‘Crass, childish, behaviour’

James Gubb, 15 February 2008

Richard Vize writes what can only be described as a vitriolic attack on the BMA in his editorial in the Health Service Journal this week, describing them as resorting to ‘sabotage to block the modernisation of our primary care services’ and ‘crass, childish behaviour’.
His particular gripe is that the BMA’s GP Committee has, very unhelpfully it must be said, advised practices they are within their legal rights to withhold data being requested by Primary Care Trusts (PCTs) on practice opening hours and the availability of appointments as part of an audit ordered by the Department of Health (DH). In this sense, Mr Vize is entirely correct in his attack, quite rightly pointing out that ‘GPs cannot take state money then refuse to be held to account for the services they provide’. But then, in the context of the whole debate on extended opening hours one can feel slightly sympathetic.

It should be remembered that it was, after all, the same department and the same government that negotiated the new GMS contract for GPs that came into being in April 2004, which removed GPs’ responsibility for providing out-of-hours care and led to a retraction in opening hours. Responsibility went to PCTs and GP practices were able to opt-out of provision at a cost of around £6,000 per year to each GP in lost earnings; 90 per cent did so. Yes, GPs have received pretty substantial pay hikes in recent years – as much as 69 per cent since 2001 – but it seems pretty two-faced of the government to then turn around just four years later and try to claw some back.
True, the current debate is not about GPs becoming responsible again for out-of-hours care – PCTs will retain responsibility outside the hours of 8.00am and 6.30pm (unless the GP surgery a patient is registered at is open later) – but the government is trying to present the debate as clearing up the problems this has created. By forcing GP surgeries to open later, unmet demand for primary care outside current GP opening hours will be significantly reduced. This is substantial, if the CBI is to be believed; up to £1 billion a year in cost to industry.
Ok, so perhaps the government made a mistake with the GMS contract; perhaps it is reasonable that some GP surgeries should open longer. But then it is the manner in which they have tried to correct this which has quite understandably got the BMA and GPs’ backs up. This whole process originates from the populist interim report prepared by Lord Darzi, which called for spending on 150 new GP-run health centres and for at least half of GP surgeries to operate extended opening hours in evenings and weekends. This is archetypal central planning and London-centric health policy, based on a scant evidence-base; little more apparently than a disproportionate response to the 16 per cent who said they were dissatisfied with GP surgery opening hours in the DH’s own patient survey.
Then there’s the way the government have gone about the negotiating process and the way it is crudely trying to lever a response from GPs. Under both options, A and B, now open to GPs, those extending hours will receive a initial directed enhanced services (DES) payment to set up the extra hours. But the government’s real method of choice is to the Quality and Outcomes Framework (QOF) – the incentivised payment scheme for GPs introduced under the GMS contract. Under option A, a total of 58.5 QOF points from the holistic and organisational domain, plus 20 points from the patient experience domain, will be reallocated to reward GPs for offering an additional 30 minutes of opening time per week per 1,000 registered patients, probably in blocks of 1.5 hours after 6.30pm or for one hour before 8.00am or on a Saturday morning. Under option B, fully 135 points are removed completely from the QOF and reallocated to PCTs who can use this extra money to “reinvest in primary care” to agree local contracts for extended opening with any practices.
Not achieving QOF points costs GPs money; 135 points is up to £12,000 per year for the average GP according to the BMA, so many will be forced to open extended hours even if there is no demand for this service; massively unproductive in itself. In some cases local planning laws even prevent GPs from opening longer hours, so they’ll lose money even if they want to open longer.
But potentially more damaging than this is the government’s use of the QOF apparently as a toy – this is their ‘crass, childish, behaviour’. The QOF was needless to say not set up for this and, just like government pushing decisions by the National Institute for Health and Clinical Excellence, will seriously undermine its credibility as a mechanism for driving performance. According to the government, ‘the core philosophy underpinning the QOF is that incentives are the best method of resourcing work, driving up standards and recognising achievement. The QOF is not about performance management of GMS [and PMS] contractors but resourcing and rewarding good practice.’ QOF is supposed to be about evidence-based practice, not political whim. In this case, more than the money, the BMA is right to clamour.
The DH would do better to leave the QOF alone, along with its mantra of directing provision from the centre, and – in the short term – allow PCTs, who are after all supposed to be the ‘world class commissioners’, to identify where demand for extended hours is unmet and commission new or existing providers to meet it (APMS contracts). In the longer term – and here I diverge from the BMA – they should be using practice-based commissioning to foster a market in primary care to drive performance, integration and responsiveness to patients.