How they plan to bribe your GP not to treat you.

One of the problems with the New NHS that has attracted relatively little notice is something with the Orwellian name of the “Quality Premium”. Like the Ministry of Plenty that controls the ration books, or the Ministry of Information that works hard to keep government activities secret, the Quality Premium has very little to do with quality and nothing to do with premium.
First they deduct money from the allocations to GP practices, then they say that you can have some of it back ‘if’. And it is in the ‘if’ that lies the secret of this tool of management. In his initial spin Andrew Lansley would have had you believe that this money would be earned back if the practices delivered a high quality medical service to its patients; but it was always obvious that the government lacks the tools to measure real quality and it would be just too tempting to use it to help manage local funding problems.
In the British Medical Journal last week we got a clue as to how the system would really work. There is a plan to set a target for reducing admissions to hospital. Draft Guidance from the NHS Commissioning Board suggests that a quarter of these incentive payments would depend on commissioning organisations achieving a reduction or no change in admissions for certain specified conditions.
Children with asthma, diabetes or epilepsy could be the first to suffer.
The conditions being suggested are heart failure, angina and hypertension in adults and asthma, diabetes and epilepsy in children.
So you can picture the scene. It is February. Your child with asthma is struggling for breath so you take him to the doctor. In the normal course of events your doctor would send the child to hospital. But we are getting close to the end of the financial year, the commissioning group has already hit their maximum number of allowed admissions for asthma. What does the doctor do? If he admits your child then the practice loses money. If the practice loses money he may have to sack the asthma nurse.
Perhaps you think that my headline is rather sensational. Maybe a better headline would be:
How they intend to penalise the conscientious GP and hit the needy patients.
Because one likely outcome is that good GPs will continue to be good GPs, but they will effectively be fined for being good GPs. And it goes beyond that because patients in less wealthy parts of the country will suffer more than the better off. In wealthy areas a GP who is about to ‘hit the buffers’ of his maximum permitted admissions may take some of the pressure off the service by referring patients privately. In the poor areas no-one will be able to afford to go privately, so they will suffer the full financial penalty of this iniquitous system.
This is, alas only one of the many unfair and damaging aspects of the changes to the NHS set in motion by the 2012 Health and Social Care Act. But none of this is a surprise to those of us who examined Andrew Lansley’s proposals.
I warned those in government and others about this very issue. I even wrote here about it.
So the question now is what are you going to do about it?

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6 Responses to How they plan to bribe your GP not to treat you.

  1. botzarelli says:

    The asthma patient child example you give would depend upon both very poor practice management coupled with being so plugged into the numbers as to make the decision not to admit on finance grounds. Maybe that’s realistic but it seems inconsistent.

  2. Charles West says:

    Thanks for your comment.
    The child with asthma was, of course only an example. Fortunately we admit few children with asthma in any given year. I could have chosen an adult with heart failure. I could have raised the issue of a child with epilepsy who has a convulsion at school, or who is taken to casualty. There are all sorts of unfairness raised by this policy, not least the fact that alternatives to admission depend largely on the other services and facilities available which are largely beyond the control of any individual GP.
    Perhaps the key message is that the so-called Quality Premium, like much of the Health and Social Care Act is more about management tools than about providing good healthcare.
    C.W.

  3. Andrew Jacklin says:

    I think that this policy is open to abuse (as is any policy) but I do feel you are putting a intensely negative spin on this. The way that admissions are avoided in long term conditions (like heart failure, angina and hypertension) is by good long term management, patient education and specialist community support teams.

    The area I work in already has a community heart failure and adult respiratory team. We have a consultant phone triage system that GPs can ring for advice. All of these are mechanisms by which patients can get the care they need in the community. They receive good quality (I would say better then they would receive in an acute inpatient setting) care for less money.

    While you do say that “alternatives to admission depend largely on the other services and facilities available which are largely beyond the control of any individual GP” GPs do/will have a say within their commissioning groups, will they not?

    • Charles West says:

      Thanks Andrew Jacklin for your balanced and reasoned comment.
      You are absolutely right to point out that there are alternative forms of treatment and working together in collaboration it should be possible for hospital staff, GPs and community staff to devise a range of services that enables us to get the best results for each patient and at the same time to avoid wasting money.
      I and other members of the Lib Dem activist team – people like Graham Winyard previous deputy chief medical officer, have been pressing for an adult debate on how we get the best service possible and the best value for money for the NHS. Unfortunately the headlong drive to fragment and privatise was so all-consuming that senior politicians did not wish to engage.
      Now we have set in train a move towards a competitive fragmented service, and it is difficult to see how any genuine collaborative dialogue will take place.
      The purpose of this little blog was to point out how the new Health and Social Care Act conceals at its heart some very nasty levers.
      You are right too, to point out that some GPs will be on CCGs and will presumably have some influence. It may interest you to know that I have been an active participant in NHS management on and off throughout my career. I firmly believe in doctors being involved in the management of the NHS. Unfortunately there are a number of problems.
      First there is, I believe, a crucially important ethical line around the holding of actual budgets to purchase healthcare.
      Second, those who chose to leave the front line and become managers may or may not be representative of the profession as a whole. Some, at least, leave clinical practice because they don’t enjoy it very much, or even dare I say, because they are not very good at it.
      And Thirdly, no-one expects the CCGs to remain fully run by GPs for very long. The DoH and NHS commissioning Board are talking more and more about commissioning support, and we know the big management consultancies, and private healthcare contractors are getting more and more involved. It is likely that before long there may only be a few token GPs at the CCGs while the work of running the NHS has effectively been farmed out to private firms.
      Many thanks for joining the debate.
      C.W.

  4. Anna Athow says:

    You are 100% right and thank you for highlighting this. We have to raise this question everywhere. They are bribing doctors to deny care. Its the US model and the aim of the Health and Social Care Act.
    Its all of a piece with the plan to close District General hospitals. There are not enough specialist hospitals to care for all the patients with common conditions like appendicitis and pneumonia.

    What are we going to do about it? Mobilise locally to save every NHS facility every DGH and keep it open by building support from staff, unions, residents and campaign groups in councils of action to occupy if necessary to keep services running.
    But actually we need national industrial action by the Trade unions to get rid of this government and its cutting and privatising agenda.

    • Charles West says:

      Thanks Anna Athow (sorry if that sounds a bit formal, but WordPress seems to jumble up the comments and doesn’t keep them threaded.)
      You are quite right to raise the issue of what next.
      Lewisham is interesting.
      One Trust in financial problems due to the iniquitous and wasteful privatisation of capital flows that Gordon Brown encouraged (PFI).
      Its neighbour, a successful and financially viable hospital gets services removed in order to subsidise the bankrupt one.
      Large demonstrations, lots of local MPs, GPs and a few celebrities backing the save Lewisham campaign.
      We’ll see what happens later this week.
      Some of us have been speaking out against the marketisation/privatisation and fragmentation of the NHS for years. Unfortunately it has remained very much a concern of a small minority until now. It is now starting to hit people in the face that the NHS which has been such a unique achievement has been under attack from the neo-liberals for 20 years, and unless very firm, widespread and co-ordinated action is taken the NHS will cease to exist as we have known it.
      We need to publicise, protest, and vote to express our views.
      C.W.

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