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Letter to Lord Darzi on GP access and the interim report of the Next Stages Review

4 December 2007

It was good to meet with you back in October. A lot has happened since then and as you were unable to attend our November meeting to discuss the interim report of the Next Stage Review, I thought that I would write to you to outline the General Practitioners Committee’s (GPC) views on some of the proposals and more recent developments in procurement of new practices and health centres. As negotiations about the issue of extended opening hours for existing practices are already underway between ourselves and NHS Employers, this is not dealt with here.

The GPC certainly welcomes the expansion of GP services in areas where, historically and relatively, there have been fewer GPs per head of population, leading to inequalities in access to primary care services. We hope that the 100 new practices in the 25% of PCTs with the poorest provision will therefore help ease any difficulty patients have faced in registering with a GP practice in these areas.

In the knowledge that the Government wishes to see increased competition between primary care providers, we are conscious that these new practices are also being used as a tool to achieve this aim. The committee views this approach as misguided and cannot support such a direction of travel. Instead, we would like to see a strategy in place that focuses on ensuring sufficient capacity in general practice based on the clinical needs of the growing population, rather than wasting time and energy on stimulating markets within the NHS and developing new practices rather than supporting existing ones. On the subject of choice, a report last year from the NHS Service Delivery and Organisation (SDO) Research and Development Programme concluded that “There is no evidence that giving patients greater choice will, in itself, improve the quality of their care [and] some studies suggest that increasing choice may result in a deterioration in the quality and cost-effectiveness of services. (1)” The report also concluded that “Wealthy and educated populations will be the main beneficiaries of a policy of extending patient choice…” thus exacerbating health inequalities.

We understand that a new National Procurement Framework will be launched in December and will be the method by which these new practices (and the 150 health centres) are to be procured. The interim report states that the 100 new practices can be either ‘traditional’ which would imply the GMS or PMS contracting route, or new private providers, which would mean use of the APMS contracting route. However, from our meeting back in October and information circulating from the Department on the new procurement framework, it is clear that in fact PCTs will only be able to use APMS. Whilst this may be appropriate for certain services provided in primary care, as you will be aware, the GPC remains committed to seeing general practice continue along the independent contractor model, based on the registered list and therefore, for reasons expanded upon below, we believe that the GMS or PMS contract would be best suited here. At the very least, we cannot see why PCTs are not being given the option of using these ‘traditional’ contracting routes, especially given the emphasis in the Next Stage Review on local change and clinical engagement as opposed to central diktat.

Private organisations holding APMS contracts employ a salaried or locum staffing model, akin to that of existing PCTMS practices where the turnover of employed doctors is often high, the running costs are higher than GMS or PMS and QOF scores are lower. In favouring such a model, we can only conclude that there appears to be a lack of recognition in the Department of the value and strengths of the independent contractor model for general practice, based on the registered list, and how it offers patients continuity of holistic care, a personal doctor, an independent health advocate within the healthcare system and value for money. The Royal College of General Practitioners’ roadmap ‘The future direction of general practice’ published in October extols further the benefits of this model. We believe therefore that patients registering with practices run by private organisations holding APMS contracts would be at a distinct disadvantage to those registered with a ‘traditional’ general practice, again, exacerbating rather than alleviating health inequalities.

We understand that under the proposed procurement timescales, the Department has set aside around three months, from mid-December 2008 to the end of February 2009, during which the new contracts will be awarded and signed. Local experience, for example from Derbyshire, has shown that APMS contracts take a minimum of a year to draw up and agree. In addition, the construction of new buildings will take considerably longer. We do not therefore see the Department’s timescales as realistic, reinforcing our view that the APMS contracting route will not be suitable here, particularly where there are immediate needs to be addressed. We have also yet to see any evidence to suggest that APMS contracts offer value for money in comparison with GMS and/or PMS.

While a commitment of £250 million for a new access fund is very welcome, the committee is concerned that this sum will not be sufficient to deliver the 100 new practices and 150 health centres. Certainly the costing assumption we have seen from the Department of around £790,000 per health centre appears particularly low and we would be interested to see a more detailed funding model. Furthermore, the ongoing running costs of these new facilities is likely to exceed this estimate and will have a significant impact on PCTs’ unified budgets in the future, with an adverse effect on funding to existing practices, and also to other local clinical services. We are aware that, in some areas, PCT managers share these concerns.

The commitment to invest solely in new primary care services, rather than improving existing services and/or infrastructures we believe is short-sighted and will not provide value for money. We would like to see some of the new access fund going towards GP premises development, allowing for practice expansion. Funding extensions to existing practice premises would allow those practices to increase their list size and provide a wider range of services to their patients. The briefing paper on practice premises, which I believe Hamish has sent you, seeks to illustrate how such an approach would prove a very cost-effective way of improving access to general practice. Alan Johnson’s announcement on 23 November stated that the first of the new practices would start to provide services from December 2008. As previously mentioned, not only do we think that if these contracts are to be APMS, this timeframe is over-ambitious, we believe that significant improvements in access to primary care services could be seen sooner than this with increased funding to existing GP practices for premises development.

Another aspect of the proposals we would like more information on is the statement in the interim report that the 100 new practices will be staffed by 900 GPs, nurses and healthcare assistants. We would be interested to know if this figure represents actual headcount or whether it refers to whole time equivalents. Either way, we would question whether the existing workforce can actually support such an aspiration.

There has been a lot of talk about the concept of polyclinics since publication of the report ‘Healthcare for London: A framework for action’ in July, the GPC’s views on which were represented in the BMA response to the report, submitted in September. It is difficult for the committee, LMCs and many GPs to see any major distinction between the polyclinic model and the health centres proposed in the interim report of the Next Stage Review. As a result, there remains a significant amount of concern that the solutions suggested for London are now being reproduced across the country without due consideration of the local circumstances and requirements. Any reassurance you can give that this is not the case would be well received.

GPs welcome the opportunities that practice based commissioning (PBC) and care closer to home provide to their patients and so as a concept, we are in favour of the development of community-based facilities from which new, innovative services can be delivered. Indeed, via PBC there are already some examples emerging of GP-led primary care provider models and these should continue to be supported by the Department rather than undermined by a requirement on PCTs to put in place completely new plans for a set number of new health centres. We therefore believe that any plans for the establishment of new health centres should be developed in partnership between PCTs and practice based commissioners, with the input of other relevant stakeholders including secondary care, patients and the public. Where there is no identified need for such a health centre however and/or it is thought that a new facility would not be financially sustainable or the best use of resources in light of other clinical needs and priorities, then there should be an option for individual PCTs not to go ahead with the proposed procurement.

A one-size-fits-all approach for the development of health centres will not work and we believe that the proposals in the interim report are therefore too prescriptive. We would hope that PCTs will be able to apply some flexibility to their planning around the services to be provided in the new health centres, which would be in line with the Department’s commitment through the interim report to supporting ‘local change from the centre rather than instructing it…’. The guiding principle that the new health centres will provide routine GP services from 8.00am-8.00pm, seven days a week, is an example of this overly prescriptive approach. The English Department of Health’s GP Patient Survey showed 84 in every 100 patients to be satisfied with the current opening hours in their practice. Only four out of every hundred patients wanted practices to open on a weekday evening and seven out of every hundred on weekends. Given that only a relatively small minority of patients actually want to see an extension of ‘routine’ GP care, the GPC believes that this proposal would be an irresponsible use of scarce resources. Although this might be attractive to a very small section of the population, it is likely that if funding for this were to be taken from cancer care for example, and patients were made aware of this, they would feel very differently about such proposals. The committee is opposed to policies that are designed to meet the demands of the articulate at the expense of those in real, clinical need. We remain very concerned that these practices may end up delivering a potentially second-class service to areas of the country that already have significant health inequalities. We believe that, in general, GMS and PMS practices offer the best option for all patients, not just those in better-off areas of towns and cities. We are not persuaded that the divide between rich and poor will reduce as a result of these proposals.

On a more general note, feedback received from GPs via LMCs indicates that the Next Stage Review has not so far presented an opportunity for greater morale to be achieved. Although it provides the opportunity to look at a number of areas which could make a real difference to patient care, there are many proposals within the interim report which raise anxiety because they lack clarity and are ambiguous in their statement. One overiding feeling is that the review fails to build upon existing best practice and successes within the NHS and may lead to the destruction of well-established and trusted structures, for example, traditional general practice. There is also a sense that taxpayers’ money is being spent on what are predominantly ideologically-led policies, unsupported by robust evidence, for example, extended opening hours.

Regarding the regional strands of work underway, I am pleased to report that a number of BMA representatives were successfully appointed to the various SHA clinical pathway groups across the country. There was one SHA, Yorkshire and Humberside, where none of the BMA nominations were accepted however, which was a little disappointing, as was the relatively low number of GPs on these groups altogether. It goes without saying that the task set for the clinical pathway groups will be very challenging, especially given the tight timescales and the very small number of meetings. We hope that these clinical pathway groups have provided a constructive and valuable forum in which local clinicians can discuss how to deliver better and more integrated patient care that is clinically appropriate, evidence-based and specific to the needs of the local patient population. There have been some reports from those participating in this work however that the questions asked of members have been very loaded with seemingly pre-determined answers and the agenda highly politicised. This is a perspective shared by clinician members, SHA facilitators and clinical leads alike.

The deliberative events held at SHA level on 18 September 2007 have also attracted some attention from our members for similar reasons, with reports of a politicised environment and a pre-set agenda. We understand the findings of the nine deliberative events, which involved around 720 patients and members of the public, to have been integral to the recommendations around access made in the interim report; the Department’s national GP patient survey earlier in the year represented the views of two million patients. In addition, LMCs were given very little information about these events and received reports from many constituent GPs that there had been no opportunity for them to participate and/or contribute. We would ask that the review team instructs SHAs to seek LMC representation at the second round of deliberative events due to take place in January, or at the very least, share with them information on the events and the method for selecting the primary care clinicians that have been invited.

I and other members of the GPC negotiating team would be more than happy to meet with you to discuss the issues raised in this letter further; please do not hesitate to get in contact.

Yours sincerely

Laurence Buckman
Chairman
General Practitioners Committee


1. NHS Service Delivery and Organisation (SDO) Research and Development Programme. (2006). "Can choice for all improve health for all? The evidence on whether NHS patients can and should become consumers of health care."