Most of the care required in our country is dispensed by the General Practice. In this essay, Dean Eggitt breaks down the GP service – on financing, governance, and priorities – and suggests reforms that should better enable it to deliver on the UK’s primary care needs.
Between 1990 and 2010, life expectancy in England increased by 4.2 years with improvements in reducing premature deaths from heart and circulatory diseases. People in the UK are living longer with more long-term conditions. Over 15 million people in England now live with a long-term condition. Most of the care required is provided in the community by general practice and thus will be the focus of this essay.
Governance and Leadership
Primary medical services in England are mostly delivered by self-employed contractors to the NHS. The terms of the contracts are largely defined nationally by NHS England following annual negotiation with the General Practitioners Committee of the British Medical Association (BMA GPC). The agenda for contractual negotiations is set by the Department of Health and Social Care (DoHSC) and the BMA GPC after consultation with relevant stakeholders.
Quality of care provided is closely monitored. Individual clinicians working within the NHS must undergo annual appraisal and doctors must undertake revalidation every 5 years. Clinicians must be registered with their appropriate Professional Regulatory Body and contractors must register their services with the Care Quality Commission (CQC), who undertake regular assessments.
This design allows for the state to maintain control of the healthcare agenda and of the quality of care provided whilst providing a mechanism of contractual flexibility to address local geographical needs. It also allows for the organic variance of the private healthcare sector to address unmet needs.
Recommendation
The systems in place to monitor quality of care create a burden on providers which reduces their clinical availability and business growth.
Policymakers should:
- Reduce the burden of regulation to encourage variation and innovation.
- Mandate a broader range of stakeholders in contractual negotiations, ending the monopoly of the BMA.
- Place a ”duty of public health” on NHS England and NHS Improvement (NHSEI) to ensure that wellness and illness establish parity as a minimum.
- The Secretary of State for Health and Social Care should be appointed the data controller for General Practice-held patient data.
Services
In General Practice, resources follow patient registrations and achievement of patient outcomes. The consequence of adopting a range of contracting mechanisms and broad qualifying characteristics for potential contract holders is to reduce barriers for access to the primary medical services market. This should result in the increased availability of independent providers to the market from which commissioners can exercise choice in the purchase of care.
Whilst the resultant increase in contestability confers an element of market self-regulation, this particular market remains challenging to enter with high levels of education and experience of industry being barriers to access. Therefore, governance arrangements are necessary to manage dominant providers where low measurability of their outcomes exists.
Recommendation
- Local authorities and NHS commissioners should establish provider organisations.
- NHS estates should be nationalised.
- The NHS should prioritise health over illness with a greater focus on establishing and maintaining wellness rather than treating illness.
Financing
In 2018/19 the budget for the NHS in England was £114 bn. General taxation accounts for around 80% of the budget. This arrangement is efficient with low administrative costs when compared to implementing multiple systems and affords the state legitimate control over the healthcare agenda.
However, healthcare runs the risk of causing a financial burden to the state. Currently, private fees provide a small contribution to the UK healthcare budget. The private healthcare market in the UK covers 10.5% of the population
Plurality of income streams with majority funding by social means appears preferable. It is sensible to ensure that the NHS continues to provide essential care whilst private healthcare is available to those with the means to purchase non-essential care.
Recommendations
Current funding is skewed to favour resourcing hospitals instead of community care, despite the latter being where more efficiencies are made, and most activity is provided. A larger portion of NHS funding should be committed to community care to realise the aim of health over illness.
The NHS budget should be based upon need, rather than want. The Carr-Hill funding formula should be adjusted to prioritise deprivation and under-doctored areas.
The UK healthcare market should be open to more purchasers of care, creating a diversity of income streams that would limit the monopsony of the state and its financial vulnerability.
The NHS should have greater flexibility to budget allocations. NHS organisations should be permitted to carry over financial surpluses from one financial year to the next without penalty. This provides an incentive to invest in services in the long term and to make decisions that result in savings and re-investment.
Hypothecated increase revenue for the NHS by increasing taxation on tobacco-based products
Priorities
NICE has the mandate to assess the evidence base of the cost-effectiveness of an intervention, service or programme, with the aim of helping decision-makers to maximise gains from limited resources. In doing so, NICE undertakes analyses of the existing evidence to estimate the impact of resource utilisation in relation to the benefits and harms of current of alternative courses of action.
In meeting the ideals of universal health care, NICE factors into its considerations access to healthcare provision and the financial consequences of not providing an intervention, service or programme. However, financial protection is not considered at an individual level by NICE and so healthcare market failure could go unnoticed unless the problem is endemic.
Recommendations
- NICE should have an additional duty to have regard for the private healthcare sector.
- State and private providers should share operational data to allow better prioritisation of resources and more strategic purchasing.
- The private sector should support NICE to meet its aims. Sharing operating infrastructure between the private and public sector would minimise resource wastage.
Strategic Purchasing
Providers of primary medical services receive financial resources via a core budget paid prospectively, based upon a weighted practice-level capitation. This allows an element of predictability of income to ensure that services can operate without interruptions. Further payment comes from the Quality and Outcomes Framework (QoF) and enhanced service contracts. QoF defines expected patient outcomes that result in increased payment, if thresholds are met. If the provider is inefficient, there is a possibility that the practice experiences a year-end financial deficit.
This approach strikes a useful balance between provider stability and encouragement toward achieving designated outcomes, ensuring the needs of the purchaser are met. It also provides financial controls that are important due to inflexible budget allocations.
Recommendations
- NHSEI should adopt long-term contracts with primary care and minimise year-to-year variability. This would provide stability for commissioners and providers, which will give them confidence to invest and innovate.
- Primary care should adopt the use of a single interoperable IT system.
- Resources should be allocated directly to providers, avoiding resource waste through third parties.
- Services should be commissioned at scale utilising as few contracts as possible to minimise the burden of managing multiple contracts.
- General Practices should be permitted to adopt Limited Company status to encourage innovation.
Human resources
Whilst the demand for GP services has increased over the years, the supply of GPs working in the NHS has fallen. The number of non-GP staff working in general practice has continued to increase.
Allied healthcare professionals (AHPs) are quicker and cheaper to train than GPs and have lower wages. Due to the less rigorous academic demands of these roles, it is likely that they are also easier to recruit to training schemes. This model of creating clinicians to supply the demands of the NHS affords quicker access to a larger, more diverse workforce that is cheaper to sustain in terms of wages.
The case for increasing utilisation of AHPs over GPs seems compelling, although there is unfinished debate over the resulting quality of care provided and the consequences that this might have downstream in the NHS.
Recommendation
- The importance of General Practitioners in supervising and training doctors and AHPs should be recognised.
The NHS should recruit more General Practitioners, by Providing:
- A change in title from General Practitioner to Consultant of Community Care
- Flexible training
- Flexible working
- Mandatory GP rotations in Foundation and Speciality Training
- Salaried employment
- An increase to the cap on pension contributions
- A national insurance contribution holiday
- 100% tax relief on internet, telephone and automobile use
Dr Dean Eggitt is an NHS GP and Fellow of the Royal College of General Practitioners.
He is the Chief Executive Officer of Doncaster Local Medical Committee and past representative on the General Practitioners Committee of the British Medical Association.