Author of the inverse care law, BMA chair and leading researcher discussing inequalities, polyclinics, QOF, out-of-hours, quality and continuity of care
Uncorrected (rough) transcript by Andy Cowper, editor of Health Policy Insight
Dr Julian Tudor Hart, Hon. Clinical Research Fellow, University of Wales Swansea Medical School
Dr Hamish Meldrum, Chair of Council, BMA
Professor Martin Roland, Director, National Primary Care Research and Development Centre
Is the ‘anticipatory care’ model reproducible?
Julian Tudor Hart – We need an anticipatory model to tackle health inequalities and the staff and continuity to deliver, but this care can’t be delivered in ‘boxes’. I measured everything our practice did from very beginning, came from epidemiology to primary care, taking very low pay and since retiring, unpaid so I’d say that’s not reproducible. I ‘misused’ MRC research funding to do more things for more people and recorded what we did. Need to see how to make it reproducible, waking up and need to move rhetoric to reality. It’s resourcing and staffing, primarily.
GPs are as it were, in a swimming pool: industrial and post-industrial areas are the deep end, where GPs can’t get their feet on floor: both the patients and they are drowning – GPs rightly save themselves first, they have to. At the other end of the pool life’s not necessarily easier, but GPs can put their feet on the bottom when need to. What we called equality was all the people in the pool getting the same. I want to see resources directed to where greatest need, measured by standardised mortality ratios (SMRs), or house prices: both reflect health needs very accurately. As to deprivation payments – not sure very good evidence, more money into GP pockets – does it go on cars and holidays, or on investing in practice and help patients more. Used for investment or poured down tube? Primary care funded that way is not taken seriously. I would be in favour of a salaried GP service.
GP Quality and Outcomes Framework (QOF)
Hamish Meldrum: QOF missed point of disadvantage, but that’s not the whole answer. QOF made us better. QOF was only designed for use with good evidence base on the primary care interventions that make a difference you can measure. That limits the areas in which it can work. Health inequalities go much wider than what the health service does – it’s about much wider social and economic situations. To address them means not just throwing money into areas, but very targeted programmes.
Martin Roland: The healthcare system is as a powerful lever to address many forms of health inequalities, though may not get to root causes. QOF addresses 60% of the differences in mortality between deprived and affluent areas. QOF does some aspects some well (CHD); some not (cancer). My surprise is how well GPs in deprived areas have done. I argued QOF points should be deprivation-weighted. Differences in scores of wealthy/deprived are astonishingly small, and have shrunk within 3 yrs. May still be argument for deprivation weighting.
HM: QOF made some GPs more reactive, and encouraged pursuit of patients with conditions like hypertension. Why should it need financial incentive? We’ve all struggled with this, and since you’ve got to pay GPs, it seems not unreasonable to use some of system to encourage and incentivise good practice.
MR: QOF is another government initiative like NSFs, or audit: government didn’t know if it was working. We now know from research that these things were, and in fact were improving pretty rapidly before QOF. QOF has made a modest further increase, but not staggering as it was already improving fast. In 2003, government made 2 errors – assuming GP care was poor (which it wasn’t) and that consultants were lazy (which they weren’t). Two very expensive mistakes.
There is a total sum of money for healthcare and it’s up to BMA to negotiate what goes to what. We do know continuity of care has become less good in last 5 years – maybe QOF, or more nurse appiontments …
HM: We argued strongly that less money should go in QOF and more in funding basic services and improving staffing in poorer practices. That would have given more balance in idea of funding basic services, and giving deprived areas bigger and better funding. The wealthy areas would get less basic, but find it easier to earn more via QOF.
Because of parliamentary interference, ended up with the minimum practice income guaranetee (MPIG) and a big overspend on GP performance.
MR: There’s consistent concern that practices in deprived areas don’t code or record true prevalence of disease. We can’t find evidence that it’s widespread, but probably patchy. This technicality means a disincentive for practiced in deprived areas to casefind – they get relatively less for doing that than practices in wealthier areas with lower deprivation. Need to encourage practices in deprived areas. To some extent fund in relation to mortality - some of MPIG relates to Jarman index of socio-economic deprivation.
JTH: MPIG is about distribution of GP income, not of investment. I want primary care to be taken seriously. Its full capacity is not used, includes mobilising patients to do something about it, which is not happening at all through fragmented mechanisms.
I detest payment by piece rates, it has poor effects on everything else, and if you’re not producing a standard product, it’s very dangerous. What do you do less of to do more tick-the-box? In my experience, it’s things like less visiting of patients dying at home. How do you balance these two? Health economists don’t and can’t have an answer. It still comes down to professional judgment of knowing and living in population, sharing buildings and school community and life stories. It’s about whole life. If primary care staff get really involved in patients’ lives, I really don’t think they need this incentive. All my career, I was straining in the practice economy to get enough staff and time. We started out with 6 mins / patient, ended up with 9-10 mins. I find nearly all discourse in this issue is off the point – always about putting more or less money into GP pockets more or less to spend a their discretion. I don’t think it’s serious. Everyone else is paid to do their job, GPs should have enough to live well on and the rest of their work is about the most interesting job in world – looking after people’s lives.
What would you add or subtract to QOF?
MR: There’s a solid academic process, which has checked patient groups for what they think should be changed. Vascular disease and osteoporosis could be added, but think government already has a good method, and we knew QOF would need continuous change and improvement. Use that mechanism.
HM: There are other ways to encourage and incentivise various new services. QOF should be national, but locally we could devise local incentive schemes, or local enhanced services that might better target resources at addressing health inequalities, rather than more national frameworks.
JTH: Realistically, at the moment we have many more innovative people in primary care today than 20 years ago. Health sciences move forward however much government tries to move things backward.
There’s also very good social motivation in most health workers of all grades. I don’t think at the moment in England, they have much confidence in any government agency giving them a real sense of direction and leadership – any of that comes form within the profession, but that’s a weak position for tackling health inequalities, and the difficulties very much greater in high morbidity, low income areas. It’s going to get much worse with the current clash between prices and wages – it’s a terrifying prospect. I don’t think breaking everything we do down into unit prices helps; it gets in way of progressive intelligent people who just want to get on with it and don’t want to tick boxes.
MR: I’m slightly keener on measurement than JTH and on localism than HM. Deprived areas have less GPs than more affluent areas of community. With fewer GPs in deprived areas, they rattle through faster and see patients with greater need. National distribution of GPs got better 1974-early 90s, and since then has got worse year-on-year till we last looked in 2005. Since 2005, initiatives into deprived areas, and looked at similar initiatives overseas. Patients in deprived areas see less specialists, which could be for a range of reasons. In a study, we found that CHD patients lacked full interventions, partly due to fatalism about their own health if parents suffered likewise; maybe as GPs don’t refer people who could benefit. My instinct is that it’s more the latter, a cultural thing. The key thing is to ensure those who would benefit get referred. Over-referring may be expensive, but under-referring is more damaging to health.
Alternative personal medical services (APMS) contracts
HM: The BMA is concerned that APMS may deliver worse services to areas with bad health inequalities. It’s too early to tell, but there’s already evidence from some private companies using short-term locum GPs rather than continuity. There is evidence that although bigger practices may have more range of services, smaller practices often do better on continuity. Traditional GPs tend not to want shorter APMS contracts with more risk attached. People with limited resources are less into something where don’t see long-term repayment. Polyclinics idea of rationalising lots of small practices into big buildings risks taking primary care away from what the majority of patients, who don’t need advanced access, want. It also might make the problem of those who already find access difficult worse. Maybe scope for community hospital development. Polyclinics won’t solve all our problems, as they’re not the answer everywhere and not answer to all problems we’ve got.
MR: APMS arose from government frustration with resistance of general practice to change, particularly where quality is low. In Manchester, I have experience of visiting practices at the bottom end of the performance scale, and there really are very few levers to encourage change. APMS came out of that frustration. If we introduce new types of providers, will they improve things with earlier hours by having to cover population, or do you put one thing in and let competition work?
MR: Polyclinics do not inherently have to be run by commercial organisations, but these organisations appear to have significant advantages in bidding over local organisations. Should practices be corralled into polyclinics? Where the general practice estate is poor, they could be good, but are not required where estate good.
JTH: in the 1970s, when NHS was more cost-effective than any health system, this was attributed to primary care system that included everybody, and gatekept access to secondary care. It even worked OK despite a lot of not-very-good doctors working in primary care. Better than direct access to specialists for customers. Now in US, we see direct-to-consumer (DTC) advertising of coronary artery stents! Polyclinics are in the pipeline in Haringey, displacing innovative practices wanting to expand. We must think hard before doing any further damage to the gateway of primary care. We need to take human mind and body really seriously. Being a good GP is more demanding than any other speciality. We are destroying it and we must stop. Russia and Cuba had polyclinics, Cuba came here and stopped their system and started ours.
Evidence of polyclinincs worsening inequalities and quality
JTH: No government is prepared to wait the time taken to produce evidence, so we have to use experience instead. In US, no polyclinics are totally socially inclusive. We’ve got to look suspiciously at things that look like shopping malls.
Incentiving continuity of care in the QOF
MR: We could incentivise continuity of care in QOF if it’s the issue, and I would do so. But moving specialists into community has modest benefit in most urban areas and does waste some of their time – I wouldn’t do it. It would be better to develop care pathways and practice-based commissioning – lots of opportunities to improve care. The primary care-secondary care split has kept our costs down. I think we could do much better with better communication between GPs and specialists.
HM: I don’t think the purchaser-provider split is here forever in all areas: it may be appropriate in one-off elective care episodes. Not convinced by arguments of higher efficiency and lower costs outweigh the transaction costs and tendency to put provider against purchaser and inhibit collaboration. I’d like to study what’s happening in Wales and Scotland: maybe the market and purchaser-provider split may not be the way ahead in healthcare. Doctor-patient trust is vital, and where the power lies depends on condition, patient etc – balance between patient and customer. Doctor-patient relationship remains vital.
Out-of-hours care and PCTs’ role
MR: There are problems in out-of-hours care, but polyclinics are not critical to the argument. PCTs are relevant, health inequalities so much outside healthcare. The PCT has remit beyond that of GPs.
HM: PCTs are vital. BMA is accused of being negative about PCTs, but we’ve issued several recent documents about possible developments for PCTs and communities, in partnership with professionals, managers and the public. Commissioning is not just about buying; it’s about assessing healthcare needs. Commissioning is poorly carried out in many areas, both in health needs assessment and letting local community move to deliver new services to meet needs.
JTH: In Wales, we don’t trust anything called a trust. Implies stand-alone institution. It’s not just getting rid of purchaser-provider split, whole point is divides those who plan job from those who do job (doctors, nurses and patients). Don’t want planners and managers in a completely separate body from those who do implementing.
Quality assessment for GP practices
MR: Practice disaccreditation is being piloted, with a set of core manadatory standards, and adding new ones year-on-year. We’re much better over the last 5-10 years at noticing practices who should not be working. NCAS do a good job.
HM: The BMA is working with the Royal College of GPs to address this issue. Unacceptable variation should be addressed – not just of clinicians, managers too. More to do.
Can PBC tackle health inequalities? Are GPs being given flexibility, or are PCTs interfering a lot?
MR: Really, it’s consortia-based commissioning. PBC is in the position to address inequalities, but the received wisdom it that it’s had little impact yet.
HM: Practices are probably too small a unit to base wider public health-type issue. They’ve been poorly resourced in many areas with bad managerial resource and the quantity and quality of data has been poor. Without reasonable effective ands speedy information, practices and consortia can’t do it.
JTH: What stands out a mile is that resdistribution of primary care to demand never really taken place. If ever suggest some areas should have more, all we hear is that people want levelling up, not down. Which doesn’t mean anything. At some point, relatively better off people are going to have to slow up a bit. The test is very crude, have we got more doctors for the same population in poor areas where harder care to deliver and sustain? Health inequalities are about poverty and demoralisation and global problems – in post-industrial communities, low incomes and demoralisation. So it’s very multi-factorial. I think we need 5-10% funding shifts, not 1%; mainly in staff, to give people time to spend with patients and to write down what they think. Terribly simplified box-ticking pathways are not it.
MR: The PCT is too small a unit for effective workforce planning. Other countries’ evidence show selective shuffling around of staff within deprived areas.
Is tackling health inequalities on commissioners’ radar in non-spearhead PCTs?
HM: It’s a tiny blip on the radar for PCTs.
Has removing out-of-hours care from the GP contract made health inequalities worse?
HM: Oout-of-hours (OOH) was changing in early 1990s, GP OOH co-ops were struggling to attract people. The new GP contract has been blamed, but more women now going into general practice. Addressing inequalities needs more co-ordinated approach to things like causes of inappropriate A&E attendance, and has to be co-ordinated by effective commissioning, which we haven’t got.
Could polyclinics allow GP to retain control over their patient’s care up till a tertiary care need?
JTH: A very doctor-centred discussion! I saw enough of outgoing cohort of GP surgeons and GP specialists to have great fear to return of that. Even people excising apparently harmless bits of skin … Life care is the real issue. The big worry for most people is the quality of their last years of life. The definition of primary care doctor will have to change, and be hugely upgraded, to end the myth of GPs being masters of all specialties. We need a human biologist, who should be good at brains, sociology, wider than any other part of medicine. It’s beginning to happen in medical schools, they’re going really well, beautifully trained people with generous imaginative idea - but I don’t see the service they’re going out into matching that. I don’t see polyclinics as locus to continue tug-of-war over patients. I also don’t think patient should be left in charge of own care. I pull my various 81-year-old’s diseases together, but I haven’t really got anyone acting as my generalist. The GP I regularly see is a nurse. She doesn’t know much pharmacology, but no do most GPs. Lots of specialists don’t read their journals any more.