled by media hostility, and you end up with a problem that won’t be solved with more resources alone.

Indemnity costs of out-of-hours

One issue not brought up in the “new deal” is the rising cost of indemnity cover which, in the case of self-employed GPs, is not paid for by the NHS and instead comes out of their remuneration. Provided mainly by two major defence unions, MDU and MPS, it varies depending on the number of out-of-hours, locum and private sessions it has to cover – anything from approximately £7,000 on average to as much as £30,000.

How does that compare to average remuneration? On the most recent available figures, the average pay for a salaried GP in England before tax was £56,400, making it about 12.5% of the total salary, higher if tax is accounted for – by no means negligible. This proportion is likely to stay the same as a GP moves up the pay scale, because the most profitable activities such as locums and out-of-hours sessions attract proportionately higher indemnity premiums. Top earners in general practice, those who may find their salaries reported in the press, are likely to be subject to indemnity costs close to 5 figures – such as one family doctor who was quoted 30,000 pounds after only doing out-of-hours sessions for 20 years.

The negative effect on incentivising out-of-hours care as part of the 7-day NHS promise is clear. As has been identified by the independent Urgent Care Commission, the disproportionate cost of indemnity is a key factor discouraging GPs taking on out-of-hours sessions, since the rewards are thought inadequate to the work once insurance cost is factored in to the equation. The providers wash their hands, citing increasing levels of litigation against GPs and increasingly excessive amounts awarded in negligence damages against the NHS.

Capping the maximum amount that could be awarded, or the maximum fees personal injury lawyers could charge (which is paid by the NHS in case of a win) has been pitched as one way of reducing the cost of medical indemnity, as well as making significant savings for the NHS budget. The discrepancy between the amount of compensation and the legal costs award can be as high as 2 figures, and is constantly attracting accusation of abuse of the NHS from personal injury lawyers.

According to the NHS Litigation Authority annual review, last year 1.2bn was spent on litigation – that figure includes about 865m paid out in damages and about 20m in claimant legal costs the NHS was ordered to pay as the losing side, making it 1.6% of the total budget. That may not seem like a lot, but the legal costs awarded against the NHS alone could pay for approx. 670 fully qualified nurses, or 250 salaried GPs at the upper end of the pay scale. Factor in the funds paid out in compensation, and these figures rise to 3,700 and 1,300 respectively. But the main effect would be a fall in the increasingly unreasonable indemnity costs for general practitioners, which should contribute to stimulating not just greater uptake of the profession, but also willingness to work out-of-hours.

Penalties and charges: unthinkable or unavoidable?

“Free at the point of use” is said to be the most important pillar of the NHS – tamper with it, and reforming becomes dismantling. At the same time, however, it is also recognised that that the health service is facing serious challenges that could see fundamental changes to the way it functions. Rising elderly population, costly new technologies as well as heightened expectations are stretching the current model of delivery to its limits – whilst public support for the institution is as high as always, an increasing number of people doubt whether the good times can continue.

As researchers from Reform think-tank point out, a factor that is often ignored in debates about the future of the health service is the difference in the state of public finances since the last report on NHS financing in 2001. They cite figures from the Office for Budget Responsibility for their prediction that the rising cost of healthcare will directly cause the public debt to rise from 60% of GDP to 70/80% from 2030 onwards, helped along by a rise in the cost of pension entitlements. If these predictions are relatively accurate, it is very likely that the issue of NHS financing will significantly gain in prominence, and measures that seem electorally untouchable now will inevitably move into the mainstream.

Charges and penalties could be one of them – pre-election poll of 20,011 participants confirmed that even the most hardened supporters of free universal healthcare are increasingly concerned with questions of how much people have “paid into” the NHS (presumably despite their disdain for insurance-based systems):

“For one of the segments, the Armchair Realists, one of the main problems for the NHS was that people’s expectations outweighed what it was realistically able to provide. For two others, Cautious Reformers and Entitlement Protection – this was also a big problem, but one that could be alleviated were it not for another, that “too many people are using the NHS who have not paid into it.” (which they rated at 9.37 and 9.18 out of ten respectively, making them the most serious long –term problems facing the NHS for these segments.)

The most striking result was a staggering 79% of respondents who thought that “the government should consider charging people for missed [GP] appointments as a way of raising extra funding.” Politicians seem to be aware of this change – Health Secretary Jeremy Hunt went as far as saying he would have “no problem” with charging for missed GP appointments.

Would introducing such a measure bring significant positive impact? International evidence suggests it may well do – almost all other OECD countries use charges and penalties to supplement their healthcare pot. France has a nominal charge of 1€ per GP appointment, in Australia the charge is equivalent to £3.90. Ireland and Italy introduced a penalty for ‘unnecessary’ use of A&E as a result of alcohol and drug use. It is not just about raising additional revenue, but also about controlling demand – in Australia, the GP charge is refundable and runs on the principle that better off users will be put off by the administrative trouble of claiming it back.

Patient work vs. paperwork

In the previously mentioned poll, ‘too much being spent on management and bureaucracy’ was the most cited problem with the NHS by all segments of respondents. In the general practice setting, it seems particularly pronounced – a survey of general practitioners conducted by the BMA reveals that the amount of red tape is a top three concern, behind only “additional funding” and “longer appointments”.

A stark example available right now, however, is the process of revalidation. At the beginning of a medical career, a doctor is “licenced” through the GMC – a confirmation of an individual’s fitness to practice medicine. The revalidation, brought in as an attempt to increase transparency regarding standards and encourage professional development, is in essence an extra bit of appraisal (already contractually required for all GPs) except it goes through the GMC and not through a local mechanism.

It is pretty clear the scheme is a financial and managerial disaster. The materials required allegedly take on average 12 to 15 hours to compile – six more than has been expected. These are just the official figures – anecdotal evidence suggests it takes anything up to 40 hours in some cases. Costly outside firms were brought in, such as the software developer Clarity, to propel to whole process, which on the whole had little or no impact. Figures this year suggest that less than 1% of GPs were identified as needing remediation, that is, identified as possibly unfit to practice. Dr Dean Marshall of the General Practitioners Committee at the BMA has summarised the process:

‘I was having a conversation with my partners, a locum and one my sessional GPs this morning (…) the process has taken over completely with no real evidence of any benefit to patients or doctors.’

From the point of view of the managers and regulatory bodies, it is understandable that data is needed to enable them to make informed decisions. The more data you have, the more elaborate ideas can be portrayed as supported by evidence. However, the rule of thumb in administration of public services is that best ideas are simple, because data gathered by tired and in some cases infuriated doctors is unlikely to give an accurate image of reality. There also comes a point where the burden of data gathering necessary for a smart idea outweighs its appeal, no matter how smart it is. Established, proud professions like medicine like to do things their own way, and any ‘brilliant new idea’ is likely to get a hostile response as ‘just another sheet to fill out at the end of the day’.

Towards appreciation

In many respect, general practice has become a lot like teaching. It is the provision of a service that, by and large, society considers their “right”. This places those who provide it between a hammer and a hard place. On the one hand, “customers” take it for granted, which often has the effect of making a GPs life miserable – why should I care if I don’t show up for an appointment, or make my dissatisfaction known just as a customer would, or put up with long queues, or think twice before making an appointment at all? This whole system was put in place to serve me. Why should I be grateful for something I deserve?

The result is that we all lose – politicians as they fail to deliver on their unfeasible promises, GPs as they crumple under an impossible workload, and patients as the quality of care spirals downwards. That is the effect of dancing around the real question – is the status quo sustainable, and if not, how can we make it so given money has to come from somewhere?

Jan Zeber graduated in law in 2014 from the Universtiy of Bristol, where he chaired the Freedom Society