ࡱ> CEB[@ N0bjbj44 .FViVi'8:4n$Rq4 4 4 4 X4 :, *  0Ry@yy|  D(X The recurring theme of the whole White Paper is how these proposals fit with the Governments Ten Year Plan for the NHS. This chapter begins with familiar ritual nods in the direction of primary care saying that, By international standards, general practice in England is efficient and of high quality and describing it as the envy of the world. Extra investment has underpinned incentives to expand services, reward improvements in clinical care and patient experience and aims to help recruitment and retention of key professionals. In fact, 3,950 more GPs now work in the NHS since the publication of the NHS Plan although there is no reference to how many of these are working full-time and whether this is a gross or net figure, allowing for retirements in the same period. Nevertheless, this does not matter because, job satisfaction has increased. Not only are health workers happier but, public satisfaction with the services they receive in primary care is generally high and with that conditional the tone of the document changes. There is variation across the country with services that do not always respond to the needs of local communities and individuals, especially those in deprived areas. There are also variations in the ease of access by telephone to make a convenient appointment. It is suggested that to improve responsiveness and equity of access the people need to be more in control so that they can really influence the development of services. This means building-up primary care capacity in poorly served areas, perhaps by encouraging new providers including commercial or social enterprise companies. The inference is that the existing practices not cutting the mustard will have to change in order to survive. Although levels of satisfaction with general practice are consistently high yet problems persist. One example is the difficulty encountered by people wishing to change practices. Some have trouble getting, good, accessible information on practices and what they offer. This will be an obligation on PCTs in future. Furthermore, if there are not always practices open to new registrations, that needs to be put right. Many practices will not accept patients who work, but do not live, in their catchment areas and these factors mean that choice of practice may be more theoretical than real. We are told that this will also be put right, by PCTs, practices and providers responding to the needs of the public and not to exhortation from Whitehall. Paragraph 3.19 contains a statement to the effect that the proposal for dual registration would undermine the positive aspects of the list system and by too costly to introduce. However, there will be a new wave of NHS Walk-in Centres in commuter areas to compensate for this. Registration with a single practice will then remain the cornerstone and, furthermore, in future there will be guaranteed acceptance onto an open list in a patients locality and the process of registration will be simplified. This section in the text is in bold type. In addition it is pointed out that only a very small proportion of practice lists are formally closed; many more are open but full. This is inconvenient for patients, fails to safeguard against discrimination and is, inevitably, described as lacking transparency. In other words practices may be choosing patients and not the other way around. In future practices will be either open or closed although there will be unspecified provision to assist practices with long- or short-term capacity problems. To ensure that popular practices benefit more money will follow the patient and popular practices will be helped to expand (Compare this with, The danger is, if you set up a good school, everybody will want to send their children there. Rt. Hon. J Prescott MP). Responsive providers will be rewarded. The Minimum Practice Guarantee, brought in with the new contract in 2004 to ensure incomes did not fall, is judged now to be a hindrance to equity of provision and NHS Employers will be asked to consider this when discussing incentives for 2007-8. After all, the UK now has some of the best paid GPs in Europe. The exact nature of these incentives let alone the balance of carrot and stick is not stated but there will be consideration of an Expanding Practice Allowance for practices that satisfy all of the following criteria; Have open lists Are growing significantly Offer extended opening hours. Interestingly, the consultation exercise asked participants about opening later than 5 pm. Otherwise, PCTs are to prioritise expanding practises when allocating strategic capital. Payments for services to unregistered patients will also be reviewed to offer more incentives to all providers when patients are away from home. All PCTs in under-doctored areas will be helped by the DH through the Fairness in Primary Care procurement project to develop new provision to tackle inequalities. Thirty PCT areas are identified by name as having between 40.6 and 47.5 WTE GPs per 100 000 weighted population, being the 10% with the fewest doctors. Only two of these lie south of a line drawn between the Severn and the Wash. Examples of ways forward include entrepreneurial GPs or nurse practitioners forming large organisation or groups of practices joining together to use Practice Based Commissioning as a prime driver. Some OOH co-operatives might be interested in providing round-the-clock services and the Independent sector is cited with the example of Mercury Health Primary Care together with its affiliation with Frome Medical Practice. The NHS Plan target of seeing a GP within 48 hours has, it is admitted, caused new problems with a growing minority of practices preventing advanced bookings. This approach is said to assume the publics time is free and will be stopped. In response to Your health, your care, your say the DH says that it has agreed with the BMA a new GP contract framework that sets the following objectives The opportunity to consult a GP within 48 hours; The opportunity to book in advance; Easy telephone access; The opportunity to consult a preferred practitioner. For the first time it is recognised in the White Paper that this latter choice may mean waiting longer. We will use our contracts to deliver both fast access and pre-booking and make public information on practices failing to comply. The public will then be able to judge. In future opening times will be agreed with PCTs and again contracts will be used to provide more incentives for new and existing providers to offer better opening hours. Furthermore PCTs will have to make sure that there is a range of opening times across the range of providers. Patient satisfaction survey will be standardised and conducted independently: because access and opening hours were rated so highly in the consultation exercise satisfied patients will guarantee reward[s] for their practices. Towards the end, paragraph 3.61 says that, Research shows that where a practitioner has an ongoing professional relationship with apatient, they tend to be more committed to that patient as a person. This is one reason why small practices are popular and will remain an essential part of general practice. It is hard to see how this will be the case given all that has gone before. So, what should be the attitude of GPs in Somerset, whether they are in smaller or larger practices, to the challenges contained in the White Paper? After all, we all deliver first class care to contented patients, dont we? Somerset is not under-doctored and so if deprived areas get better funding and patient more choice surely that should be welcomed? Like so much in the New Labour narrative the White Paper invites, indeed expects, agreement from all reasonable people. To disagree is tantamount to setting oneself up against motherhood and apple pie. Some extremists think the right to professional autonomy was sold in 1948 and that now the debt is being called-in from those who Took the shilling. In any event we must leave aside such questions as whether health professionals exist to give patients what they want or what they need or how odd it is that this Government introduced a new GMS contract just over a year ago which restricted contract hours. In the immediate future the devil will be in the detail and this White Paper is short on detail. The suspicious will ask what incentives will be used in well-doctored areas like Somerset to encourage better opening hours? Will it be comfortable additional funding for an Enhanced Service or, at the other extreme, will Saturday morning opening become a condition for a practice to continue with its already over-generously rewarded contract? Good quality healthcare such as that performed in Somerset has nothing to fear from patient satisfaction surveys. But what will be the nature of these independently conducted and assessed surveys? How many people will be asked, how will they be selected, what will they be asked and where and by whom? Research has consistently shown that those with most contact with health services express greatest satisfaction. But perhaps these are a self-selected group of sick people and those individuals with plenty of time on their hands to fit in with their practices priorities. What about all those would like to visit the surgery to discuss some mildly perplexing worry but find it inconvenient to attend when it suits their doctor to see them? The Government has made no secret of its intention to use patients as a lever for change. It regrets our self-employment and sees it, together with the professions high status with the public, as an obstacle to its ambitions for society. Great care must be taken in the months ahead if we are not to see a wedge driven into the doctor-patient relationship. Of two things we can be sure: that history teaches that medical profession will probably adapt to make the best of any transient reform. because there will always be a queue of people wanting to see a doctor every Monday morning.     Our health, our care, our say: a new direction for community services The Governments White Paper January 2006 Chapter three: Better access to general practice ")`a] _ p t }   > $ % & de,óç}nnnnnnhwOhACJOJQJaJhwYCJOJQJaJhwOhwYCJOJQJaJhwOhwOCJOJQJaJhdCJOJQJaJhwOhX6CJOJQJaJhwOhXCJOJQJaJhwOhfCJOJQJaJhCJOJQJaJhwOhdCJOJQJaJhd+% & abcAQk  $a$gdwO $ & Fa$gd|E1$a$gd|E1$a$gdX/M0,02>LQ1HN\c$',/IQTstuvjhCJOJQJaJhwOhCJOJQJaJhACJOJQJaJhwOhfCJOJQJaJhwOh)CJOJQJaJh* PCJOJQJaJhwOh= zCJOJQJaJhwOhwOCJOJQJaJhwYCJOJQJaJhwOhACJOJQJaJhCJOJQJaJ%uFGH `acw|qrzĸvj[O@j@j@@hwOh|E1CJOJQJaJhw>BCJOJQJaJhwOhCJOJQJaJhCJOJQJaJh=CJOJQJaJh)CJOJQJaJhwOh4iCJOJQJaJhwOhfCJOJQJaJh* PCJOJQJaJhCJOJQJaJh* Ph* PCJOJQJaJh6CJOJQJaJhhCJOJQJaJh* Ph* P6CJOJQJaJz{K  !I U!V!$$$$%A%R%q%&& ' ' 'ƷƷƷxxxl`lhCJOJQJaJhTCJOJQJaJh6~-CJOJQJaJhCJOJQJaJhwOCJOJQJaJhwOhwOCJOJQJaJhCJOJQJaJhwOhHU>CJOJQJaJhwOh)_CJOJQJaJh* Ph* P6CJOJQJaJhwOh|E1CJOJQJaJh* PCJOJQJaJ  @ A V!W!V#W#$$$$$$((M-N-////////$a$gdHU> $ & Fa$gdHU> ''''V'Z'['d'''8(9((()@))):*[*r*}*I+d++,,L-N------..?.//A/B////////////иhdh5OJQJh"x8jh"x8UhwOhCJOJQJaJhlZCJOJQJaJh6~-CJOJQJaJhCJOJQJaJhCJOJQJaJhTCJOJQJaJh"CCJOJQJaJ3///0K0L0M0N0$a$gdHU>$a$gdd///00K0L0M0N0³hwOhCJOJQJaJh"x8hhdh5CJ OJQJaJ h5OJQJhdh5OJQJhdh5CJOJQJaJ,1h. 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