Editor's blog 21st November 2008: Notes from a sickbed

Cough, cough, cough. Splutter. Spit. Shiver. Cough, cough, cough. Feel sorry for self. Self-medicate with pills or cask-strength single malt, depending on time of day.  Cough, cough, cough. Repeat.

OK, you have probably now captured the reason for radio silence over the past week. It's not as if nothing has been happening. As ever, the excellent Sally Gainsbury of Health Service Journal has been keeping us up to date with the latest financial shenanigans (www.hsj.co.uk/news/2008/11/restrictions_planned_on_spending_the_surplus.html and www.hsj.co.uk/news/2008/11/pbr_tariff_delayed_until_january.html) It's just like 2006 all over again.

Meanwhile, peace has broken out between the ABPI and the DH over the reforms to the Pharmaceutical Price Regulation Scheme renegotiation, off the back of the Richards Review of top-ups.

Primary colours
Two interesting primary care-focused policy documents were published this week - from Civitas, we had James Gubb and Grace Li's Checking Up On Doctors - a review of the Quality and Outcomes Framework for general practitioners (www.civitas.org.uk/nhs/download/Checking_Up_on_Doctors.pdf), and from the Kings Fund, Practice-based commissioning - reinvigorate, replace or abandon? (www.kingsfund.org.uk/publications/kings_fund_publications/pbc.html), by Natasha Curry, Nick Goodwin, Chris Naylor and Ruth Robertson.

Both reports are interesting documents. In Checking up on doctors, Gubb and Li examine whether the QOF's potential to affect 33% of GP practice income is distorting primary care professionalism and delaying genuinely patient-centred services. They concur with Professor Martin Marshall of the Health Foundation's suggestion that the QOF should be restricted to about 7% of potential income, and refocused entirely onto cost-effective, evidence-based interventions. They also note that conditions not yet included in the QOF, such as various indicators linked to depression and arthritis, saw tiny improvements between 2003-5.

Gubb and Li add that data on various key indicators, including CHD, had already been moving in the right direction prior to the QOF's arrival, and suggest that "existing methods such as NSFs (national service frameworks) would have been sufficient ... the intervention standards of the QOF are too modest for many indicators and payment is not linked to health gain, which has distorted its effectiveness".

They conclude that "on balance, it is likely that the marginal improvements in technical effectiveness, while commendable, have come at too high a cost in terms of the interpersonal, patient-centred and holistic strengths of general practice. Incomplete attention has been given to the context in which patients receive their care, to consulting skills vital to the proper recognition of patients' problems and needs, and to the outcome of care as patients perceive it, and whether the experience of patients is a good one."

The BMA strikes back - 'short on evidence, long on opinion'
Perhaps revelling in their new-best-friends status with ministers, the BMA promptly went on the attack in a statement, dubbing the QOF "the one government target that has brought real benefit to patients across the UK".

Dr Laurence Buckman, Chairman of the BMA’s GP committee, added, “it is very disappointing that this document is short on evidence and long on opinion about one aspect of the GP contract that has brought real benefit to patients. A lot of government health targets have distorted clinical care – the 48-hour access target, for example, doesn’t allow doctors to prioritise their patients on the basis of need. Yet the QOF is different. It was never intended as just an incentive payment; its introduction marked a huge step forward in the government’s promise to address health inequalities across the UK. Unlike other government targets, it was developed in close partnership with the profession, together with experts and the involvement of patient groups.”

The unlikeliness of the BMA's welcoming a change to reduce the QOF payment potential is fairly self-evident, in the absence of a concrete proposal to ensure this income is not otherwise made good. This is a noticeable lack in the Civitas proposals. There is nevertheless much to applaud in their comments about avoiding turning GPs into purely mechanised, box-ticking compliance monkeys, in Phil Hammond's lovely phrase. The issue of medical professionalism remains a live wire.

It's important to recognise that the QOF was born out of a recognition of the pre-2004 data vacuum about activity in primary care. GPs argue that they were all already doing it anyway - but by and large, cannot prove that this was the case. The monumentally high first-year achievements of the QOF points around the country do not give the impression that the agreed targets were stretching.

The QOF will, over time, lead to a culture of routine checking of common risk factors for disease in general practice. Eventually, that should lead to improved management of long-term conditions in primary and community care; to better quality of life; and to lower rates of hospital admissions. It is a long-term payback.

The QOF is probably a very expensive way of doing things, but as vaccination take-up has previously proved, GPs are very good at working out where there is the potential to make money and then doing so. This is not a criticism - that is part of their role. The task of policymakers is to ensure that the incentives are not perverse, and that the routine checking of risk factors does not overweigh the more important person-centred care that GPs are meant to provide. Particularly since many of these check-ups can and should be done by relatively inexpensive practice nurses.

The future for PBC?
The DH has been chuntering on for some months now about the need to 'reinvigorate' GP practice-based commissioning (PBC), without giving any very clear sign of what, how and whither.

The arguments about PBC will already be very familiar to you if you've spent any time on our sister site, Commissioning Health (www.commissioninghealth.com) - apart from the vanguard of enthusiasts, largely in the NHS Alliance, PBC is making scant difference because of incomplete, late data; incomplete or late indicative budgets; and little or no management resource and support from the PCT. You'd get the hump, wouldn't you?

The Kings Fund report echoes previous observations that the only real answer to 'what's happening with PBC?' is "not much". As with the QOF issues, there is a problem across the NHS management culture around letting go of control. Curry, Goodwin, Naylor and Robertson have explored the situation in four PCTs, and found the usual problems around data; capacity and capability; roles and responsibilities; local relationships within health economies; conflicts of interst; governance issues and wider policy and operational contexts.

The same old, same old problems
Their report says that “Progress to date has been slow in all sites: very few PBC-led initiatives have been established and there seems to have been little impact in terms of better services for patients or more efficient use of resources.

“Where initiatives have been developed, they have tended to be small scale, local pilots focusing on providing hospital services in community settings. Few practice-based commissioners have taken an interest in wider commissioning activities. Whether this represents a failure of the policy depends on whether it is seen as a mechanism for achieving widespread change, or as a more modest lever for enabling small-scale innovation.

“PBC has been partially successful in encouraging GPs to become more engaged in commissioning and budgetary decision-making, but this has generally been limited to a small group of enthusiastic GPs in each PCT. The majority of GPs were supportive of the principles of the policy, but this has not translated into active engagement, with most GPs reporting that they were happy to observe passively and let others lead on their behalf”.

The authors suggest that “a ‘matrix’ model” is needed for PBC, “that recognises the multilayered nature of commissioning and the fact that certain types of commissioning are best performed at different levels … responsibility for strategic, population-wide commissioning would remain at the PCT level, but would be informed by a panel of GPs and other primary and secondary care clinicians who would be provided with incentives to play an advisory role. This would seek to build on the positive relationships that have emerged in many cases as a result of PBC”.

The report also calls for PBC consortia to get real budgets in tightly-defined areas (thus becoming statutory organisations), which follow PCT strategic direction but can gain ‘earned autonomy’ (in the same manner as NHS foundation trusts have) through high performance.

Responding to the report, NHS Alliance chair Dr Michael Dixon repeated the Alliance's suggestion that a key element to improve engagement within and uptake of PBC would be to make changes such that hospital discharge information should include financial information about treatments performed, thus effectively becoming the ‘invoice’. Such letters are frequently sent so late as to be useless for practical purposes of checking on activity and outcomes: however, under NHS Alliance’s proposal, “if the letter is late or inaccurate, payment would be delayed”.

Dr Dixon said, “there should be no excuse for failing to provide budgets and accurate financial information to practice-based commissioners. Yet that is exactly what has been happening. It is often not the fault of PCTs but of the system above them.

“The King’s Fund is right to say that urgent action is necessary to overhaul PBC. But that action need not be complex or costly. The simple solution we have proposed would transform commissioning by putting the power where it should lie – with the commissioners instead of, as at present, with the acute sector.

“If providers find they do not get paid unless they do the job properly, that would sharpen everyone’s performance. And it would also enable practices and PCT commissioners to become fully engaged in NHS decision making.”

Conflict of interest declaration - I do bits and pieces of paid work with and for NHS Alliance, so please treat my views on this with a certain caution (as you damn well should anyway).

But I don't think they could be more right. General practice is the NHS's risk sink. We are coming into a period where resources will have to be used more wisely - and that means getting GPs intimately involved with their referral decisions. Commissioning needs clinicians at its core. They are not there presently.

Handing more financial power over to GPs may scare policymakers and politicians. It is probably a bit unfortunate that the megaphone diplomacy and pitched battles between ministers, DH officials and the BMA over pay and polyclinics (amusing as they were) have entrenched the narrative of the grasping GP in media and public consciousness.

The NHS is going to have to do more with less. For all the referral management centres that you can create, the real demand management work is done in general practice. The ongoing failure to engage more GPs in PBC is not just a speed bump - it's a cul-de-sac.