RCGP Policy debate: The end of the NHS as we know it

Can a new obsession with quality and productivity beat the financial crisis facing the NHS? The RCGP brought GPs, managers and policy makers together to discuss the key issues. GP was at the table to exclusively report the debate.

The Panel

(clockwise from the top left)

Jim Easton, England's national director for improvement and efficiency

Dr Mo Dewji, England's national clinical lead, primary care development

Katrina Percy, Chief executive (designate) of Hampshire Community Health Care

Professor Steve Field, Chairman of RCGP council

Dr Mike Bewick, Medical director of NHS Cumbria

Professor Roger Jones, Wolfson Professor of General Practice at King's College London

The NHS is facing a 'seismic shift' in its funding environment, according to Jim Easton, and the next five years are going to require major changes to how every part of it operates.

As England's national direc-tor for improvement and efficiency, he wants to instil a new hunger for high-quality patient care that will push up productivity and drive out waste.

He predicts 'huge opportunities' for GPs and primary care within a more united service, but at the expense of local autonomy and the ambitions of individual professionals and practices. He explained his rationale at a roundtable meeting organised by RCGP chairman Professor Steve Field at the college's London headquarters.

How can the NHS tackle this £15bn shortfall in funding?
Jim Easton
We have taken a key decision to try to tackle this challenge by driving quality up. We have to think about significant levels of change and the game plan falls into two parts. You can drive inefficiencies and waste from the current system, but there is nothing like enough in that to tackle this whole problem.

We have to look at changes to the system itself. How can we move care from expensive settings and do more preventive and out-of-hospital care? There is nothing new in that but we have not done it on a transformational scale. There is no evidence of spread.

So across the whole range of levers that exist nationally, regionally and locally, we are trying to understand how we can pull all the levers at once.

Where does primary care stand within this new NHS?
Jim Easton
There are huge opportunities for primary care to grow and build in a way that delivers the overall quality and financial agenda for the NHS and strengthens primary care. It's already the keystone of the system and becomes even more important when you are trying to build more systems outside of hospitals.

And we have some fundamental questions to answer together about how we should be guiding the development of primary care as a profession - of its education and training, of its structure - and how should we incentivise its organisation.

There is an interesting debate about the balance between very localised primary care and the tradition of continuity - which in my view is sometimes over-stated in practice but still important to many patients - versus notions of how you create capability to run complex systems of care that do fantastic things, and then how we design the packages of rewards and incentives to allow and facilitate that to happen.

Is there a real sense in primary care of the size and urgency of the problem?
Professor Steve Field
I actually don't believe that all of our colleagues in general practice understand how bad the financial situation is. I think people see the big figures, but I don't think that below that superficial skin level we have actually got a clue about the scale of change needed and what we have to do as individual GPs.

Dr Mo Dewji
They have not internalised the scale of it. People realise there is a big problem but whether they realise the absolute scale, and more importantly how pressing it is, within every practice, I am not so sure.

Jim Easton
People's actual behaviour has not yet become switched on to the problem. In an extended period of growth, which we have been through, most people's game has been a willingness to drive up quality in return for a share of that growth. It's a profound mindshift for people to be able to say they are prepared to go for quality to sustain the current level of funding.

And there is not a shred of doubt that the pace of the financial problems is way in excess of our current pace of change.

So how do we improve quality with limited incentives?
Jim Easton
Governments around the world have looked at market-based systems or incentives to create the hunger to improve quality. You could argue that QOF is one of those.

My prediction - which is not a precursor of a policy - is that if we wanted to keep QOF but really drive the standards harder, which personally I can see a strong argument for, then what are the mechanisms that drive people? Is there enough hunger?

Because whether you are running a hospital or a practice, over the past decade you did not have to exhibit massive hunger to do fantastic things to get a reasonable return for your business.

What support do practices need in order to change?
Professor Steve Field

We need good leadership in PCTs as well as good clinical leadership. And we really struggle on workforce. In some areas you cannot get practice nurses or physician assistants to take some of the load off GPs.

It's about making the life of the GP easier to change. We can do things quickly. It's not just down to the GP not wanting to change, it's actually quite tricky for some GPs to change in the environment they are working in.

Jim Easton
This is a systemic issue. I believe that GPs are an integral part of the solution. But it is not an excuse for anyone in the system to say they are too pressurised to change. I hear it from everyone and it's completely unacceptable as an argument.

Some people find the time to make change happen. If colleagues felt it was the right thing to do to transform diabetes services across their patch they could do it in a month and a half. But because there is a lack of energy and support, and the right incentives, it doesn't happen.

But is there really such an unwillingness to change?
Katrina Percy

I don't think there is unwillingness to change but people don't know what to do differently because no one takes the time to see what 'good' looks like or what they are trying to deliver.

One of the issues for me, working with small practices and community staff who have never been held to account for outcomes, is that they are just trundling along without understanding what they are trying to deliver, doing the same thing they have done for 60 years.

Accountability for clinicians is fundamental because they often see it as the manager's problem. You have to create the vision and then an understanding of what the outcomes are going to be to deliver that vision, and then hold people to account for delivering it.

I think that is being done reasonably well now in the acute sector, but we have to do that and hold people to account in primary and community care.

So there is a clear need for more collaboration?
Professor Roger Jones

One of the problems is that when the NHS was founded it was divided in to primary and secondary care, which has been useful but has also been very problematic over the past 60 years.

It's now becoming an issue not only because of the history but because of the various funding mechanisms that we have, and the tribalism that develops, which keeps consultants and GPs apart. We need to work more closely together, but that is more easily said than done.

In terms of evidence, everyone says how important it is to have strong primary care and that primary care keeps people out of hospital, but more of the evidence is that primary care and secondary care collaboration is the way to do things. There is a growing body of evidence to support the idea that integrated primary care and secondary care management is more cost-effective and clinically effective.

Professor Steve Field
In this country we do not have the continuity of the patient record, or the care pathway. GPs tend to protect what they do.

We tend to get very anxious about people looking at what we are doing or about getting other people to do things. We tend to tolerate poor performance and lack of integration, and for some reason we have been against integrating medical records. There are all sorts of things that as doctors we have stopped.

Dr Mike Bewick
If you look at QOF it looks wonderful, but in fact the mirror to QOF is quite disappointing and that's because we have not engaged with leaders in other fields such as public health, who would look at the hard-to-get and the hard-to-reach patients.

We are not very good at that cross-functioning with other parts of the service, and that is what integration is about, to me. It's about joining up with the leaders of the other side to share what your problems are and come to common solutions rather than just inventing another organisation and compartmentalising the problem.

How can the NHS balance these issues of quality, autonomy and productivity?
Jim Easton

My job is all about quality and productivity, and I am passionate about both.

If you look at the Francis Report on Mid Staffs, it's a service in which, right now, local autonomy doesn't just trump good practice, but local autonomy sometimes trumps death.

Some people say it's very distressing to clinical colleagues when we link quality to productivity and it's damaging to the cause, but I am not going to let it go. Because as soon as we just say we care about quality we will let go of the financial issue.

We will just end up tackling quality in the way we have always done, by saying we need to add more to the current system. I am not saying that is wrong, I am saying that is our mindset.

If we carry on like that we will lose the money and tip the NHS into a terrible position.

So I am passionate about the quality agenda but I simply do not see it to be in conflict with the financial agenda. We are trying to focus on quality and cost-effectiveness together.

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