The Case for Funding Primary Care for work transferred from other agencies
Background - Structure of General Practice
General Practitioners are self-employed. Their Practice is a business. GP services are delivered under the national GMS (General Medical Services) contract of 2004 which superseded the Red Book containing statements of fees and allowances. About 1/3 of practices hold a PMS (Personal Medical Services) and APMS (Alternative Personal Medical Services ) contract under which was individually negotiated with the NHS, but as all Practices are under similar financial and workload pressure at the moment we will not make a distinction in this discussion paper.
The 2004 Contract
The ‘Essential ‘ or ‘core’ services that GPs are required to provide are itemised in clauses 47 to 52 of the Contract. It is the LMC view that any service not provided by a Practice in England at that time is by definition not Core Work since Practices would have been in breach of their Contract and taken to Court if this was not so. This is very different from services that Practices have and continue to provide historically. Unfortunately the distinction between these two situations is poorly understood by other organisations who make assumptions on what Practices should be providing under Contract. For example, there is no requirement for Practices to provide phlebotomy or Nursing services. These assumptions lead to increasing requests for performing technical and clinical duties in Primary Care that traditionally have been done by the referring organisation and are not followed by appropriate resourcing. This presents a significant problem to Practices and is increasing year on year. The following paragraphs explain why this is and demonstrates the depth of the problem.
Background on payment structures
Being that GPs are Partners, their incomes (known as ‘drawings’) are calculated from the residual profits of the business after overheads. GPs pay their own staff, including practice nurses who are employed by the Practice not directly by an NHS body. Generally, Practices do give their staff an annual increment in pay – even if their profits fall, as has happened over the last few years. By far the largest expenditure by Practices is on staff salaries, followed by building upkeep and running costs. Recent years have seen a growing squeeze on Practice profits and some Practices in neighbouring counties have folded as they have become non-viable.
In the current economic situation, the only choices that GPs have had to sustain the current level of service have been either to reduce their own drawings, or work longer hours. Most GPs have done both of these. Every time a Practice takes on new work and has to increase staffing to cover the extra, the cost of this comes out of the Partners’ drawings. General Practice is therefore fundamentally different from the other organisations in the NHS as the doctors’ incomes are directly affected by the amount of work that they and their staff do and whether this is paid for or not.
Morale. The latest national DH survey of GPs’ work life shows the lowest level of job satisfaction since before the new contract in 2004, the highest level of stress since the first survey in 1998 ,and, in the last two years, a substantial increase in the proportion of GPs who are planning to quit direct patient care in the next 5 years
Increased patient demand. In 2009 over 300 million consultations took place in Practices – over 80 million more than in 1995. The average member of the public sees a GP 6 times a year, twice as often as 10 years ago. Since 1993 the average consultation time has gone from 8 to 12 minutes because of the complexity of the nature of patients’ conditions. People with long term conditions take up 50% of GP time spent with patients. In 19/20 consultations the problem is dealt with entirely in Primary Care
Financial. National spending on GP services increased by 10.2% between 2006/7 and 2010/11 (compared this to the 41% received by hospital services) but GP practice expenses have risen faster. The proportion of NHS funding spent on General Practice has fallen from 10.4% to 7.4% over this time.
Evaluating the demand
It has been a constant source of disappointment to Practices that successive commissioning organisations have said that work transferred from other organisations will have appropriate funding following the patient, only to find that ‘no new work without new money’ has proved a hollow promise. The LMC has repeatedly requested that this be addressed. With the New Contract in 2004 a ‘pre and post-op’ Enhanced Service was agreed to recognise the historical unfunded work that Practices had undertaken prior to that time from hospital care with a cap of 10% below or above activity at which point the situation would be reviewed. The LMC presented information to Somerset PCT in 2010 demonstrating that work from other agencies, now covering more than just ‘pre and post op’ amounted to a third of HCA time. Further studies this year over a spread of Practices have shown that the figures of increased activity range from 25- 30% of additional work related to HCA and Nursing duties e.g. injections, blood tests and monitoring (areas otherwise funded by ES such as DMARDS were excluded from the study).
In addition GPs are increasingly requested to take on various duties that otherwise have been done by clinicians in other organisations with a recent personal study giving a figure of 27% of communications from these parties requiring one two or even three subsequent actions.( Again, any actions that could be considered essential services were excluded from the survey)
As well as resource implications, this work is often given to GPs without a simple negotiation or request to take it on, without clear guidance on the process of referral back mechanisms or consideration of the GPs sphere of knowledge. This has implications for Patient safety and care.
Examples of work that has been introduced without consultation and/or resource
- PSA monitoring and re-instatement of anti cancer injections when this has reached a certain level.
- Titration of heart failure drugs – previously largely done by the heart failure nurses
- CEA monitoring -Somerset Cancer Clinical Programme Board have recently supported the resourcing of this service in Primary Care
- Discharge summaries requesting 1-3 sequences of actions, chasing up scans that have been requested by secondary care, making clinical decisions on treatments without support from Secondary Care expertise
- Denosumab administration
- Monitoring of initiation of DMARDS – now in the Enhanced Service but additional funding for the work has not been, as yet, forthcoming. Some Practices are now doing this ES at a cost to themselves.
- Anticoagulation monitoring pre and post cardioversion
Examples of work that GPs have been asked to do but have been resisted until funding, training and capacity is available and agreed
- DVT pathway
- ADHD monitoring
- Weekly monitoring and management of patients with eating disorders including mental health assessment
- Review of vulval dysplasias
- Coeliac disease monitoring
- ECG monitoring of antipsychotics to fulfil the Royal College of Psychiatrist guidance to Consultant Psychiatrists
- Anti TNF monitoring
- Early discharge care
At an LMC/CCG liaison meeting towards the end of last year this subject was discussed again and the CCG asked for specific figures on the level of the problem of transferred unfunded care. This details of the most recent studies as above were given at the latest meeting in May 2014 and a formal report was requested which we now provide.
Whilst General Practice acknowledge that other organisations are also under pressure of capacity the fact is that the financial investment between Secondary and Primary Care, to name just one organisation is not equitable, as indicated in the figures given above. We ask that the CCG address this matter along the following lines:-
- Ensure that other organisations are aware that work transferred has to have funding transferred appropriately.
- Acknowledgement that this a real and significant problem in General Practice causing increasing workload and stress on Practices and is contributing to the recruitment and retention difficulties that Practices currently face
- Addresses the ongoing lack of funding for work already transferred
- Negotiate on suitable funding for transferred services from now on – The LMC acknowledge that it is often more convenient for patients to have services nearer to home but this does come at a cost. The main concern is whether Practices will have the capacity to do so
We look forward to further discussions on this matter
Dr Sue Roberts Somerset LMC Chairman 2014