Primary Concerns

GPs received a new contract in April this year after many months of
wrangling, and the consequences look likely to take years to pan
out.

The contract allows GPs to hand over responsibility for
out-of-hours primary care to primary care trusts from December this
year, and the vast majority have done so. Research for PCT
representative organisation the NHS Alliance suggests that about 80
per cent of all PCTs will have their new out-of-hours arrangements
up and running by the end of this month.

Besides the shift to out-of-hours care, the new contract means that
for the first time, the quality of services provided by GPs is
being tightly measured and specified – and linked to the practice’s
income. A Quality and Outcomes Framework lists four different
domains, within which practices can earn points by providing
services of increasing quality. The maximum is 1,050, although no
one is expected to reach that. Each point achieved generates
£75 for the GP’s practice.

While this “cash for quality” has been welcomed, there is concern
that these incentives might result in practices industriously
focusing on meeting as many points as possible rather than on true
patient care. Or, in the words of one PCT manager, “ticking all the
boxes but missing the point”.

Another development is “choose and book”. Tony Blair has followed
in the Conservatives’ footsteps with a health policy dominated by
“patient choice”. Hence, from December 2005 GPs’ patients should be
able to choose where to have their operation or procedure and – in
theory – book their appointment, there and then.

This move raises a string of questions, not least whether the
thousands of GPs’ practices will manage to co-ordinate their
computer and IT systems with those of hundreds of contracted
service providers. And with the average consultation lasting seven
minutes, are GPs in any position to explain the “choice” and debate
the relative merits of different hospital locations with a patient
and then – in theory – book their appointment online?

Then there is the National Programme for IT. Large national IT
projects have a reputation for being late and running over-budget.
The NHS IT project – currently under construction – is bigger than
most and is likely to be similarly troubled.

The new system will need to work across all aspects of primary and
secondary care – a vast task. As part of the GP contract the
government agreed that GPs would be reimbursed for the computer
equipment needed for this massive project, provided the computer
system was compliant with the new national system. And the country
has duly been split up into areas and a local supplier of computer
equipment selected in each area.

But the National Programme for IT will not work with the computer
system currently used by around half of all GPs in the UK, and this
has thrown a spanner in the works. Predictably, the costs have also
been underestimated, and the government had to allocate another
£30m to the project in January this year. Whether this will be
the last “readjustment” of the figures remains to be seen.

Foundation Trusts

Another development is foundation trusts. Three-star, financially
balanced trusts are being offered foundation status and significant
new freedoms in return for continued performance. Although it is
still early days in the development of these trusts, their freedoms
and flexibilities are likely to have a significant impact on
PCTs.

Many foundation trusts want to move to a three-year cycle of
commissioning and budget-setting rather than the current annual
round, much of which consists of relatively simple block
contracting.

But this change would limit the freedom of PCTs to commission and
innovate – difficult at a time when the government’s health agenda
means PCTs are attempting to draw the focus away from secondary
care and provide many more traditionally hospital-based services
from primary care settings.

Another change is the introduction of “practice-led commissioning”.
Under this regime, individual GP practices would be entitled to ask
for an “indicative budget” and could commission services – more or
less any service that the NHS provides – directly.

However, this process would not be GP fundholding by another name,
as there would be considerable oversight and the savings – assuming
there were some – would be split between the PCT and the practice.
This process starts from April 2005 and is expected to be voluntary
(at least initially).

The government is keen on this type of commissioning as a means of
incentivising more primary care developments. But many GPs are
suspicious that it is simply as a way of PCTs shifting their
financial problems onto practices. The NHS is awaiting further
guidance.

Clinicians On Top

The creation of PCTs marked a sea change in that it brought to an
end several decades where the management of the NHS resisted the
involvement of clinicians at the most senior levels. The advent of
PCTs brought a new body – the professional executive committee –
which is (in theory) an equal core partner in the running of each
PCT.

Professional executive committees include representatives from all
professional bodies and a wide range of experts including doctors,
nurses, allied health staff and social care professionals. Their
chairs are required to be clinicians. The NHS Alliance is pressing
the government to ensure that the committees are involved in
planning the practice-led commissioning and in decisions on how any
savings are spent.

According to a spokesperson for the NHS Alliance: “Unless NHS
clinicians and managers work together and with their patients and
the local population, they [PCTs] won’t work. PCTs that have good
relationships with their local clinicians are doing some amazing
things, and those that haven’t often have disgruntled clinicians
who don’t want to play.”

Location, Location

Premises remain a big issue for PCTs, despite the version of the
private finance initiative for PCTs, the NHS Local Improvement
Finance Trust. One of PCTs’ prime roles is to shift the balance
away from secondary hospital care towards interventions that do not
rely on referrals to consultants.

Yet to do this, appropriate premises are always going to be
required and the health service simply doesn’t have them at present
– acute hospitals are often unsuitable for use as places to deliver
primary care. There are many more GPs being trained, but there is
concern about where exactly their training is going to take
place.

When you look at the list of the major developments PCTs and their
partners are facing, it seems amazing that anyone is getting any
primary care at all.

As one commissioning manager says: “Working in PCTs sometimes feels
as though you’ve got this enormous 3D puzzle to put together, and
at the moment, none of the pieces quite fit.” Anyone who expects to
use primary care at some point in their lives should be keenly
interested in the way the puzzle is being solved.