The cornerstone of Labour's 'New NHS': reforming primary care

Two remarkable aspects of the Thatcher ‘internal market’ reforms of the NHS were the focus on creating a market for hospital services and the way in which primary care was treated almost peripherally in the 1989 White Paper (Department of Health 1989a). The 1991 NHS reforms introduced general practitioner (GP) fundholding almost as an afterthought, and the revision of the GP contract in 1990 Paper (Department of Health 1989b) was conducted separately from the implementation of other health care reforms. In contrast the principal focus of Labour’s ‘new NHS’ reform is primary care (Department of Health 1997). The intention of the government is both to improve the efficiency and equity of primary care provision and to develop Primary Care Groups and Primary Care Trusts which both provide care efficiently and act as agents who purchase secondary and tertiary care on behalf of patients. This is an ambitious agenda. This paper explores the policy context of Primary Care Groups in sections 1 and 2, describes and appraises the government proposals in section 3, and identifies major issues involved in the implementation of change in section 4.fundholding, rationing

Public spending must improve health, not just healthcare : A narrow focus on the NHS neglects the much wider determinants of health

Last week’s budget held few surprises for the NHS because the “star bunnies”1 had already been released from the chancellor’s hat by the prime minister, whose summer announcement included a £20.5bn (€23bn; $27bn) “70th birthday present” for the NHS.2 But, as many have noted, the extra funding committed by 2023 (3.4% a year) is relatively low compared with historical trends—average annual increases since 1948 have been around 3.7%3— and it follows a long period of very modest growth. When adjusted for need, NHS spending has risen by only 0.1% a year since 2009-10 in real terms,4 and the spending pledge is widely viewed to be only enough to get the basics back on track.5 Top line figures also ignore what is happening to different funding streams. Increases are directed at only one part of the healthcare system—NHS England—ignoring NHS infrastructure such as training, IT, and buildings, all of which are under increasing pressure, as well as spending in Wales, Scotland, and Northern Ireland. Despite the efforts of local authorities to protect social care spending, it has fallen by 1.5% a year between 2009-10 and 2016-17,4 and as the deputy chief executive of NHS Providers put it, “When social care is cut, the NHS bleeds."

Effectiveness of nurse delivered endoscopy: findings from randomised multi-institution nurse endoscopy trial (MINuET)

Objective To compare the clinical effectiveness of doctors and nurses in undertaking upper and lower gastrointestinal endoscopy. Design Pragmatic trial with Zelen's randomisation before consent to minimise distortion of existing practice. Setting 23 hospitals in the United Kingdom. In six hospitals, nurses undertook both upper and lower gastrointestinal endoscopy, yielding a total of 29 centres. Participants 67 doctors and 30 nurses. Of 4964 potentially eligible patients, we randomised 4128 (83%) and recruited 1888 (38%) from July 2002 to June 2003. Interventions Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy, undertaken with or without sedation, with the standard preparation, techniques, and protocols of participating hospitals. After referral for either procedure, patients were randomised between doctors and nurses. Main outcome measures Gastrointestinal symptom rating questionnaire (primary outcome), gastrointestinal endoscopy satisfaction questionnaire and state-trait anxiety inventory (all analysed by intention to treat); immediate and delayed complications; quality of examination and corresponding report; patients' preferences for operator; and new diagnoses at one year (all analysed according to who carried out the procedure). Results There was no significant difference between groups in outcome at one day, one month, or one year after endoscopy, except that patients were more satisfied with nurses after one day. Nurses were also more thorough than doctors in examining the stomach and oesophagus. While quality of life scores were slightly better in patients the doctor group, this was not statistically significant. Conclusions Diagnostic endoscopy can be undertaken safely and effectively by nurses. Trial registration International standard RCT 8276570

Rewarding excellence? Consultants' distinction awards and the need for reform

It is essential that excellence in the performance of doctors in the National Health Service is rewarded explicitly and efficiently. Unfortunately the existing system of Distinction Awards which, for the select few, can double a doctor’s public sector pay is both secretive and of unproven efficiency. Distinction awards have existed since 1948 and at present 34% of consultants receive them. They are payable at four levels: A+ at £46,500 per year, A at £34,260 p.a., B at £19,580 p.a. and C at £9,790 p.a. Since 1989 a few managers have been involved in the allocation of ‘C’ awards but all the other awards are determined by committees of consultants who meet in secret to decide who deserves rewards for “distinction”. The costs of these awards, in excess of about £80 million per year, have to be met by the hospital in which the consultants are employed. Ideally these payments should be related to performance and their award should act as signals to NHS purchasers and customers regarding the excellence of the care that is available. Unfortunately a rationale for these payments is absent. It may be that their allocation reflects excellence in some way but this has not been demonstrated by the advisory committee on Distinction Awards. Indeed the secrecy of the award system and the difficulty of explaining the distribution of awards with available “indicators” works to sustain a conspiracy theory that the awards are made to “the boys” to inflate their income whilst in practice and their pensionable earnings after they retire. Such assertions do little to enhance efficiency and the development of effective clinical management. The distribution of distinction awards between specialties and regions is described, and attempts are made to evaluate its efficiency. This statistical analysis shoes that there is little relationship between the value of awards and available crude indicators of productivity. Tens of millions of pounds are used annually to fund the system of distinction awards for NHS consultants. Those who determine the use of these resources are not accountable for them and few NHS managers understand the system let alone recognise the need to reform it and facilitate the true reward of excellence. There is a need for the medical profession to deal explicitly with payment for excellence and also for them to realise that such a remuneration system will have to be controlled in conjunction with NHS managers. Both professional groups, clinicians and managers must move rapidly to reform the way in which clinical excellence is rewarded in the NHS.Distinction awards, remuneration

Non-steroidal anti-inflammatory drugs: a suitable case for treatment?

Non-steroidal anti-inflammatory drugs (NSAIDs) are used widely throughout the world to relieve the symptoms of musculoskeletal disorders, in particular osteoarthritis and rheumatoid arthritis. These drugs produce significant side effects, including gastro-intestinal ulceration and the associated complications of perforation and bleeding. The relative toxicity of competing forms of branded and generic NSAID scary considerably. Their cost also varies considerably, often with the relatively more toxic formulations being more expensive. These characteristics, differing toxicity and cost, offer the possibility of reducing both adverse effects to patients and pharmaceutical expenditure if doctors’ behaviour can be changed. A tentative exploration of alternative patterns of NSAID use demonstrates that it may be possible to reduce expenditure below the 1994 level of around £175 million and reduce adverse events. An illustrative model shows that if prescribing was reduced by 25%, average dose reduced by 10% and patients switched to less toxic NSAIDS, up to £86 million could be saved, the number of serious adverse events per year reduced by 189 and the number of gastrointestinal complications reduced by 127. Such results may be achieved without reductions in the quality of life of patients using these drugs. Available clinical and economic information about NSAIDs is limited, with numerous published studies of poor quality which corrupt the knowledge base. Despite these problems there appears to be enough evidence to indicate that expenditure on NSAIDs could be considerably reduced and significant adverse effects could be avoided if general practitioners can be persuaded to change their prescribing behaviour. Inefficient and inappropriate prescribing of these often beneficial but sometimes dangerous drugs appears to be wasting scarce NHS resources and harming patients.NSAIDs, prophylaxis

Equity in primary care

The allocation of funding and the distribution of the workforce in primary care is very unequal in England. Whilst hospital resources have been allocated in relation to a weighted capitation formula in each of the component parts of the United Kingdom since the late 1970s, there have been minimal efforts to equalise the distribution of general practitioners and the budgets which finance them and the services they provide. The purpose of this paper is to illustrate both the existing inequalities in the distribution of primary care funding and the impact of alternative, simplistic but illustrative formulae which could be used as a basis for achieving more equitable funding of primary care in England. These calculations show hat a weighted capitation formula would have a significant impact on the old fourteen regions of the English NHS with major losses in funding and staffing levels in the South, particularly the South West, and major gains in the North of England. For example, using one of the models, the South West would have lost 14 per cent and the Northern region gained over 9% of FHSA expenditure with ‘RAWPed’ primary care budgets in 1990-91. The pursuit of greater equity in primary care funding may require a radical change in the GP contract, perhaps with it being replaced by franchises for primary care which are let to multi-disciplinary teams of providers. Such change requires careful evaluation to ensure that the hospital gatekeeper role of the GP is maintained and the incentives to ensure efficient use of scarce primary care resources are improved.RAWP, weighting, FHSA

Expenditure on the NHS during and after the Thatcher years: its growth and utilisation

Has government expenditure on the National Health and Personal Social Services increased significantly in real terms over the past decade? If so, where has this growth in expenditure been utilised? This paper investigates claims of real increases in expenditure by examining trends in total expenditure on the NHS between 1979 and 1992, and disaggregating these trends to concentrate on different sectors, the influence of changes in NHS personnel, the revenue/capital split and the geographical distribution of expenditure increases. The total cost of the UK NHS has increased from approximately £9.2 billion in 1978/79 to £37.4 billion in 1991/92. Adjusting this figure to account for general inflation shows a real increase of 50.4% over this period. This gives a reflection of the increased cost of the NHS to the economy. However, adjusting the increases to account for changes in NHS pay and prices shows a smaller increase, of about 22% over the period, an average annual increase of around 1.5%. As NHS costs are taken into account, this measures what the NHS is able to buy with the increased resources. Increases in expenditure have not been evenly distributed between different sectors. The smallest relative increases have been in the hospital sector, which have absorbed a decreasing proportion of overall NHS and PSS expenditure over the period. The relative restriction on hospital budgets during the 1980s contributes greatly to the public perception of a parsimoniously funded health service. Expenditure on community health services has increased by the greatest proportion over the period, but this is still a small, though increasing, proportion of overall expenditure. The family health services budget (which funds primary care) has remained relatively stable as a proportion of overall expenditure over the 1980s. This means that significant real increases have taken place. This is due largely to increases in general practitioner and other staffing. Between 1980 and 1991, the number of GPs increased by around 19%, with average list sizes decreasing from 2,247 to 1,918. In addition, GPs have increasingly employed nursing and other support staff. There has also been increasing expenditure on pharmaceutical services (the government’s net expenditure on pharmaceuticals has increased by around 47% over the period 1778-79 to 1991-92). Finally, expenditure on personal social services has increased at around the same rate as overall health and PSS expenditure. The NHS is a labour intensive service, and this means that changes in personnel have major expenditure implications. Over the period studied, numbers of whole-time equivalent medical (particularly senior medical) and nursing staff increased steadily, and these staff received significant real increases in salary levels. There were also increases in the number of professional and technical staff and administrative and managerial staff. Numbers of whole-time equivalent administrative and clerical staff increased from 105,430 in 1980 to 129,716 in 1990, i.e. by around 23%. There were, however, significant reductions in numbers of directly employed works professional, maintenance and ancillary staff, due to government policies of contracting out these services. The resource consequences of the apparent shift towards relatively high paid staff are substantial, and if these trends continue the overall wage bill for the NHS will continue to increase considerably even if staff numbers do not. The majority of NHS expenditure is current expenditure, primarily on salaries and wages, with capital expenditure representing around 5-6% of total NHS expenditure in England over this period. Geographical distribution of hospital and community health services expenditure has also changed relatively little, despite the implementation of the RAWP formula for HCHS in England and similar formulae subsequently and elsewhere in the UK. No attempt has yet been made to equalise primary care spending using a RAWP-type allocation formula. This is surprising given the government’s emphasis on the integration of primary and secondary care and the primacy given to the services managed by general practitioners. The ‘Waiting List Initiative’ and more recent government pledges in the ‘Patients’ Charter’ were aimed at reducing waiting times, particularly the number of long waits, with guarantees that no one should wait more than two years for a procedure. This goal has been achieved but, as ever, supply creates demand in the absence of agreed clinical practice guidelines and the number waiting have, as a consequence, grown to over one million. This policy concentrates on activity, which is an unsuitable goal and an unusable measure of success. In allocating resources to the NHS, as in all other policy areas, the appropriate target should be efficiency. Increasing activity, where this activity is often of unproven effectiveness is inefficient and inappropriate. The level of public expenditure devoted to the National Health Service is largely a political decision – the overall budget, as in all other departments, is determined by the political bargaining of the annual public expenditure round. The settlement for 1994-95 includes a real funding increase and meets the 1992 Conservative election pledge, provided the Treasury estimates of inflation are correct (which is rare!) However, to achieve efficiency in the NHS, expenditure increases must be directed to areas of proven cost-effectiveness. This goal would be assisted by publication of more detailed breakdowns of NHS expenditure increases and more economic evaluation of new and existing health care programmes. In future there will be increasing pressure on limited NHS resources due to demographic change and technological advance. The vague ways in which NHS expenditure is monitored and “value for money” determined will have to be replaced by more sophisticated monitoring of spending and the provision of cost effectiveness data to ensure society’s scarce health care resources are used effectively. There is evidence of considerable scope to improve the efficiency of resource allocation in the NHS and this may be best achieved by the ‘leverage’ of parsimonious funding.expenditure

Promoting cost-effective prescribing in the UK National Health Service

Pharmaceutical prescribing currently represents around 10% of total National Health Service expenditure, and is one of the most inflationary elements of spending (Parliamentary Office of Science and Technology 1993). Between 1980 and 1990, the overall cost of a prescription increased by 19%. Pharmaceuticals are one of the most commonly used and important interventions available to doctors in clinical practice, and their appropriate use can reduce mortality, morbidity and costs falling on other parts of the health care system. However, evidence from systematic reviews demonstrates that current prescribing may not always be effective or cost-effective (Effective Health Care, 1993). A number of policy initiatives have been introduced which attempt to contain prescribing costs. These include provision of Prescribing Analysis and Cost (PACT) data; the limited list; the indicative prescribing scheme and GP fundholding. However, these schemes have had limited impact and tend to focus on cost containment rather than cost-effectiveness in prescribing. Confusion remains concerning current knowledge and good practice in cost-effective prescribing. This confusion could be reduced with appropriate research making use, where possible, of the valid and reliable routinely collected activity data available on prescribing in the UK. In other countries, particularly Australia and Canada, policies have been introduced to limit the introduction of new drugs to those which demonstrate cost-effectiveness. Other countries, including European countries and the United States, are encouraging provision of economic evaluations of pharmaceuticals and have introduced varying initiatives to control prescribing costs and increase cost-effectiveness. UK policy initiatives should be informed by the experience of other countries. There is a considerable inertia in prescribing habits, and evidence of effectiveness and cost-effectiveness, when it exists, is not always used. A number of organisations are attempting to improve this situation. The NHS Centre for Reviews and Dissemination, at The University of York, produces and commissions systematic reviews of specific health-related questions, and disseminates these findings throughout the NHS. The Cochrane Collaboration, at the UK Cochrane Centre in Oxford and around the world, aims to produce systematic reviews of randomised controlled trials. The Cochrane Collaboration for Effective Professional Practice, an international collaboration with an editorial office at The University of York, conducts systematic reviews of initiatives aimed at changing professional behaviour. These and other organisations all attempt to improve the process of getting good evidence about health care interventions (including prescribing) into practice.prescribing, pharmaceuticals, PACT, cost-effectiveness

General practitioner well-being during the COVID-19 pandemic : a qualitative interview study

OBJECTIVES: The COVID-19 pandemic presented new challenges for general practitioners' (GPs') mental health and well-being, with growing international evidence of its negative impact. While there has been a wide UK commentary on this topic, research evidence from a UK setting is lacking. This study sought to explore the lived experience of UK GPs during COVID-19, and the pandemic's impact on their psychological well-being. DESIGN AND SETTING: In-depth qualitative interviews, conducted remotely by telephone or video call, with UK National Health Service GPs. PARTICIPANTS: GPs were sampled purposively across three career stages (early career, established and late career or retired GPs) with variation in other key demographics. A comprehensive recruitment strategy used multiple channels. Data were analysed thematically using Framework Analysis. RESULTS: We interviewed 40 GPs; most described generally negative sentiment and many displayed signs of psychological distress and burnout. Causes of stress and anxiety related to personal risk, workload, practice changes, public perceptions and leadership, team working and wider collaboration and personal challenges. GPs described potential facilitators of their well-being, including sources of support and plans to reduce clinical hours or change career path, and some described the pandemic as offering a catalyst for positive change. CONCLUSIONS: A range of factors detrimentally affected the well-being of GPs during the pandemic and we highlight the potential impact of this on workforce retention and quality of care. As the pandemic progresses and general practice faces continued challenges, urgent policy measures are now needed