Examination of Witnesses (Questions 660-675)
DR DAVID
MCKINLAY,
DR GRAHAM
ARCHARD, PROFESSOR
SELENA GRAY
AND MR
PAUL HOLMES
29 JUNE 2006
Q660 Mr Campbell: What about your
comments in your submission that there is a shortage of education
facilities in primary care. You mentioned that in your submission.
Can that be addressed?
Dr McKinlay: We are addressing
it and that is the way in which I was just mentioning it, capital
outcome. There was a second tranche of money for primary care,
£108 million a little while ago, that did not require a consultation
with the deaneries. I surveyed my other fellow directors and with
one exception, which was South Yorkshire that came to light only
later when I shared this evidence with them, the deaneries were
not consulted and that money had not been used to develop training
capacity, which is a shame. There is a small sum of money called
the Primary Care Development Fund that is out there now which
again requires consultation with the deanery. They are very small
sums and it is also deprivation weighted so some areas that could
provide more training would not get that funding if they are considered
to have enough doctors. In the North West six of the bottom 15
PCTs are in my patch so we would be very keen and we have pushed
a lot. When you mention re-organisation, I have been around for
a while and there has been roughly re-organisation every two years
and there is a period of limbo while we are settling in. A key
of our strategy has been getting out of the deanery and talking
to the PCTs. Four or five of those meetings have been cancelled
in the last few months by the PCTs because they did not know whether
they would exist, so we have got a built-in cycle of inertia while
things bed in before the next.
Q661 Dr Taylor: I want to go back
to redundancies, first in primary care management and then possibly
in public health too. Mr Holmes, obviously there is going to be
a tremendous reduction in the number of PCT staff when we cut
them. Do you think redundancies are mostly going to be in managers
or will they be in people who are working on commissioning?
Mr Holmes: The people who work
on commissioning largely are managers working within primary care.
Q662 Dr Taylor: I put that badly,
direct service managers as opposed to those who are coping with
commissioning.
Mr Holmes: I think it more likely
that the redundancies would come in the range of corporate functions
within Primary Care Trusts. There are a wide range of corporate
functions so, for example, in addition to commissioning there
would be information technology support provided to practices
and performance management of contracts, the actual administration
of contracts, financial functions and human resources, et cetera.
It is that range of functions where the bulk of redundancies would
fall. The provision of community health services provided by Primary
Care Trusts is a relatively small proportion of the business of
the Primary Care Trusts and effectively it is an operational management
service which needs to be supported.
Q663 Dr Taylor: Do you think the
economies that are forecast will be made? Cutting the PCTs by
half, is that going to cut the staff by half or are lots going
to have to go and continue to work for the bigger PCTs?
Mr Holmes: I think we will see
a significant reduction in the overall number of managerial and
administrative staff within Primary Care Trusts. I could not venture
a figure to you.
Q664 Dr Taylor: Do you think there
will be an overall saving?
Mr Holmes: I think there will
be, yes.
Q665 Dr Taylor: In our inquiry into
changes to Primary Care Trusts, we did get a statement from the
Department of Health that public health departments would be excluded
from the £250 million cost saving exercise. Is that being
borne out? Do you hear of public health doctors who are likely
to be made redundant where you lose a Primary Care Trust that
has got its own Director of Public Health or an area like mine
where you are going to lose three Primary Care Trusts and three
Directors of Public Health, do you get any inkling that there
are going to be redundancies there?
Professor Gray: The statements
made by the Department of Health are very helpful. I think what
is not completely apparent is the mechanism by which they are
going to make sure that happens. We have got a series of recruitment
rounds taking place now with various guidance which does not give
any guarantees that these posts will not be lost. What we want
to see is a very strong line from the new SHAs and the regional
directors of public health to make sure that the existing capacity
is protected. We know from our survey that only 36% of the current
ones feel that they have got enough people to do the job. We cannot
afford to lose anyone in this round.
Q666 Dr Taylor: Are most PCT directors
of public health applying now for the one job that still exists?
Professor Gray: Yes, in the next
few months they will be going through that process.
Q667 Dr Taylor: We have heard of
one SHA Director at least who is resigning in complete frustration
to all the changes. Are there any more that are going?
Professor Gray: A number of the
top tier, the regional directors of public health and the strategic
directors of public health, who are currently going through the
appointment round, have chosen to take early retirement or not
to go through the process.
Q668 Dr Naysmith: Mr Holmes, as you
are well aware there have been new contracts in Primary Care for
doctors, dentists and pharmacists and there were lots of ideas
behind these contracts but they were supposed to improve productivity
and quality at the same time. In your experience, have they done
that?
Mr Holmes: The dental and pharmacy
contracts have only very recently been implemented, it is too
early to say what the impacts will be. In relation to the GP contract,
again I can provide you with some local evidence. The scores,
as evidenced by the quality and outcomes framework, are uniformly
higher across my own PCT, so 91% of the available points have
been attained by the practices within Kingston and that compares
very similarly with the national average. We have seen, in the
first two years of the quality and outcomes framework within Kingston,
a 5% increase in the number of points which would indicate that
there are improvements in quality. For the forthcoming year, or
the year we are in now, the bar has been set a little bit higher
and it will be interesting to see whether we maintain the rate
of improvement.
Q669 Dr Naysmith: The QOF targets,
being met and met much higher than expected, cost the NHS about
£150 million nationally and some people are a little bit
cynical about whether that quality of improvement has been reached
and some suggest that there should be changes to the contracts
to make the GPs work harder. Now, having been married to a GP
for a long time, I know that many GPs work very hard but it does
seem sensible that if these targets were met so quickly and so
easily maybe you need higher and more demanding targets. Is that
your view?
Mr Holmes: Certainly as I said
earlier, Dr Naysmith, for the current year we are seeing the targets
being somewhat stiffened. The process of assessing the performance
of individual practices is a very robust process in my own PCT.
It entails a combination of PCT managers, non-executive directors
who are specially trained for the purpose and clinical advisors
going into practices. One of the benefits we are learning from
this process is that they are identifying where there are particularly
good examples of good practice and are able to then share that
learning across the Primary Care Trust. We should also remember
that the quality and outcomes framework is not just about performance
of individual GPs, it is about performance of the whole practice
team and the more effectively the team work, the more likely their
performance will be strong.
Q670 Dr Naysmith: Do you think that
the contract is delivering value for money?
Mr Holmes: Again, I think it is
too early to say. I think we need to allow a longer period of
time to assess whether we secure continuous improvement over that
period of time.
Q671 Dr Naysmith: I agree with what
you said about dentists, it is too soon to say about dentists,
but with pharmacists it was last year that the contract was renewed
and there has been a lot of talk about things. Do you think there
is going to be delivery of some of these things that have talked
about, pharmacies having places you can basically drop in and
discuss aliments with pharmacists and so on. Is that beginning
to happen?
Mr Holmes: It is, we have seen
some good evidence of an extended range of services being provided
by practices. For example, in my own patch we have pharmacists
who are now offering needle exchange services and safe needle
disposal services, advice to individual patients, assessment of
patients and something that we are particularly proud of in Kingston
is last year we asked all pharmacists who contracted with us to
support six public health campaigns during the year and they did
that very effectively.
Q672 Dr Naysmith: Do either of the
other two general practitioners want to comment on what has happened
since? It has been widely misunderstood in many places. It is
a question of quality and value for money really.
Dr Archard: The first point is
that the very term Quality and Outcomes Framework would imply,
and I think correctly, that all those practices which are achieving
a high return on their points which is, as we have already heard
the performance has been significantly greater than initially
anticipated, is a demonstration first of all of quality because
those markers were agreed markers between the profession and the
department. These were markers of quality, not the only markers
but nevertheless they were markers of quality. By achieving high
standards in that, that would demonstrate that quality has improved.
The second thing is that this is an outcome as well and by improving
the quality of patient care, our outcomes should also be improving.
It will not be in the first year but on the long-term basis, outcomes
will have improved. When it comes to productivity, this rather
depends on what you mean by productivity. If you mean by that
the number of patient contacts, then there is no doubt that patient
contacts have increased dramatically within the primary health
care in order to achieve the outcomes framework in as much as
seeing patients more frequently, ensuring that people are chased
up more for their regular reviews as well as for ongoing conditions.
I do rather take exception to your words that targets were met
so easily. Like most practices in my area, we scored extremely
highly; the reason we scored extremely highly is because we worked
extremely hard. We employed two full-time nurses as well to try
to move this agenda forward. We had practice meetings on a weekly
basis to try to move the agenda forward. We had meetings with
our patient group to try to find ways of encouraging patients
as well to adopt the standards and so on and so forth. If my practice
is anything to go by, and I have no reason to believe it is not,
then it was far from achieved easily, it was achieved by extremely
hard work.
Q673 Dr Naysmith: Why then do you
think there was this junction between what the Department expected
to happen and what did happen?
Dr Archard: There is an old adage
which says if you want a GP to do something write the instructions
on the back of a cheque, I do not think that is necessarily true
but nevertheless there is some incentive there.
Q674 Dr Naysmith: Some people would
take exception to that statement!
Dr Archard: If you do provide
resources in the form of a financial reward that means, as in
my case, we were able to employ two full-time nurses and that
resource enabled us to employ those people in order to achieve
that quality objective. Without that resource, we would be unable
to do so and that is why, the Government put their money where
their mouth was and said in order to achieve this quality we need
to put some money in. They put some money in perfectly appropriately
and as a consequence that was reinvested in a big way by the primary
care. Every single member of our practice team, from the most
junior receptionist to the most senior nurse had a cut in the
QOF and that is the case with a vast number of practices, everybody
benefited from the QOF, everybody was a team member and it is
because of that team approach, which has been encouraged by the
QOF, that we were able to move forward. I have no doubt at all
that, even with the higher setting of the level in the next year
the performance will increase yet further.
Dr McKinlay: I strongly support
everything Dr Archard said, I have just one or two other small
points. The risk here is to personal and continuing patient care
which is much valued by patients and I think that has been put
at risk by what are essentially incentives to fragment the service.
This is reflected in us having a cancer network, a vascular disease
network and a diabetes network. My patients have diabetes and
vascular disease and they are pretty depressed about it so which
of the silos do they get fitted into? Primary care is one of the
great benefits of the NHS and the patients need their advocate
and their guide to the NHS more than they have ever needed them.
If I get through next Tuesday's surgery, I will have got through
my career without being sued, I do not think that is ever going
to happen in the future because of the changing culture. When
I mentioned my concerns about the retirement workforce, there
was a follow-up study to mine done in South Yorkshire by Dr Pat
Lane—and the Chairman might be interested because Rotherham
was included in that—it was clear that the same factors
that were operational, revalidation, litigation and turning up
the burner on the QOF in the wrong directions, ie more hoops,
would have a detrimental effect on the people who are going to
retire. It would seem that we are looking at about 15% of GPs
in the next two to five years, there were one or two studies.
There was a straw poll done the other week by one of the GP newspapers
which said 17% in two years; the South Yorkshire survey suggests
22% in Barnsley and Doncaster and 14% in Rotherham and 10% in
Sheffield we are in that sort of area but if we make life harder
for a lot of GPs who feel they are working harder, it will affect
retirement. The other bit of anecdotal evidence is that my team
tell me that the gap between training and non-training practices
has narrowed substantially. I have got people going out to advise
non-training practices how to become training. We have had quality
assurance of training practices for a long time. I have always
defended the strengths of the independent contractor status because
it gave us the flexibility to deliver a local service but the
downside was that you got some unacceptable practice, you have
got an unacceptable face. That independence has gone so I think
this framework has great potential to redeliver the quality and
it was not always back of a cheque. For years GPs were paid to
do cervical smears and the cervical smear rates did not respond
as we wanted so it is not just about money, I think the culture
has changed towards quality.
Q675 Chairman: Can I have a supplementary
on that. South Yorkshire has always had very high levels of GP
patient ratios, I know 15 years ago it was the highest in England
and Wales, that has changed a little bit now. I asked the question
earlier about whether or not the new contract is likely to change
in terms of getting GPs to come and work in places because we
have on my border the constituency which has got the United Health
Care preferred bidder in there to GP practices. One of them, as
I understand from the MP there, has been empty for years and we
could never deliver a GP to come and work in these mining communities
or ex-mining communities that we represent. Is it to be helped
that we are going to be able to get the National Health Service
to provide us with more GPs than what it has done for the last
60 years, particularly with our health inequalities?
Dr McKinlay: If the PCTs have
the resource and the flexibility to make it attractive. This is
why our strategy is grow your own. There is evidence from a London
study that people do settle near where they train. I am afraid
disparity was mentioned about where GPs are trained, there was
this idea a few years ago, which I was trying to rebut, that people
would train in Brighton and work in Blackpool, it does not work
like that. I think the MPC did quite a good job over the country,
it had problems with London, but the Medical Practice Committee
had its incentives like initial practice allowances to get people
to set up in new towns and in deprived areas and over a number
of years, they did quite a bit to improve it. It would be better
local solutions but they need to be able to put together a package
that is attractive. One of our other strategies is to get bright
school kids and give them good quality work experience in general
practice before the consultants in the teaching hospitals poison
their minds and that has worked quite well in some of our deprived
areas.
Mr Holmes: I would totally endorse
Dr McKinlay's comments. When I was working in the South West in
the workforce development, we put a huge amount of effort into
both retaining and attracting GPs, and I fully concur with Dr
McKinlay's comments about the importance of hanging on to the
trainees who you have. We spent a lot of time working with groups
of GP registrars to find out exactly what they were looking for
in a first job and did our utmost to work with PCTs to ensure
that some of those aspirations were met. At the other end of the
scale we did a lot of work with GPs nearing retirement who did
not necessarily want to keep on day in day out—Dr McKinlay
may be an exception—running their surgeries but were very
interested in, for example, areas of work such as mentoring, supporting
and developing GPs. We did our best to encourage that and to enable
those people to stay in the workforce longer. I think you have
to work really, really hard at it.
Chairman: Could I thank you all very
much indeed for coming along to this morning's session, and we
have not run too far over this week I am pleased to say. Can I
thank my colleagues for that as well, I hasten to add. Thank you
very much indeed. I suspect it is going to be 2007 before this
report comes out in any shape or form but it is a bit of a moving
picture. Your assistance has helped us greatly this morning, thank
you.
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