Newsletter 48 August September 2009

NASGP Newsletter August September 2009

In our 48th edition, Judith looks at some fascinating ways to spend less in the NHS; Liz reiterates her robust advice about running one’s own business; lots of twittering has been going on; there’s a very brief summary of activity from the NASGP blog; Michelle has started something off down in Winchester and there’s a load more clever stuff going on in groups around the UK.

How would you cut the NHS budget?

NASGP member Judith Harvey has some ideas on how to save money in the NHS.

The NHS budget is going to be cut. Recently the Today programme asked for money-saving ideas. Here are some suggestions.

How would you cut spending?

1. Remember that health is a not a commodity and keep the market out of it. Professor Michael Sandel made the argument elegantly in the 2009 Reith lectures.
2. Do not let direct advertising of prescription medication into the UK. And stamp on pharmaceutical advertising aimed at ‘disease mongering’. See the BMJ article by Ray Moynihan, Iona Heath and David Henry.
3. Do not allow doctors a financial stake in businesses which give them an incentive to investigate and hospitalise patients. In his article in the New Yorker in June 2009 Atul Gawande illustrates how much this adds to costs and how it actually worsens health outcomes.
4. Educate the public to understand that investigations have a false positive rate, and in a healthy population this is likely to be far higher than the true positive rate. Health care professionals could do with a revision course too. Whoever does the testing, it is the NHS which pays for investigation of these false positives. This is not without risk, and we know that a positive test, even if subsequently negated,  permanently undermines people’s confidence in their health and increases health-seeking behaviour. Professor Charles Warlow’s describes his experience of commercial screening in a church in Edinburgh in his recent BMJ article.
5. In my experience of sitting on committees, the smaller the pot of money to be disbursed, the larger and lengthier the meetings called to decide on its fair distribution. Are we reaching the Jarndyce v Jarndyce point at which all the money is spent on making the decision, leaving none for distribution?
6. Fire the management consultants. I understand that a PCT spent £45,000 on management consultants whose advice led to a saving of £10,000. £35,000 could have financed quite a lot of patient care. Managers are paid high salaries to manage, so how come they have to pay large sums to consultants to tell them what to do? On the Today programme, Roy Lilley, terrier of the NHS, opined that many are incompetent. Many GPs would agree.
7. Put patient benefit at the top of every PCT agenda. Anything which directly improves patient care is difficult and seems to take second place to government must-dos and displacement activities like writing ‘latex policies’.
8. Most managers are very remote from patients. I would like to see every manager, including GP practice managers, obliged once a week to walk through a full waiting room and to talk to some of the patients. And to ask themselves every time they launch a policy what difference it will make to the patients they met last week. I recall meetings at a community mental health trust. The board room was near the wards for severely mentally disabled patients, who would wander in during meetings grinding their teeth and grabbing handfuls of sandwiches. They provided a powerful reminder of why we were meeting.
9. Whatever your view on the regime in Cuba, there can be no doubt that it is a poor country with a first world standard of health. Cuba’s expectation of life and infant mortality rates are at least as good as the UK’s and better than the USA’s — at a fraction of the cost. Yet when planners look around for models for improvement they have a blind spot: the Cuban experience is rarely if ever considered. It should be. Not everything in their health service would work or be acceptable in this country, for social and political reasons, but there may be lessons we can learn, and if we don’t look we won’t find out.
10. Educate the public to understand that good health is not a right but a matter of luck, self help and good sanitation. Doctors and medication play an important, sometimes vital, role, but there is not a pill for every ill, and pills are no substitute for personal effort and attitude. Nor are normal emotional states such as low mood, shyness and grief, illnesses. And it would help if more people realised that most illnesses are self-limiting and what is needed is time not tablets.
11. The NHS has a carbon reduction strategy. There are plenty of examples demonstrating that reducing the NHS’s huge carbon footprint can also save money and improve patient care and working lives.
12. Look hard at prescribing. Medication is large part of both the NHS budget and its carbon footprint, and much of it is wasted. I recall a patient who came up every month for his pills. When he died a five year supply was found untouched in his wardrobe. His prescription was a passport to a chat with the receptionists. Many of those who do open the packet take their medication incorrectly, so gain no benefit but risk adverse reactions. Patients accept prescriptions for all sorts of reasons, including over-optimism about the efficacy of pills and a wish not to say no to doctors who are ‘doing their best’. And doctors write them for all sorts of reasons with only a tangential relationship with therapeutic efficacy. Doctors need time to establish the sort of relationship with patients to say honestly what they feel about medication and why they don’t want to take it.
13. Walking is good for health, for the environment, and the NHS budget. That applies to staff and patients. Regular exercise improves health and may reduce the need for drug treatment of hypertension, cardiovascular disease, hyperlipidaemia, diabetes, COPD, obesity, depression, anxiety, agitation (in both the young and the demented), stress in all its psychological and physical manifestations, many rheumatological problems, constipation and no doubt other conditions I haven’t thought of.

What are your ideas?

Moynihan, R. (2002). Selling sickness: the pharmaceutical industry and disease mongering * Commentary: Medicalisation of risk factors BMJ, 324 (7342), 886-891 DOI: 10.1136/bmj.324.7342.886
Warlow, C. (2009). The new religion: screening at your parish church BMJ, 338 (may20 1) DOI: 10.1136/bmj.b1940

The salaried/partner divide

NASGP member John Pike puts forward the case for a seperate trade union for Sessional GPs.

Most salaried doctors believe a damaging split has opened up between them and GP partners, a “GP” newspaper survey reveals.

It is clear that the profession is deeply divided and a divided house will fall. There has been much talk in recent years of tackling this most serious issue, but little if anything has changed.

A few weeks ago, a “GP” survey showed that, on average, salaried GP pay was just over 50% that of PMS partners.

Despite tht greater burden of management that Partners must bear, I do not think that can justify such a huge differential and, in addition to the issue of pay, I have seen anecdotal evidence to suggest that some Partners do not always treat their salaried colleagues fairly in other ways (eg contractual).

As has been highlighted on the NASGP blog recently, it is impossible for the BMA to represent both Partners and Sessional GPs when their interests are so different and, indeed, opposing in some aspects. What is needed is a new union, specifically for Sessional GPs, without a conflict of interest issue, and to address matters of pay and contracts without further procrastination.

GOK why MSF and PSQ are being used for SGPs

NASGP member John Pike has written a comprehensive document on the problems relating to Multi Source Feedback and Patient Satisfaction Questionnaires with specific reference to their use with Sessional GPs.

We’re inviting our members to contribute to this evolving document which cab be downloaded from our main website. Here’s the executive summary:

• A patient satisfaction survey giving timely feedback to the doctor should be helpful for his personal reflection and for discussion at appraisal, but
• Patient-satisfaction surveys and MSF tools are not sufficiently robust for revalidation
• Neither of the two patient satisfaction tools currently used for the Quality and Outcomes Framework (QOF) has been formally assessed for reliability and their validation has been sub-optimal
• Currently used Patient Satisfaction Surveys and MSF are subjective and subject to huge elements of bias and to many variables outside the doctor’s control
• They are therefore unethical
• Some studies have shown no benefit, and even adverse results, from the use of MSFs
• A large study of a patient satisfaction survey used in Australia showed that it did not help GPs to improve patient-satisfaction over a nine year period
• Any tool used must be useful to GPs, helping GPs to improve their practice
• Any tool used must be acceptable to all GPs using it and GPs must have confidence in it
• Qualitative feedback is an essential part of any survey but commercial companies are not qualified to interpret it
• Qualitative feedback should be given to the GP at the end of each day for his own personal reflection and for later discussion at appraisal
• The GP concerned (perhaps with help from an appraisal discussion) is the only person qualified to interpret, and to reflect on, the results of Patient-Satisfaction Surveys and of MSF regarding himself.
• Different tools may be needed for regular members of a practice and for locum GPs

There’s still life in ‘Death in Service’

Death in Service benefit can apply to GP locums

There seems to be a leedle bit of confusion over the perceived lack of ‘death in service’ benefits for GP locums. The BMA has recently flagged this up as an issue apparently because on the flu pandemic – something that leaves us here at NASGP a little confused, but I’m sure there’s a good reason somewhere.

Hopefully, we can clarify the situation for you thanks to our friends at the NHSBSA.

Freelance GP locums doget death cover from the NHSPS, even though they may not be tied to a particular PCT/LHB. If [a locum] were contracted to work at a GP Practice as a freelance GP Locum from Monday to Friday however died on the Wednesday you (or rather your family) would get the full death in service benefits; i.e. the same as a GP Provider would. This includes a death gratuity which would be based on twice your average uprated (dynamised) GP Locum pensionable income. A widow’s pension and child allowance may also be payable.

If, however you died on the Saturday (i.e. between jobs) you would fall under ‘the death within 12 months of last pensionable job’ rule. You (or rather your family) would get slightly different death in service benefits. This includes a death gratuity which would be based on three times the value of your accrued annual pension. A widow’s pension and child allowance may also be payable.

Like pretty much any freelancer, we’re not covered by a corporate injury scheme (in our case, the NHS Injury Benefits Scheme which can also pay out a death in service benefit). So, for that, the BMA’s interim advice does apply.

BJGP editorial provides mandate for making demands to clarify revalidation

From NASGP member Stephanie Franz.

Martin Marshall‘s editorial in this month’s  BJGP Volume 59, Number 564, July 2009 , pp. 476-477(2) is a very tough read, but although he has a very high opinion of the principles behind revalidation, he does in my view mention almost all the problematic areas (including the needs of “non-standard” GPs): he is sympathetic to GPs concerns and he calls it a bureacratic nightmare and a dreadful waste of resources (if perceived as imposed from above). He is right, we can’t be paternalistic half gods in white anymore, but if we want to introduce revalidation to improve informed trust as opposed to implicit trust, then it needs to be done in a way which is trustworthy itself. I see his editorial actually as a good starting point for making demands. For example, we need to know what the expected timeline is, the funding issue must be adressed properly and the criteria for failure and consequences of failure must be clarified in much more detail.

He is inviting GPs to re-engage and contribute to the ongoing design of revalidation, so here is the email I sent him a few days ago:

Dear Professor Marshall,

As you point out in your editorial in the BJGP, revalidation is going to be a fundamental change to professional self-regulation with potentially serious implications for individual doctors. It’s main purpose must be to deliver explicit trust in the profession and this will only happen if the profession is willing to engage.

Reading your article, however, makes clear that, despite many years of very hard work on revalidation, too many big questions remain unanswered at present, which risks leaving the public and doctors with too many doubts.

You suggest that some of the methods have uncertain validity and reliability, which may have legal implications if a doctor’s licence is removed, based on these methods. Surely there are serious implications even if no licence is removed. We need absolutely watertight methods if revalidation is to be accepted by the profession and if it is to deliver trust.

One cannot expect the process to be acceptable to the public and to doctors when the rigour of the measurement tools still needs improving, and while there is a reliance on answers to some issues emerging after revalidation has been implemented and the process evolves. This amounts to turning hard-working professionals into guinea pigs whose livelihoods are put at risk. Also, to anticipate a trend towards a stronger emphasis on hard data is unsatisfactory; hard data is needed from the outset.

It is also difficult to see how revalidation is to be supported by GPs if it is not even clear what the implications of the assessment decisions are, where and how the line will be drawn and what actions will be required as a result.

You say that revalidation is going to be a dreadful waste of resources if it is perceived as imposed from above. Unfortunately, it can’t be denied that, for most grass roots GPs, revalidation is seen as not just imposed from above by politicians, but also by academics who, in the context of revalidation, are often seen as out of touch with real life General Practice (a view often expressed in online doctor’s fora).

GPs could be forgiven for thinking that revalidation was introduced to “prevent the next Shipman”, given that it came in the wake of the Shipman enquiries. However, in the recently published GMC Guide to Revalidation this view is described instead as “a common misconception”. There is still a need for real clarity about why revalidation is necessary and doctors need to be convinced that revalidation is an appropriate vehicle to achieve those goals, given that there are already other successful mechanisms in place for monitoring fitness to practice, continuing professional development and improving patient care, such as Clinical Governance, Appraisal and QOF.

All other issues, such as inadequate IT systems, funding and support, the anticipated amount of bureaucracy involved and the needs of non-standard GPs cannot be addressed properly until the basics are sound.

Before revalidation can become a professional imperative, it is imperative that revalidation becomes professional.

Yours sincerely

Dr Stephanie Franz

I even had a personal friendly reply, so try it yourself!

Marshall, M. (2009). Revalidation: a professional imperative British Journal of General Practice, 59 (564), 476-477 DOI: 10.3399/bjgp09X453486

BMA letting salaried GPs down

Salaried GPs really need to see both sides of the BMA coin. On the one hand, the BMA, through its General Practitioner’s Committee (GPC), has an active Sessional GP Subcommittee; produces an excellent Salaried GP Handbook; has a veritable army of industrial relations officers and has the fair representation of salaried GPs enshrined as part of its core business.

But this wonderful altruism towards salaried GPs lacks one very basic yet fundamental law: an organisation designed to represent employers can not possibly ever do the same for its members’ employees. I’ve yet to come across any other trade union in the democratic world that makes the same claim as the BMA.

The BMA is the doctors union, predominantly representing employed hospital doctors and, through its craft committee the GPC, GPs. These GPs, however, are mostly contractors and not employees – only 17% of GPs are, strictly speaking, employees. 25% are locum GPs and the remaining 60% are PMS/GMS contractors.

It’s a representational mess and the BMA is just tying us in knots. And its salaried GPs who are being strangled.

Here at the NASGP we get email after email from bullied, neglected and abused salaried GPs, often too scared to make a fuss as, not only do they know that ‘making a fuss’ will be followed by them being ostracised for being an employee at another practice, they will be unable to get impartial help from their trade union that also represents even more GPs on the other side of their employment contract.

So the BMA needs to make a choice and let go of its hold on the representation of either its employers or employees. Although it has been looking after PMS/GMS contractors the longest, I actually think it’s this lot, already well organised and empowered, who would be the best group to be jettisoned from the BMA, leaving Sessional GPs under the protection of the BMA, particularly as the BMA already looks after many more employed doctors in secondary care.

If they don’t make up their mind, or whilst they’re trying to decide what to do, Sessional GPs need to consider an alternative to the BMA-GPC-LMC trade union axis and join an independent trade union. I’m not saying that Sessional GPs need to necessarily resign from the BMA – the BMA offers services above and beyond a trade union – but we need to belong to a trade union independent from our employers.

Working in isolation is not an option

I’m just on my way back from giving a talk on ‘Enhanced Appraisal’ for GP locums. When I arrived in the afternoon, I was leapt on by some a few delegates who’d been there for the morning and who reported the general angst about what PCTs should be doing about locums and appraisal.

I gave a half-hour presentation using Maslow’s Hierarchy of Needs as the model we need to be using when we think about planning resources that will actually support locums through revalidation. It’s all very well to look at the higher functions of quality and performance, but when the basic needs of education, work, security and ‘professional community’ are not being met then expecting locums to do audit, Multi Source Feedback etc are pointless.

The solution, as summarised by the conference’s chairman Dr Emyr Jones, was ‘if the problem is because GP locums have to work outside a managed environment, the solution is to create a managed environment for them to work within’. Fortunately examples do exist, and on these occasions I am able to give my own example of working in a Locum Support Team within Pallant Medical Chambers, where 45 locums work within separate local locum chambers. For those unable or unwilling to work in other similar locum teams, the opportunity to work as affiliates to a conventional practice also exist in the form of the affiliate Freelance GP Scheme.

What is clearly not an easy option – a point made very well by those from secondary care – is working in professional isolation. All doctors need to have a certain minimal level of integration with other professionals, and ‘soft’ features relating to communication, behaviour and clinical performance are increasingly being looked at as indicators for concern.