Examination of Witnesses (Questions 20-39)
NATIONAL HEALTH
SERVICE
26 MARCH 2008
Q20 Chairman: I have already given
you credit for trying.
Mr Nicholson: Thank you. Nowhere
else in the world have they got something quite like this and
this is a really important part of the contractual arrangements
for us. It is absolutely true that we judged that general practice
might get in the region of 750 points and, to be frank, in the
negotiations and discussions we had various views were expressed
from 500 points right the way through to 1,000. The critical thing
for us, to be honest, was how we could move the middle group of
GPs' average performance forward; there were always general practices
at the top end of performance. I think QOF has proved a very powerful
way of moving that average performance up.
Q21 Chairman: If you look at paragraph
4.4 you will see that you are basing QOF on things which are easily
measured rather than making patients healthier, for instance it
throws doubt on the number of heart disease patients who have
received treatment.
Professor Colin-Thomé:
I disagree that it was easy. Most of us thought that we would
get about 750 points and even a practice like mine, which had
a track record of doing a lot of chronic disease work, estimated
we would get 90% rather than the nearly 99% we got. That took
a lot of hard work. The thing that QOF does is raise the average
up and it meant that general practice had to get itself prepared
by having systems in place to identify patients who were not diagnosed
and patients to follow up. That took a lot of work; it was not
about being cleverer. On the issues about the processes, some
of those processes are absolutely crucial. One of the processes
mentioned is about measuring blood pressure. About 30% of us have
raised blood pressure. If you can reduce the level of people with
existing high blood pressure, you would save a significant amount
of ill health.
Q22 Chairman: I am in danger of getting
high blood pressure.
Professor Colin-Thomé:
The issue is that that will lead to an outcome by measuring the
ones who are not diagnosed as having high blood pressure. On outcomes
there is also good evidence that on things like heart disease
we have shaped outcomes. There is a guestimate that we could save
something like 400 lives per 100,000 patients. That is what we
can do with QOF and it has already demonstrated it.
Chairman: That is what we are all about:
saving lives.
Q23 Phil Wilson: How much is the
improved recruitment and retention of GPs down to the contract
when you consider that the number of overseas doctors has increased
and the number of doctors that are in training has increased as
well. How much of that increase do you reckon is actually due
to the new contract?
Mr Nicholson: We think the bulk
of the improvement in retention and recruitment of GPs is down
to the contract. It was absolutely the case that lots of GPs were
planning early retirement as part of their contractual arrangements.
We were getting a position where, certainly in the year or so
coming up to the introduction of the contract, it was commonplace
to have one or no applicants for GP appointments. The contract
transformed both of those things. We found that more GPs were
prepared to stay on longer on the one hand and it was becoming
a much more attractive career option for doctors coming out of
training to the extent that there are now lots of applicants for
most GP appointments when they come up. As part of the contract
we had a significant expansion of the number of salaried GPs as
well and you can see that developing something between 3,000 and
4,000 extra during that period.
Q24 Phil Wilson: On deprived areas
again, towards the end paragraph 3.10 talks about difficulty in
attracting GPs to more deprived areas; even though other PCTs
are complaining about the increase in the number of GPs in general
it is these specific areas, where you probably will have the most
issues around public health, et cetera, that need the GPs. Is
this a problem which has persisted over the years? How do we get
round the problem?
Professor Colin-Thomé:
It has persisted since the inception of the Health Service; more
socially deprived areas have been relatively under-doctored for
lots of reasons, some of them more difficult to recruit general
practice and the patients had more problems and therefore needed
extra staffing so it was lack of resources. We have increased
the number of GPs in those deprived areas from the contract. What
we have not done is tackle the difference. That is why our new
policy is to get extra practices specifically into socially deprived
areas. We have tried loads of things over the last sixty years
to try to redress this without any success, whereas the focus
we have with these 113 new practices we are going to get will
make a difference and bring a lot more doctors and nurses into
those areas. It is a very focused bit of work and maybe we should
have done that 20 or 30 years ago, but we did not.
Q25 Phil Wilson: So you are saying
that the contracts are helping to solve the problem.
Professor Colin-Thomé:
It has increased the numbers but it has not closed the gap yet.
Q26 Phil Wilson: Figure 23 on page
20 shows an increased proportion of consultations being carried
out by practice nurses whilst the number of consultations taken
by doctors is actually decreasing. What monitoring is there of
this development to ensure that patients receive appropriate levels
of care and nurses are rewarded accordingly.
Professor Colin-Thomé:
Two things on that. One is that most of those extra appointments
done by practice nurses are reviews of people with chronic disease
which the contract has generated because that is part of the quality
contract of QOF, the quality and outcomes framework. There is
in fact international evidence that nurses are sometimes better
at doing regular reviews than doctors. That is practice based,
the practices have to make sure that quality is there and they
will suffer any consequence of litigation, whatever. Practice
nurses have to be trained and part of the QOF was to make certain
the quality of the team was better. One of the attractions of
QOF was that you have to have proper induction and training programmes;
that was one of the indicators in the organisational framework.
A lot of that work by nurses is the review work for people with
existing diseases.
Q27 Phil Wilson: The new contract
seems to increase the time GPs spend with individuals who are
high risk patients, for example. Is this something you would expect
to see extended?
Professor Colin-Thomé:
Yes and that is partly because of the consequence of taking some
of those reviews away from doctors, who were doing those as well
in the old days, so they could concentrate on the people with
more complex problems. About a quarter of a million patients really
have lots of illnesses in the one person, as it were, and are
getting older and they are the ones we want to focus our attention
on quite a lot because they may not have had the maximal care
they could have in the past.
Q28 Phil Wilson: The new contract
has enabled GPs to offer a greater breadth of services and increased
the consistency of care of long-term conditions. Have you seen
a reduction in the number of emergency admissions because of this?
Professor Colin-Thomé:
No. Emergency admissions have gone up and went up before the new
contract but the amount of time people stay in hospital has gone
down significantly. Even if people are being admitted, they are
ready to be discharged back to general practice much faster and
part of that is because we have better systems in place to review
patients in primary care now. If you look at the emergency admissions,
what they do not tackle in the report is the emergency bed days,
the length of time people stay, which have come down quite considerably.
That is almost all a consequence of care of long-term conditions.
Q29 Dr Pugh: Figure 12 is "Expenditure
against the Gross Investment Guarantee" and what it seems
to show is an overshoot of £200 million in 2003-04, an overshoot
in 2004-05 of £746 million and an overshoot in 2005-06 of
£816 million and the trend is up, in other words the gap
between what you are expecting to spend and what you do actually
spend. Is there any reason to believe it will not continue to
go up?
Mr Nicholson: Yes, there is. Those
total figures were based on an estimate which proved to be incorrect
and the real cumulative figure there is more like £400 million
in real terms. What we have found in the two years since then
is that that has been recovered by primary care trusts. You will
see that over the two years to come after this we would expect
a cumulative underspend of £400 million over those two years.
We expected both to change and reverse.
Q30 Dr Pugh: Okay, but there might
be a certain amount of shifting of costs. I note that you spent
a lot more on out of hours; £78 million more than you expected
to spend. I think it would be fair to say that not all the out-of-hours
organisations set up performed adequately. One of the reasons
for that might be that not enough money was transferred out of
the doctors' contract for out-of-hours provision. Is that a reasonable
assumption?
Mr Nicholson: We transferred £6,000
per GP out and we added to that.
Q31 Dr Pugh: Which probably did not
approximate to the cost of the out-of-hours service.
Mr Nicholson: No; we knew that
because the Department had always topped up the cost of out-of-hours
nationally anyway.
Professor Colin-Thomé:
In the past GPs did not get a fee for out of hours, it was at
a marginal cost to their normal earnings. If we were going to
have a separate service it had to be funded fully and that was
an extra cost.
Q32 Dr Pugh: We needed to find another
£78 million. The service provided then failed to satisfy
the public right across the piece and my presumption is that many
PCTs have put a lot more money into the out-of-hours contract
since then. Am I correct?
Mr Nicholson: They put the amount
of money that is described in the National Audit Office Report.
It is absolutely true that we have implemented a whole series
of schemes in relation to out of hours to improve our monitoring
and the quality of it and the auditing of it. It is true, as part
of that, that to improve some services PCTs may have put relatively
small amounts of money to improve it, but we do not expect anything
of that scale.
Q33 Dr Pugh: "Relatively small
amounts".
Mr Nicholson: Yes.
Q34 Dr Pugh: You do not think an
appreciable amount of money has been invested by PCTs across the
country which will show up in later years' accounts.
Mr Nicholson: No.
Professor Colin-Thomé:
One of the reasons we took out of hours, apart from the low morale,
was that there were loads of complaints about the previous service
and there had been reports and a quality paper published. So it
was not as though there were some rosy past in out of hours; there
had been lots of complaints about the former service.
Q35 Dr Pugh: I am familiar with local
examples from my own constituency where extra money has been put
in because it was thought that the service was not adequate as
it stands and that is going on now, this year and not just immediately
after the GP contract. I wondered whether that pattern was replicated
across the country and you are saying that it is probably not.
Mr Nicholson: Yes.
Q36 Dr Pugh: Emergency admissions.
On page 32 there is an alarming blip in emergency admissions more
or less when the contract kicks in and the NAO are slightly struggling
to come up with a true explanation of that. They mention a variety
of factors there including apparently an increase in violence
in society round about 2003 peaking at round about 2005 and diminishing
thereafter. What is the real explanation for that?
Professor Colin-Thomé:
It predates the opting out of GPs from the 24-hour responsibility
by a good year so that we cannot see any correlation with the
out-of-hours work and the rise in emergency attendances.
Q37 Dr Pugh: So this is nothing to
do with the GP contract.
Professor Colin-Thomé:
That is what we think. It pre-dated, then it flattened, then it
appeared to increase again and it has flattened out again. The
GP contract happened after that. GPs were still working out of
hours even when the numbers went up.
Q38 Dr Pugh: I accept that is an
unfounded allegation put on you by the NAO which you are rebutting.
Practice efficiency. I was surprised to learn that, if you do
things to make your practice more efficient as a GP, the net effect
of that is that you take home more salary. There is no sharing
of the gains of efficiency at all. Am I right there?
Professor Colin-Thomé:
The NAO report says that nurse pay has not gone up to the same
degree as that for GPs, so in that respect you will be right.
Q39 Dr Pugh: If my practice becomes
more efficient—I am a GP and I make it more efficient—the
real beneficiary is me the GP not the NHS.
Professor Colin-Thomé:
No, the NHS has benefited from you running a good practice and
we have some measurements.
| 
