Memorandum by the Royal College of General
Practitioners (PEX 21)
EXECUTIVE SUMMARY
1. I write with regard to the Health Committee's
inquiry into public expenditure. The RCGP welcomes the Government's
commitment to the NHS. However we recognise that significant efficiencies
will still be required. Current resource allocation will need
to be reconfigured with greater emphasis placed on community and
social care than is currently the case. GPs have a significant
role on this.
OVERVIEW
2. The Royal College of General Practitioners
is the largest membership organisation in the United Kingdom solely
for GPs. It aims to encourage and maintain the highest standards
of general medical practice and to act as the "voice"
of GPs on issues concerned with education, training, research,
and clinical standards. Founded in 1952, the RCGP has over 42,000
members who are committed to improving patient care, developing
their own skills and promoting general practice as a discipline.
3. The College welcomes the opportunity
to give evidence to the Health Committee's inquiry. It is impossible
to escape the implications of reduced public spending, but the
reality of reduced funding must not be allowed to cloud the fact
that providing care for patients is the top priority of the health
service.
4. At the heart of general practice is the
relationship GPs have with patients. We provide them with lifelong
care. Patients want personalised care from a GP they know and
who knows them. This is the best, most cost-effective way to deliver
health services—GP care for a whole year costs less than
a single day's hospital admission.
5. The RCGP recognises that an effective
way to cut costs is to treat more patients in the community and
to reduce unnecessary hospital treatment. Making the shift to
treating more conditions in the community will require all parts
of the health service working together. This is outlined in a
Joint Statement from the RCGP and the Royal College of Physicians
Making the best use of doctors' skills: a balanced partnership.[30]
Doctors must be encouraged to work together across traditional
boundaries to meet the needs of patients.
RESPONSES TO
SPECIFIC QUESTIONS
Strategic Assessment
— What level of commitment is national
government making to the NHS, and how does it compare with long
term trends of demand, cost and efficiency?
— What are the implications of the "£15-20
billion efficiency challenge" described in the Revised Operating
Framework for the NHS as "absolutely critical for the future"?
— What commitment is the government making
on capital expenditure as opposed to revenue expenditure?
— What level of commitment is national
and local government making to Social Care, and how does it compare
with long term trends of demand, cost and efficiency?
— What are the implications of the government's
plans for the interface between the NHS and Social Care?
6. The RCGP welcomes the commitment made
by the government to the NHS. The coalition government has placed
great emphasis on its commitment to the NHS in its plans and has
ring-fenced its budget. Despite the government's commitment[31]
substantial efficiencies will still be required.
7. The revised operating framework for the
NHS[32]
reaffirms how the NHS in England has been tasked with making £15-20
billion efficiency savings from 2011-14 with a focus on improving
quality and efficiency simultaneously. To meet this the NHS has
identified that there needs to be a focus on Quality, Innovation,
Productivity and Prevention (QIPP). Proposals for new ways of
working or service redesign should demonstrate how they meet the
QIPP challenge if they are to be successful.
8. These aims cannot be met under the current
methods of interjecting intermediate services and making savings
on the margin of the number of referrals. The change required
is broader. If £15-20 billion of savings are to be made,
the needs of patients currently requiring referral need to be
met in other ways: either by redesign of services to lessen unplanned
hospital input, by earlier intervention in the community, or (if
appropriate) by improved knowledge of both doctor and patient
that enables more effective prevention of referral.
9. Additionally savings will need to be
delivered in hospital care. It is the main part of the NHS able
to deliver the bulk of the savings required. However it will need
to concentrate on procedures of limited effectiveness, if it is
not to stop worthwhile procedures. The implication is that referrers
will have to target procedures to those most likely to benefit.
Protocol based services are not good at this and therefore it
is necessary to roll back on current policy and encourage GPs
to target referrals at the individuals most likely to benefit.
That produces a profound change in policy and leads to reductions
in employment of intermediate services and those performing the
unnecessary procedures in hospitals.
10. The King's Fund and Institute of Fiscal
Studies' (IFS)[33]
examination of the impact of the economic crisis on NHS spending
from 2009 contends that government estimates of an efficiency
challenge of £15-20 billion are somewhat under estimated.
They compared likely funding with the original funding estimates
produced by Sir Derek Wanless in his 2002 report. Here estimates
are in the range of £21-30 billion.
11. The King's Fund[34]
revisited this study again recently following the change of government.
They highlight how critical decision areas for commissioners will
relate to allocation of resources and improving health outcomes
from existing budgets. They argue that focus should be on reducing
spending on low-value interventions; integrating care between
health and social care boundaries; and redesigning patient pathways
to avoid unnecessary hospital episodes.
12. This strategy is also echoed by the
Nuffield Trust who state that in the short to medium term the
biggest efficiency savings could be made in hospital services.
For example, through reducing preventable emergency admissions.
(Dixon, 2010;[35]
Blunt, Bardsley & Dixon, 2010)[36]
Interface between health and social care
13. The Coalition Agreement states that[37]
"we will break down barriers between health and social care
funding to incentivise preventative action". In addition,
they have established a commission on long-term care. However,
it is uncertain how this will impact on the funding allocation.
14. Preventive action is said to reduce
cost, however it does not always do this. First, there are costs
to saving premature death and putting patients into chronic disease
management programmes as they still need care but it is delayed
a few years. Secondly, some programmes have been successful but
admissions have still risen, for example, cardiovascular disease
where the premature death rate has halved but admissions have
risen not fallen due to early intervention and the change to encouraging
all undiagnosed chest pain to go to hospital.
15. The Government's commitment to social
services will hopefully be greater understood by the forthcoming
proposals for the future funding of social care and the white
paper on public health later this year. It is hoped that greater
clarification on the additional remit of local authorities will
be provided.
16. The RCGP believes that integrated working
between primary and social care is important to ensure a joined-up
and holistic approach is taken to the delivery of care in the
community and the effective reduction of health inequalities.
This is particularly important in areas such as end of life care,
substance misuse, care of the elderly and mental health services
where a high proportion of patients will have co-morbidities requiring
non-medical interventions that could be facilitated through the
development of an integrated care plan.
17. If more people with debilitating illness
are treated in the community, then social care will need to reorganise,
with closer working with local practices and GP consortia. It
is currently focussed on the hospital sector because demand from
community is lower.
Centrally funded health services
— What proportion of the health budget
is "top-sliced" (ie reserved for central disbursement
by the Department of Health or NHS—and not allocated to
PCTs)?
— What services are procured from this
"top-sliced" budget, and how do the government's plans
for those services compare with long term trends of demand, cost
and efficiency?
18. The greatest proportion of Department
of Health expenditure is spent directly on the NHS with 80% of
the NHS budget spent through PCT allocations.[38]
(For example, approximately £80 billion of the Department
of Health's £99.8 billion budget was initially allocated
to PCTs for 2009-10.) Of the health budget that is "top-sliced"'
it is variously allocated to services such as: arm's-length bodies,
connecting for health, research and development, NHS Litigation
Authority, vaccines and pharmacy. Arm's-length bodies have already
been ear marked for cuts and reform.
19. The principle of the reform of the NHS
is to give responsibility to the user of resources. For the community,
that is the GP. GPs will need to manage other community referrers.
However for tertiary care, secondary care is the referrer. The
move to paediatrics and maternity as separate services means that
GPs will find it difficult to control these budgets. These referrers
will need training and introducing to budgetary responsibility
unless these budgets are also given over to GP commissioners.
20. Highly specialist services will have
to be purchased separately if it is felt that the service they
provide is of value. Of all services these cost the most and deliver
the least in population health.
Resource Allocation within the NHS
— How is the formula for allocation of
NHS resources between PCTs constructed and reviewed?
— What arrangements exist to "cushion"
resource shifts implied by the allocation formula?
— What is the impact of this system on
the budget allocations of a representative sample of PCTs?
21. The underlying principle of the formula[39]
for allocation of NHS resources between PCTs is to distribute
resources based on the relative needs of each area. This is to
enable PCTs to commission similar levels of healthcare for populations
with similar healthcare needs, with the further helping to reduce
avoidable health inequalities. The formula covers three main components:
hospital and community health services; prescribing and primary
medical services.
22. Currently PCT expenditure roughly breaks
down as follows: hospital services account for approximately 65%;
primary care accounts for about 11%; prescribing 12% and community
services 9%. (Dixon 2010).[40]
23. The allocation of budgets and the variation
each year is troublesome. It is a difficult and inexact science.
The long term healthcare of populations cannot be turned on and
off. The system currently is not that good but a doctor is not
going to be able to fix that. The system will need to address
the existing problem of variable distribution within PCTs.
24. We believe that the way that resources
are allocated should be closely linked to deprivation and health
need. We believe that the number of patients with major chronic
illness, the numbers in nursing homes and other factors are reflective
of health need and deprivation, and should be considered within
the allocation of budgets.
Locally commissioned health services
— What are the implications of the government's
top-slicing decisions for the budgets for locally commissioned
health services? How do the resulting budgets compare with long
term trends of demand, cost and efficiency?
— What proportion of locally commissioned
health services are absorbed by services which are:
— Demand-led according to nationally
prescribed formulae?
— Driven by demand for emergency or
urgent care?
— Available for elective or non-urgent
services?
— What scope exists for locally commissioned
health services to manage demand, cost and efficiency to increase
the resources available, in particular, for elective and non-urgent
services?
25. Scope for the management of demand,
cost and efficiency potentially lie in a number of areas. For
example, shifting care from hospital to community settings, self-care
for minor ailments, further reducing waste in the NHS and avoiding
duplication. Equally greater integration of services may also
reduce avoidable costs.
26. In relation to the proportion of locally
commissioned health services driven by emergency or urgent care,
it is difficult to obtain exact data on this, as it is not routinely
collected. It is estimated that non-GP referrals, principally
emergency represent 74% of non elective admissions locally.
27. As Dixon (2010)[41]
who points out there are still significant levels of waste in
the NHS that can be reduced. For example, there continue to be
unaccountable variations in clinical practice; there have been
significant rises in emergency admissions to hospital for patients
with conditions amenable to primary care and for admissions with
zero length of stay.
28. However it is not known if the problem
is provider pull or referrer push. The system creates incentives
for provider pull. The number of emergency admissions have been
rising significantly. A study by the Nuffield Trust[42]
found that the overall number of emergency admissions in England
rose by 11.8% over the five-year period 2004-05 to 2008-09.
29. Currently there is limited ability to
control this activity. Robust data and clinical review are required,
however Trusts do not collate this data at present. As discussed
earlier, referral management needs to be addressed. However it
is usually applied to elective not acute activity. It is usually
GP not other. The best trained and qualified referrers are subject
to review whilst the largest part of the referrers are not. These
are new and inexperienced referrers as well. Despite these concerns
it is difficult to see how real time review of acute casualty
referrals can be introduced. It would be preferable to intercede
by referral education.
30. There is scope to manage demand, cost
and efficiency by shifting care from hospital to community settings.
There has already been a considerable shift of care into the community
in chronic disease management. The care of many diseases, such
as, hypertension, ischaemic heart disease (IHD) and diabetes has
largely moved from outpatients to the community. The problem is
that resources have so far not followed which needs to be addressed.
Social Care Resource Allocation
— What is the expected impact of the local
authority settlement on social care budgets?
— How does the local government funding
formula reflect differential demand for social care services in
different areas?
— What is the impact of this system on
the budget allocations of a representative sample of social service
departments?
31. The RCGP[43]
has previously stated that the care and treatment of those who
are significantly sick should be state funded; otherwise those
without financial resources are likely to be disadvantaged. Dementia
care should be a priority within nursing home care. However, a
balance should be struck between clinical, treatment based care
and non-treatment based holistic care. We must avoid an over-reliance
on technical or drug-based solutions, especially if this at the
expense of person-orientated care. The latter can be far more
important and effective for many patients, and resources should
be allocated with this in mind.
32. Social care has embraced commissioning
and any willing provider better than health care. It has something
to teach in this area.
Social Care Services
— What scope exists for social care services
to manage demand, cost and efficiency within constrained budgets?
— What are the implications of social service
budgetary pressures on the interface between health and social
care services in a representative sample of areas?
33. Social care budgets are tight now. It
is likely that they will become tighter with increased demands
and pressures on them. Without sufficient resources there will
be pressure to admit and an increased risk of bed-blocking as
local authorities struggle to cope with increasing calls on limited
social services budgets. Hospitals then become the only resource
to deal with desperate situations; and they will be used Intermediate
nursing services are required to avoid pressure on admissions.
The way quality is assessed and the views of regulators profoundly
affect this.
CONCLUDING COMMENTS
34. As pressure increases on the NHS and
social care services budgets it is ever more essential that services
are delivered as efficiently as possible. This will entail greater
use of community services and GPs are well placed to deliver this.
October 2010
30 Making the best use of doctors' skills: a balanced
partnership. A joint statement from the Royal College of General
Practitioners and the Royal College of Physicians on how specialists
and generalists can work together for the benefit of patients
in the NHS. http://www.rcplondon.ac.uk/news/statements/jointRCPGP.pdf Back
31
The coalition agreement commits to increases in health spending
in real terms in each year of the Parliament. Back
32
Revision to the Operating Framework for the NHS in England 2010-11
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_116860.pdf Back
33
Appleby J, Crawford R, Emmerson C, How cold will it be? Prospects
for NHS funding: 2011-17. London: The King's Fund, July 2009.
http://www.kingsfund.org.uk/publications/how_cold_will_it_be.html Back
34
Appleby J, Ham C, Imison C, Jennings M. Improving NHS productivity:
More with the same not more of the same. London: The King's
Fund, July 2010. http://www.kingsfund.org.uk/publications/improving_nhs.html Back
35
Dixon J. Making Progress on Efficiency in the NHS in England:
options for system reform. London: Nuffield Trust, June 2010
http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=713 Back
36
Blunt I, Bardsley M and Dixon J, Trends in Emergency Admissions
in England 2004-09. London: Nuffield Trust, 2010 http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=714 Back
37
The Coalition: Our programme for government. London: Cabinet
Office, May 2010. http://www.cabinetoffice.gov.uk/media/409088/pfg_coalition.pdf Back
38
Department of Health: Departmental Report 2009. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_100667 Back
39
Resource Allocation: Weighted Capitation Formula (Sixth
Edition) London: Department of Health, December 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091849 Back
40
Dixon J, Making Progress on Efficiency in the NHS in England:
options for system reform. London: Nuffield Trust, June 2010
http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=713 Back
41
Dixon J, Making Progress on Efficiency in the NHS in England:
options for system reform. London: Nuffield Trust, June 2010
http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=713 Back
42
Blunt I, Bardsley M and Dixon J, Trends in Emergency Admissions
in England 2004-09. London: Nuffield Trust, 2010 http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&prID=714 Back
43
RCGP Response to Health Committee Inquiry on Social Care. October
2009. http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/1021/1021we28.htm Back
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