So what does clinical-led commissioning mean for Sessional GPs?

Whether you like it or not, it’s going to happen. As sessional GPs, particular as freelance GPs working in many different practices, you will no doubt have some across a huge diversity in the way in which the care is delivered to the patients you’re caring for. Although sometimes the cause of some failings lies with the way the practice is organised, more often than not it’s to do with resources that are above and beyond the control of local practices. And this is what commissioning is setting about to change; it has the potential to radically change the way we help manage patient care.

A la recherche du temps perdu

I have just been clearing out – old textbooks, cuttings from Update and BMJ from the days before information could be stored electronically, even some old lecture notes (did I once know all that?).

Since I don’t recall my days as a clinical student with fondness, I was surprised while leafing through dog-eared volumes to experience a degree of nostalgia, though not strongly enough to put many books back on the shelf. However, a few escaped the cull.

Why no man is an island

If you plot a graph of the wealth of nations against the health of their citizens, it is clear that, up to a point, the more you spend the better the health outcomes. But if you then analyse the health of the rich countries that cluster at the top of the graph, where extra spending has ceased to buy significant gains in health, something very interesting emerges. The more equal the society, the better the health of its citizens. And not just their health: on a wide range of social measurements equal societies score better. In contrast, societies where a small percentage of people hold most of the wealth, everyone, rich or poor, is less healthy, less comfortable and less fulfilled. In UK, one of the least equal countries, we have never been so anxious about being happy.

‘The Spirit Level’, written by two British epidemiologists, examines the phenomenon in detail, plotting physical and mental health, teenage pregnancy rates, children’s educational performance, community violence and levels of trust against the level of inequality in 23 countries of the rich world, and also against the level of inequality in the states of the USA. In almost every case, the problems are worse, often much worse, in unequal societies. There is no evidence that this is due to confounding factors: inequality appears to be at the root of many of the social ills which occupy news headlines.

Intuitively, the idea seems right. Gang warfare and the demand for respect which fuels it are responses to inequality. The rich may try to isolate themselves in gated communities, but electronic barriers, security guards and razor wire cannot entirely eliminate the  fear and anxiety which must gnaw away at their enjoyment and their health. The cost of managing the problems of inequality suck money from the services which should be promoting equality: responding to the democratically expressed wish of its citizens to control antisocial behaviour, the government of California now spends more on prisons than on education.

The society most people dream of living in is an equal one – everyone in the village drinking in the same pub and sharing the pleasures of the summer fete. Though humans quarrel over resources, we also co-operate, and the pleasure we get from group activities is demonstrated way beyond the football field and the orchestra. There is a balance between our hierarchical and our co-operative natures

The ideas in ‘The Spirit Level’ are not new. I first came across them in a BMJ editorial in 1996, It was a ‘eureka moment’,  and I still have on file the series of articles under the title’ socioeconomic determinants of health’, edited by ‘Spirit Level’ author Richard Wilkinson, which followed. And in 2008, the report by Michael Marmot, chair of WHO commission on social determinants in Health, declared  ‘social injustice is killing people on a grand scale’.

So, since equality is good for us all, what can be done to promote it? Ironically, war fosters equality. Faced with an external threat, we all pull together. But there are other ways of generating equal societies, and it doesn’t matter how the equality is achieved. Both Japan and Sweden score well on equality. In Japan, there is a narrow range of incomes, while Sweden has a much wider disparity between incomes but a progressive taxation system which redistributes wealth. Even inside the USA the same is found: New Hampshire and Vermont both score highly on equality, but in New Hampshire income is evenly distributed while in Vermont it is redistributed through tax.

“There is no such thing as society: there are individual men and women, and there are families.” said Margaret Thatcher, setting the tone which accompanied the growth of inequality in this country. But in reality we are all in the same boat, and on the same planet, and not just our happiness but our survival depend on us pulling together. How can we persuade our politicians and those who soar in the financial stratosphere earning hundreds of times more than most of the rest of us, that equality is good for all of us, poor or rich? Put another way, how can we start to reaccumulate the social capital that we have thrown away over the past twenty years?

Well, there is an election coming up. The government has responded to economic collapse by trying everything it can think of to stimulate economic growth. The opposition is pursuing the same solution. But where is the evidence that economic growth is going to mend our ‘broken society’? There seems to be no voice speaking out for using the collapse to forge a different strategy. No-one is pointing out to the wealthy that it is in their interest, not just that of the poor, to review the way companies are run and the level of rewards of those who currently command stratospheric incomes. The easy way for a government to be seen to be doing something is to slap on a sticking plaster, and that is what most politicians are proposing. But these problems are gaping wounds, and exhortations to eat green vegetables, lectures on the dangers of obesity and posters about knife crime don’t change society. So when the election candidates come knocking on your door, ask them what they plan to do for equality. And check http://www.equalitytrust.org.uk/ to see what you can do.

The Spirit Level  Richard Wilkinson and Kate Pickett 2009 Penguin 978-0-141-03236-8

Revalidation – where next for Sessional GPs?

The final report on “Revalidation processes for Sessional GPs – A feasibility study to pilot current proposals” is now available to read here. The study set out to explore the potential problems locum, salaried and remote GPs might have with the proposed supporting information required for appraisal as part of the revalidation process. GPs who experienced the most difficulty tended to be peripatetic locums and out of hours GPs with no permanent practice base.

The findings will come as no surprise to these GPs and will make worrying reading for those tasked with implementing a revalidation process that is fair to all doctors. Concerns raised in the report included:

• lack of support by practices and locum isolation.
• There were significant problems with the key revalidation requirements of Clinical Audit, Significant Event Audits.
• Patient Satisfaction Surveys and Multi-Source Feedback.

Possible solutions suggested included peer groups for reflective discussions, locum Chambers, greater support from Deaneries, LMCs, practices, OOH organisations and PCOs, alternatives to audit and other requirements, mentoring schemes, and locum prescribing numbers.

The RCGP has already gone some way to find alternative evidence that it would be acceptable for Sessional GPs to collate, and Version 4 of the Guide to Revalidation of GPs describes “equivalent portfolios” that GPs in Special Groups can present. However, substantial problems persist, and it remains to be seen how much support for locums will actually materialise. Past experience would suggest that there is a steep uphill path.
The BMA, in its evidence to the GMC consultation, had a number of criticisms of the current proposals, and opposition has come from several other quarters.

According to “Pulse” today, the “Department of Health is planning to substantially scale back revalidation in light of concerns over cost and anger among GP leaders about the level of bureaucracy to be heaped on practices”, and the article suggests areas where cuts may be made. With so many concerns about the cost, process, and fairness of the current proposals, it is surely time for the GMC to go back to the drawing board.

Unite-MPU seminar for Sessional GPs

We’re inviting all Sessional GPs to the Unite/MPU seminar for salaried and Sessional GPs, to be held on the afternoon of 23rd September 2010. The aim is to hear how Unite/MPU can better shape its services for this large section of the GP community.

A draft conference program and invitation can be found here, but we are very keen to focus this seminar on what you and your colleagues would like from MPU-Unite, so as well as hearing your suggestions in advance, we’re keen listen to your issues on the day and discuss possible solutions and a way forward for MPU-Unite to offer services to Sessional GPs.

If you’re interested in coming please register your interest by Monday 6th September.