Examination of Witnesses (Questions 60-79)
NATIONAL HEALTH
SERVICE
26 MARCH 2008
Q60 Mr Mitchell: What, making a profit?
Mr Nicholson: Absolutely.
Q61 Mr Mitchell: It is creamed off.
Mr Nicholson: There is no doubt
that in the two years since the contract the amount, as a proportion,
which the GPs take in as profit has gone up. We are confident
that over this year and next year that will go down to historic
levels, so we think that the split will be in the future what
it has been in the past and it does not take into account all
the benefits to patients that we have got out of the contract.
Q62 Mr Mitchell: It points out in
paragraph 2.18 that they are making more profit because expenses
are down and that means they are exploiting the rest of the people
in the practice: the income of salaried doctors has gone up 3%,
the practice nurses are working harder, they are being exploited
so the practice can make a profit.
Mr Nicholson: They are improving
productivity. It seems to me a perfectly reasonable thing for
a small business to do.
Q63 Mr Mitchell: Is it?
Mr Nicholson: Absolutely. They
are also improving services for patients at the same time. It
seems to me that both practices and patients gain from that.
Professor Colin-Thomé:
You might want to quibble about the percentage of extra money
but if you are running a practice—to introduce a bit of
history—in times when it has not been as good the partners
would not get any gain at all, whereas the salaried employees
like nurses would, because they were on a salary. If you are running
a business, sometimes there are vagaries as to how much earnings
are. Two years after the contract deliberately put more resource
into primary care for the reasons we gave, to get more GPs and
so on, but running the business is not an easy pattern, it is
not always profit. In the past we have had staff who decided not
to be partners when offered.
Q64 Mr Mitchell: They want to be
partners, do they not? They want the status of being a partner.
Professor Colin-Thomé:
Not all do. Quite a lot of doctors want to be salaried nowadays
without the responsibility because if you are a partner you have
to run the practice and take responsibility for all the actions
of the practice rather than just your own. Many doctors prefer
to be a salaried doctor now rather than take the responsibilities.
Q65 Mr Mitchell: Let us take the
position of the practice nurses. They are taking more appointments,
dealing with more patients and their pay has not increased anything
like it. They have a grievance, do they not?
Professor Colin-Thomé:
No, but we did increase the numbers to cope with that.
Q66 Mr Mitchell: The numbers, yes.
Professor Colin-Thomé:
The numbers of practice nurses are much higher. The figure about
nurse pay, as the NAO would admit, was done on a sample at a conference
so we do not have detailed figures about their poor pay increase.
It was not a very systematic review. Most of us have increased
the number of practice nurses for the work rather than making
their existing ones work that much harder and many of us also
gave them bonuses but we could not guarantee the year-on-year.
We have had a continuing increase in nurses.
Q67 Mr Mitchell: Is it a good thing
that practice nurses are doing more of the appointments?
Professor Colin-Thomé:
It is for the reviews. There is a lot of evidence from international
work that if you have a chronic disease like diabetes the systematic
review is done better by nurses than doctors; doctors are better
at handling more and differential problems.
Q68 Mr Mitchell: I take that point.
Why, if the contract was so good, do you now have to bribe practices
into staying open longer, which is what you have been doing?
Mr Nicholson: We are not actually
bribing them.
Q69 Mr Mitchell: You are offering
to pay more if they work longer hours.
Mr Nicholson: No, we are recycling
money we already give them for other things into this area. We
currently give them money for choose-and-book and the access which
we expect them now to deliver and we are moving that money over
to pay them to open for extra hours. It is recycling money: it
is not extra money we are giving them to do it.
Q70 Mr Mitchell: It is still more
money for them, is it not, to work longer hours which they should
be working anyway?
Professor Colin-Thomé:
No.
Mr Nicholson: No, they are losing
money out of one part of the contract and they have to earn it
in another part.
Q71 Mr Mitchell: It struck me, going
round talking to doctors when this proposal for longer and longer
hours was put up, that they did not want it, they did not feel
it was necessary. They were prepared to accept it because they
were getting more money but the chief opposition came from the
practice nurses and the other staff who wanted more time at home
with the kids. They were the ones being exploited and they were
the main opposition to longer hours.
Mr Britnell: I understand some
of the concerns. Just a quick point on the progressive nature
of the contract. As we have already said, through pay and prices
and also recycling money both in QOF and also in access, we have
over the last two or three years started to make the contract
in a global sense much more efficient and effective. As Mr Nicholson
has said, you will see over the next period of time, the next
couple of years, how the contract is working more progressively.
While this Committee is absolutely right to point out in the first
two years the performance of the contract, we are confident that
the mechanisms in place through QOF especially but not exclusively,
are starting to make the contract work much more efficiently in
the interests of patients. Specifically in terms of the points
you raise, we have worked very hard with the GPC, with the profession,
with the Royal College of General Practitioners and others in
primary care and I cannot find anybody who does not believe that
extended hours are a better thing for patients. That is why, in
the recent GPC ballot 92% of GPs expressed a preference for option
A, which was extended hours which come out of existing money.
Q72 Mr Mitchell: Let me stop you
there because I want to move on to another issue. You obviously
hoped and we would have wanted you to improve the number of doctors
and the quality of service in the deprived areas, of which Grimsby
is certainly one. Why has there been no improvement?
Professor Colin-Thomé:
Previous incentives just have not worked. We had all sorts of
inducements for people.
Q73 Mr Mitchell: What is the problem?
Are they not paid enough?
Professor Colin-Thomé:
I used to work in a socially deprived area myself. It is partly
that you did not get any extra resources in the old contract.
In the new contract you do, but it is still not focused enough
on the underprivileged areas. The money followed the doctor and
it was often nicer to work in posher parts of the country and
that is why we lost out. The contract could redress that, but
it has not been focused enough so we are tweaking it now to make
it even more focused and producing more practices in there as
well.
Q74 Mr Mitchell: Are there not levers
in the contract for the PCTs to lever more people into deprived
areas? Why are you now having to put up another £250 million
under the Darzi proposal to establish 113 more practices in deprived
areas? Why?
Mr Britnell: When we looked at
Fairness in Primary Care which had patchy success, it was a combination
of capability, capacity and cash. Our strategy this time is to
move quickly, because we should have addressed this issue some
time ago, by putting extra cash in over five years, £1.25
billion, and helping PCTs commission services. We are looking
at the primary and community care strategy which was part of Lord
Darzi's work in the Next Stage Review. We are looking at other
issues which actually stop patients moving around more quickly,
where commissioners and PCTs want to commission new services.
We are looking at that matter.
Mr Mitchell: Could you tell us in a written
answer where the money is going to go and what I am going to get
out of it?[1]
Chairman: Send us a note.
Q75 Angela Browning: Is it not the
case that when the Government first set up the new GP contract
they really failed to understand the quality of the service which
was already being provided and therefore the QOF resulted in them
reaching their targets relatively easily because they were being
paid extra money for pre-existing activity? Is that not one of
the problems in terms of delivering good value for money under
the new contract?
Mr Nicholson: There is no doubt
that one of the real issues was that we did not really know very
much about what was happening generally. The nature of the contract
was such that it was extraordinarily difficult to be able to identify
what the quality of a particular general practice was, the quality
of the services it was providing, because there simply was not
the information. The contract itself was so Byzantine that it
was difficult to get to the bottom of it; that is absolutely true.
It was very difficult to get a handle on what the existing quality
was. What we were doing then in those negotiations was using the
best information that we had to make the judgements that we made.
Even the best practices had to improve themselves to deliver QOF,
to be much more systematic and very often outcomes are driven
by the way a practice is organised, by the nature in which patients
are followed up, by the way in which services are wrapped round
their individual need. That is quite tough and quite hard work
and lots of practices, even the best ones, had to do things to
make that happen. Whether it was going to be 75% or 85% or 60%
was a matter of judgment at the end of the day and the best people
we got to look at it thought it might be 75%. It proved to be
a very effective way of driving improvement in primary care because
the general practitioners got hold of the issue and drove it very
quickly. As you have seen by the results, there has been a massive
shift in terms of QOF points.
Q76 Angela Browning: Do you feel
you have now got your benchmark, given that you did not have the
necessary information to start off with?
Mr Nicholson: Yes, we have much
more information now about the quality of primary care and we
are in a much better position now to drive things on. What we
have done already is to look at new clinical domains for which
we can develop quality and outcomes frameworks. The whole quality
and outcomes framework is based on continuous improvement, so
it is not that you get your quality points and you will get them
for ever by just doing the same thing. We will constantly, year
on year now, be looking to ratchet up quality and improvement
as part of the QOF scheme.
Professor Colin-Thomé:
In fact in 2006-07 we did that; we took 138 of the existing points
saying we could move on and brought seven more clinical areas
into the contract and increased the minimum that you had to hit
to get the threshold. So already there was a continuous quality
improvement approach.
Q77 Angela Browning: Thank you; you
have led me very neatly into my next question which is about omissions
and that is things which were not actually included initially
in terms of the GP contract and you have mentioned seven clinical
areas which you have just added. What is the criterion for deciding
what you add?
Professor Colin-Thomé:
People put in their submissions and it could be lay people, it
could be interest groups. We have an independent academic unit
which assesses the cost effectiveness and the evidence base. Even
though there are many worthy causes, there is no evidence base
that actually seeing the doctor will make any difference. So this
academic unit makes the decision as to the effectiveness and the
cost effectiveness of the submissions people put in.
Q78 Angela Browning: Thank you for
that. I do not want to go too deeply into this because I want
to go on to something else. There are certain things that GP practices
can do within the practice but they are also a very important
referral gatekeeper to other services, other disciplines. Is that
primary role as gatekeeper still there in terms of them referring
on across the piece rather than the specialisms that might be
developed because of the QOFs?
Professor Colin-Thomé:
Yes, most general practitioners are proud to be generalists, that
is you can serve the individual patient and their varying needs
rather than one special area. That gatekeeper function is an essential
part of general practice and with practice-based commissioning
we are going to reinforce that gatekeeper function so that more
care can be done in community settings.
Q79 Angela Browning: Could we move
in a similar vein on to the question of the GP out-of-hours service
where we notice on page 6 in the general point under paragraph
10 it says "We found that the costs exceeded estimates and
out of hours providers, although beginning to deliver satisfactory
standards, were not yet meeting the national quality requirements".
Clearly we have heard various reasons as to why there were problems
with the out-of-hours service. I have heard some of them from
my own constituents and as a generality I would say, from my constituency,
a lot of problems are around matters to do with the elderly who
very often are a big call on out-of-hours services. What are these
national quality requirements that they are not meeting and how
are you addressing that?
Professor Colin-Thomé:
They were mainly on speed. I do not have them all in my head I
must admit. They are on how quickly you access the phone, how
quickly you respond to an urgent appointment, how quickly you
actually visit and so on. It was on access. Part of the quality
requirements were also that you could see a GP, if there were
a need for it, you could get a home visit, if there were a need
for it and the PCT has to audit their services. There were also
some very quick access ones which I do not have in my head and
they did not meet all those. However, there was no evidence that
clinical care was bad, it was more on speed of access and that
is what we are going to improve. Since that last NAO report we
have set in process a benchmarking system and an audit system
which makes it easier for PCTs to assess their success against
these criteria.
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