July 2001

Stockport Local Medical Committee

July 2001

Stockport Health Authority
Springwood House
Poplar Grove
Stockport
SK7 5BY

July 2001

Contents - Just Click on the Bookmark - Home Page

General Practice & PCTs - Dr Ranjit Gill	LMC & Consultants Ball 2001 - A Success
Electronic Consultations	LMC Office—Contact Hours and Telephone Numbers
Brainteasers Return!	LMC Members Election 2001
Premises Valuations - An Update	Old Farts Young Turks - Dr Keith Wells
PCT Update	Congrats to Elected PCT Exec Ctte Members - Dr Keith Wells
Appointment of PCT Chief Executive - Dr Keith Wells	Annual Conference of LMCs Report
LMC Annual Golf Challenge	New Pharmaceutical Advisors
Health Authority Late Payment

General Practice & PCTs - Dr Ranjit Gill

A lead article in the British Medical Journal ¹ makes plain the high esteem in which British general practice is held in the world. It is a pity that the exact opposite is the case in Britain. Neither national Government, the NHS Executive, nor the local NHS seem to understand what makes British general practice the jewel in the crown of the NHS.

The same article makes clear why general practice is so highly regarded elsewhere, and why most countries in the world are seeking to imitate it. The core values of general practice, a capitation based list system, where patients have freedom of choice, continuity of care by an individual doctor and mutual respect between patient and doctor, is the ideal relationship for patient, doctor and the NHS. It allows timely, appropriate care to be delivered, in a cost effective manner.

General practice was never meant to be sporadic care. “Docs in boxes”, walk in centres and anonymous voices (telephone or internet), cut across the evidence of the quality and cost effectiveness of maintaining long term relationships.

Unfortunately general practice has been starved of resources, despite which, it has been responsible for delivering first world health care despite being funded at third world levels.

It is unjustifiable that in Stockport the money the NHS spends on general practice, to support premises, staff (excluding GPs) and IT was, in 1999-2000, around £4.7m, whilst the cost of running the Health Authority itself (including staff and premises) was £4.2m. The total NHS budget for 1999-2000 was £176m. Therefore general practice received 2.6% of the total Stockport NHS budget. It should be remembered that despite these paltry resources, Stockport general practice helps to deliver the best health outcomes in the North West for disease morbidity and mortality.

Unfortunately many unresourced demands, such as anti-rheumatic drug monitoring, or the management of drug misusers have been made on general practice under the catch all “GMS” contract. That doctors should be asked to deliver additional work, such as the new NHS National Service Frameworks for mental health and coronary heart disease (with more to come), clinical governance and improved quality and accountability, without an increase in real funding is unacceptable. GPs have been far too willing for far too long to accept extra work without new resources.

General practice can no longer accept new demands without a transparent framework of accountability, which in true partnership terms is two way, with quantifiable resources to fund extra work.

Primary Care Trusts, at level 4, will both commission and provide services, including primary care services. To truly invest in, and improve primary care, Trust boards and executive teams need to understand that they must fix what’s wrong with general practice in Britain and not what is right.

A GP is the only health professional who is likely to serve a population continuously for up to 38 years. Other primary care staff, including district nurses, health visitors, podiatrists, speech therapists, social workers, dieticians and physiotherapists are much less likely to be based in a particular area for such a length of time. A GP provides such commitment because of the nationally agreed contract between the profession and the NHS. This enables the continuity of care so cherished by patients, and which has delivered such cost effective care.

Successful PCTs will value this commitment and invest in it. They will recognise that GP practices need to be the building blocks of the Trust, and that genuinely devolved management structures, providing real financial control at practice level, with clear accountability agreements between the PCT and practices will most quickly deliver the changes needed in primary care. General Practice’s flat management structure enables GPs and their teams to quickly develop and implement new ideas, policies and change to health service delivery, both effectively and efficiently if given sufficient resources.

The modernisation of general practice, with for example, wider access to routine consultations outside conventional surgery hours, involvement in intermediate care, leading primary care teams and implementing evidence based care will radically alter the workload of GPs. These changes must be brought about by consensus, with no coercion, whether financial, professional or regulatory.

The current Health Authority stipulation that staff, IT and premises investment for general practice are reimbursed at only 70% has constrained the ability of practices to take up resource offers, and is an early candidate for correction. All stakeholders need to recognise that 30% of all investment in current general practice infrastructure and staff is directly owned or funded by GPs, and needs to be reimbursed.

Early consideration must also be given to the time constraints faced by GPs, with consultation length varying from 5 to 20 minutes. The evidence for better outcomes for patients, doctors and the NHS of longer consultations is clear. To achieve this, PCTs need an imaginative approach enabling the primary health care team (PHCT) to manage more of the routine GP workload, thereby giving GPs the priceless resource of time, to manage the complex clinical problems presenting from an increasingly elderly population.

Each member of the PHCT needs to be adequately trained to perform their new responsibilities, so that individual professions carry responsibility for their own actions. The demands on resources to deliver real improvements in primary care therefore will be great. The investment will need to be made by both PCTs and Local Authorities, so that all PHCT members contribute to the agenda for cultural change.

Time will also be required for in-service training to enable re-accreditation and enhancement of existing clinical skills and the development of new skills to increase services available in the community. Many GPs have specialist skills in, for example dermatology, gastroenterology and rheumatology. These skills could be invested in, to improve access for patients. Furthermore, additional services, currently provided by the secondary sector, such as anti-coagulation, blood testing, ECGs, cryotherapy and smoking cessation could be better provided more conveniently for patients within their local practices.

The implementation of evidence based medical practice and a wider range of primary care services requires both time and more, better trained, staff, (both within the practice and in the PHCT) managed by degree qualified Practice Managers. In an ever more litigious world the demands for a different approach to risk management in general practice require careful consideration. Chaperones, for example, for all examinations need to be recognised as a legitimate need.

PCTs must recognise the risk of undermining general practice, by implementing ill thought out schemes without express consent. Token consultation will only damage the key relationship between PCTs and general practice. PCTs will also recognise the threat to general practice of implementing Primary Care Pilot projects without the consent of general practice. Such radical changes should be consulted on widely, and implemented only with support of all stakeholders in a PCT.

A salaried GP service is a much-discussed option, favoured by many in NHS management. The aim, to better control clinical behaviour both in terms of cost and quality, may seem laudable, but the role of the GP as the patient’s advocate in the NHS needs to be recognised. Higher quality primary care will cost more, not less, and a salaried service should not be considered a cheap way of “taming wayward” GPs. A doctor’s duty is always to the patient and not to the system. The current lack of clarity in the national debate, regarding whom a doctor has a higher duty to, the NHS or the General Medical Council, in the proposed system of appraisal and re-validation, highlights the potential risk to patients of the introduction of a salaried service.

The ability of PCTs to jointly commission, with Local Authorities, services for patients will require health professionals on the ground and Local Authority members to understand each other’s pressures, and develop locally sensitive services to promote the health of local communities, within the district. GPs, with their close commitment to the communities they serve are ideally placed to facilitate appropriate development, of for example, improved local leisure facilities, after-school clubs, volunteer schemes and support mechanisms for single parents and carers and support for drug misusers. The regulatory framework for Nursing and Residential Homes is being reviewed nationally, and GPs are ideally placed to ensure that any new standards are adhered to, particularly if their involvement in intermediate care is helped to develop.

GPs 24-hour duty commitment may remain and PCTs will need to ensure that real partnership working exists, in meaningful 2 way relationships between OOH organisations and with other developments such as NHS Direct, Walk-In Centres and Healthy Living Centres, so that patients receive correct and consistent advice and health messages in cost effective ways.

To ensure that PCTs are able to develop primary care, changing the focus of the NHS away from secondary sector, the Executive teams of PCTs will require clinically active professional members, who can relate to the day to day problems facing their peers, and not be too distracted by the corporate approach that such teams will have to adopt.

REFERENCES

1. BMJ 17^thJune 2000 320:1616-7 Jan De Maeseneer, Per Hjortdahl, Barbara Starfield Fix what’s wrong, not what’s right, with general practice in Britain