Examination of Witnesses (Questions 40-59)
NATIONAL HEALTH
SERVICE
26 MARCH 2008
Q40 Dr Pugh: But there is no sharing
of efficiency gains.
Professor Colin-Thomé:
No. In many practices, like the one where I was, we actually used
to give bonuses. We could not guarantee year on year a quality-of-outcomes
result so many of us gave bonuses. I cannot substantiate how many
did that.
Q41 Dr Pugh: Did you not think to
cap efficiency gains? Did you not think to cap the amount doctors
could take in efficiency gains from their practice that they could
transfer into their salaries?
Mr Nicholson: They are small independent
businesses at the end of the day. Whilst we are the major customer,
they are still small independent businesses.
Q42 Dr Pugh: It is the entrepreneurial
spirit, is it?
Mr Nicholson: There is something
about that and the benefits that brings to patients overall. It
is true that over the first two years
Q43 Dr Pugh: They benefit better
from doctors who get better paid universally, do they? That is
what you seem to be suggesting. Maybe it is true.
Mr Nicholson: What I am saying
is that practices that are successful, which generate surpluses,
do reinvest them in their practice, but it is true to say that
over the first couple of years or so general practitioners did
take more out of their income from profit than they had in the
past. The indications for this year and probably next year, given
the settlements we had last year under the Doctors' and Dentists'
Review Body, are that will return to more normal levels of profits.
Q44 Dr Pugh: May I touch briefly
on the business of exception reporting which is mentioned on page
36, paragraph 4.8? I understand this to be a sort of gaming device
which you can use to get more QOF points by excluding certain
patients from your assessments where you can give a valid reason,
because they refused to attend an appointment, are allergic and
so on. We know this goes on and clearly the NAO picked up some
of it. Are you confident that the procedures for tracking this
and restraining this are in place? I would have thought it was
extraordinarily difficult, no matter what the PCTs do, to track
doctors not recording their patients.
Professor Colin-Thomé:
There are several things. One is that you need to have exception
reporting. Most contracts in other parts of the world which have
not had that have found that doctors have sometimes coerced patients
into treatment because of the incentives. So you do need exception
reporting. There is a system whereby PCTs can track what percentage
of exception reporting there is. So if there are significant outliers,
as there are in some practices, that is for local management action
to challenge that.
Q45 Dr Pugh: So 84% of PCTs said
they intend to benchmark exception reporting rates and you are
confident that they have the mechanism to do so.
Professor Colin-Thomé:
Yes.
Q46 Dr Pugh: Do you regret in a sense,
given the fact that you have not addressed as many of the health
inequalities through this contract that you had hoped to do, that
QOF points were not more locally determined, allowing people to
deal with the local health problems they were presented with,
which do vary from community to community?
Professor Colin-Thomé:
Number one, we had to get the show on the road first of all and
that is what we want to move towards in the next phases. In terms
of health inequalities, the biggest causes of health inequalities
and diseases are national issues about cardio-vascular disease
and QOF gives quite big incentives to get the care of that better.
If you look at the health inequalities issue, it is not local
issues, it is things like cardio-vascular disease and diabetes
which have a huge class gradient in severity as well as incidence
and that is what we want to tackle straight away. We are in our
next phase, looking at how we can get something local for particularly
local issues, but those are national inequalities issues. The
two biggest causes of inequality are cancer and heart disease.
Q47 Geraldine Smith: What concerns
me is, if doctors are having it so good at the moment, why are
they all so fed up? I have had lots of discussions with GPs recently
and when the new contract was brought in I think there were some
real reasons for doing it and recruitment was one of them and
morale was becoming very low then so you had to increase the earnings.
Looking at the BMA, they talk about a doctor, when you take into
account salaried GPs, just being on £88,000 a year on average.
That does not sound extortionate to me. Since the contract has
been brought in I notice that there has been no inflationary increase
in the value of the contract since 2006. What is going to happen
this year?
Mr Nicholson: That is a matter
for the Doctors' and Dentists' Review Body which will be reporting
soon. They will decide what that is. We put evidence and the BMA
put evidence in and they make their judgments.
Q48 Geraldine Smith: Doctors tell
me locally that one of the problems with the contract was that
there was a significant underestimate of the additional cost of
PCTs providing the out-of-hours service and they argued that it
was because they did so much work that you were not aware of.
Mr Nicholson: Yes.
Professor Colin-Thomé:
Because we were not paid a specific fee extra for out of hours
when we had 24-hour responsibility and it was done at marginal
cost in our existing money, when you costed it per hour of work
then it appeared to be more expensive. I remember the NAO Report
was saying also—and we have addressed this—that if
the PCTs where the most was spent could get to the level of the
ones who were more efficient, there would not have been anywhere
near that significant difference. There was quite a variation
between PCTs. We have addressed that through various techniques.
We had to pay extra for out of hours because it was a new service
in many respects.
Q49 Geraldine Smith: One of the things
in my own area was that we do appear to have a very good service
from our GPs in Morecambe and Lancaster and I have very few complaints
from the public about the service they provide; quite the reverse.
We are one of these under-doctored areas and the proposal is to
bring a new practice forward. This has caused an awful lot of
instability with local GPs. I would ask: why is there no flexibility,
why is there a national diktat, why can local PCTs not decide
which is the best way forward for them to address the problem
of under-doctoring in their area?
Mr Britnell: I was up in your
neck of the woods a couple of weeks ago—Blackpool; I did
not get quite as far as Morecambe. The design of the new service
is going to be very flexible. There is a core specification giving
patients more access to GPs' services, but in terms of the total
flexibility of the contracts which will be awarded, I would say
that over 90% flexibility resides with the PCT. We are being quite
prescriptive in access to GP-led health services because, as you
rightly said, 84% of patients nationally think GPs provide good
services. There are over 6.5 million patients up and down the
country who would like hours extended to be more accessible and
more responsive, so we have been very, very limited in our central
prescription and local prescription is quite wide and varied.
Q50 Geraldine Smith: That is not
the impression I get from my primary care trust. Our local GPs
are asking me, if they could meet the service specification being
demanded of them, if they could do all the things required and
address the problem of under-doctoring in this area then why can
they not do it? Why is there a procurement process? Why is there
going to be a new practice which could in effect destabilise them?
I can see that in the inner cities there might be good reasons
for doing it, but in areas such as my own there is a real need
for flexibility. The PCT have told me that flexibility does not
exist. Are you telling me that is wrong?
Mr Britnell: No, that is not the
case. We are encouraging all sorts of people to tender for the
services the PCTs will commission. We have set aside £1.25
billion over five years for the best of existing general practice,
for new providers, for social enterprises and others to step forward
and compete for the work which will be tendered. They have as
great an opportunity as any other provider to tender for those
services and if they are successful they indeed will provide those
services.
Q51 Geraldine Smith: The problem
is the timescale. With timescale contracts have to be in by December.
Why the massive rush? If you rush things through you are in danger
of making mistakes.
Mr Nicholson: Part of the issue
is, in defence of national action—I normally spend most
of my time defending local action—people could have done
this before but they have not; for a whole variety of reasons
people have not done it. We have not made these improvements and
in a sense that is why we are saying, being slightly more prescriptive
now than we have been in the past, that they must do it and we
are saying they must do it to this particular timetable. To be
frank, we and the population, I am sure, are fed up of waiting
for improvements to primary care services. That is why we are
being quite prescriptive about driving it. Mark is absolutely
right: if local general practice can provide a service to specification
required in the way it was required they will be very competitive
and I am sure the PCT will be as free to pick them as anybody
else. There will certainly be no pressure on them to go outside
of the existing NHS or general practice to do that.
Mr Britnell: It is an opportunity
for those who want to provide even better services to provide
better services. Looking at the previous initiatives, arguably
from 1911 with the National Insurance Act, but I will not bore
you by going that far back, looking at the Fairness in Primary
Care initiatives our analysis is that there are three or four
reasons why PCTs did not get to the hard-to-reach communities:
capability, capacity and also cash. What we have been trying to
do over the last seven or eight months since the publication of
Darzi back in October of last year is work on capability, capacity
and also on cash, which is why the extra £1.25 billion over
five years is a real increase in spending for PCTs. We make it
very clear to PCTs that they can decide as commissioners—and
we may come onto this later on—what else they want to put
in the specifications. We think we have listened to local people,
we have looked at the national GP survey, the biggest one in the
world, and there are 6.5 million people up and down the country
who want extended hours, better access and responsiveness. Therefore
the core national prescription is just looking at access to services
at the weekend and also in the evening. Anything else PCTs want
to do locally is an absolute matter for them.
Q52 Geraldine Smith: So basically
you are telling me that GPs could work together, could say they
can solve this problem by working together, we could put in a
case for that to happen and the PCT will look on it favourably.
Mr Britnell: Yes. One of the issues
raised in this report is in Chapter 4 which talks about PCTs having
to develop competence and confidence to be commissioners. What
we are doing now is giving them national support and encouragement
to commission services for their resident population and that
means that people who want to design and procure better services
have the opportunity also to provide those services as well with
their existing GPs or others.
Q53 Geraldine Smith: Just one other
thing, the 48-hour target. A very well respected GP in my area,
for whom I have a lot of time, complained to me about this. He
said that by having this target it means that the doctors who
have appointments booked ahead where people want to ring and book
an appointment a few days in advance to see their doctor are being
held back in order to meet those targets, so half the appointments
are gone. It means there is very little flexibility within the
system and they are having to tell people who want to make an
appointment to ring back the following morning at 8am and it is
causing jams on the phone lines; 4,000 in one day. Is this a national
problem? Is it happening in other areas? I notice that one quarter
of patients could not make an appointment to see a GP more than
three days in advance and that is often a complaint.
Professor Colin-Thomé:
And yet three quarters did. Many practices have actually tackled
both by having emergency access for people who need it as well
as forward booking. That is the idea; that is our policy and most
manage to do that. Some of it is planning your workflows during
the week and so on and using other persons in the team and using
phone calls and all sorts of things to patients. Arguably three
quarters managed to do both.
Q54 Geraldine Smith: A fair point.
Mr Nicholson: I do think though
that our first priority was speed, it was not convenience. Now
we are into convenience and how we can make services much more
convenient. There are lots of examples around the country where
people have managed to get over this and sort it out really well.
Q55 Geraldine Smith: Would you say
the increased access is demand-led or clinically-led?
Professor Colin-Thomé:
It is patients; it is their Health Service. We have not been as
good. People who like GPs the most are often the elderly with
complex problems who see us a lot. What we have not done as well
with are sometimes younger people with kids and so on and it is
to meet some of those needs that we need to increase hours and
that came from patient surveys. It is for patients who need to
have a better range of services.
Q56 Mr Mitchell: The cost was £1.76
billion higher than the estimate and the statement we have here
from the BMA tells us what a good job doctors are doing, indeed
so they should be if they are 58% better off. What does this reflect:
the superior negotiating skills of the BMA or the incompetence
of the Department?
Mr Nicholson: What I say again
is that the actual overspend was £400 million not £1.8
billion.
Q57 Mr Mitchell: It is still big.
Mr Nicholson: It is still big.
Q58 Mr Mitchell: I do not suppose
you envisaged a 58% increase in the pay of partners.
Mr Nicholson: In a sense part
of the issue was that the existing contract was so complicated
and so difficult to deal with and, interestingly, was not for
the most part, until relatively recently, cash limited at all.
There was no cash limit at all, it was incredibly complicated
and moving to a new contract was bound to be difficult. It is
true that we were really clear at the beginning that we wanted
to boost GPs' pay as a part of it and we wanted to link GPs' pay
to performance and we were successful in doing that. As David
has pointed out, you are driving increased pay through more QOF
points and it seems to be a really good way of doing it. We can
demonstrate, as David has, some of the clinical benefits and outcomes
you can get from driving GPs' pay in that kind of way. The framework
is a good one.
Q59 Mr Mitchell: I accept that things
have improved; I am sensible of the improvement in the service
I get from my own doctor. There still is an inequitable situation
within practices in the sense that the partners are creaming it
off, taking it in profit and the rest of the practice is being
worked harder and paid less. Why did you not cap the profits of
partners?
Mr Nicholson: They are small independent
businesses and that seems to me a really important part of what
general practice is.
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