Last month’s Newsletter was vaguely informative and moved away from my usual rants and Doomsday scenarios. This month we’ve returned to more normal ground and open up with a couple of articles predicting the demise of General Practice—both from differing but ultimately similar causes—the profit of private companies working in the NHS.
GP at hand— The future?
I recently wrote about how GP is funded – many countries in the world fund GPs for the work they do. This seems obvious but it has one serious problem, doctors have a financial incentive to do lots of work and it is easy to justify doing lots of work – for example when Mr. Smith presents with some pains in his chest it is reasonable to send him off for a battery of blood tests, an endoscopy, a CT scan, an MRI scan, an Echocardiogram, an ECG, an exercise ECG and finally an angiogram. Net cost to the health services tens of thousands of pounds, net profit for the GP thousands.
Net cost to the patient, sleepless nights, risks from the procedures, lost days at work and so on. Broadly speaking, if you live in the USA and have access to health care insurance this is how you’re treated. I can justify all these tests because I can argue that I cannot fully exclude heart disease or lung pathology without doing all these tests.
However, imagine a health care system which rewards doctors for simply keeping their patients well. In other words no matter how many investigations a patient receives the doctor gets paid the same amount. In the situation of the patient above the consultation is entirely different, Mr. Smith as a result of my examination today I can reassure you that your heart and lungs are absolutely fine. ‘Ok doctor but what’s causing my pain?’ Well that’s a good question, often when patients present with these symptoms they are worried about something and that worry goes on to cause very real physical pain, do you think this is possible? ‘Now you mention it I thought that might be the case….’ This is the system used by the NHS. Net cost to the health service about £25 in GP time. Net cost to the patient—possible 2hours off work.
You may think I’m exaggerating to make a point but both examples are of similar patients with similar problems. The only difference is that the first patient had the misfortune to get ill on holiday and ended up on the investigation conveyor belt and the other was seen in GP. The first patient took 6 months to get better – he was only able to accept the psychological basis for his pain after all the results came back normal—the result of being investigated abroad led to further investigations in the UK which could not be avoided.
The second patient walked out of the consultation feeling much better. We know that the average life expectancy of Americans is lower than other developed countries and this is, at least in part, related to over investigation and treatment.
It looks much more profitable for a society to pay its doctors to keep their patients well. Roughly speaking 20% of our patients need our support regularly and they account for 80% of our workload. But we can only afford to look after this 20% if the other 80% play ball. The difficulty is that they often don’t play ball. These are the young, fit and healthy. They are not bothered about which GP they see, their main concern is merely where and when. We live in an instant world – ideally, these fit patients want to be seen at their convenience with minimal wait. Few practices are able to accommodate these needs – mainly because their resources are all focussed on the other 20%.
However, things are changing. Babylon an innovative GP tech service has an app based GP service in London that is signing up patients quickly and they are targeting the fit 80% who need instant care. Their model is working well in fact they’ve quadrupled their numbers over the last month. Which is fine for Babylon but is an issue for the other practices because once you’ve registered with Babylon you are no longer registered with your old GP whose funding suffers as a result— if Babylon’s exponential rise continues almost every other practice inside the M25 will soon no longer be viable. I understand that Baylon is looking to expand its practice area to the whole of the UK!! If the government doesn’t act soon ……
Accountable Care Organisations
It can hardly have escaped anyone’s attention that the NHS is in dire straits. At times it does feel as though we are practicing in a protected bubble at Denmark Road – our patients are still seen on the day for routine problems and, thankfully, we have a great team who are all still enjoying their work. But the pressures are mounting – our list size continues to increase at an alarming rate. The practice is bulging at the seams and the car park is often over spilling onto the local streets. You may wonder why we don’t close our list to new patients – the problem is that such measures are seriously discouraged by NHS England and if you do stop taking on new patients it can be hard to reverse the trend. The bottom line is that someone has to look after the local patients and all practices are struggling – if we stop taking on new patients we only compound the problem for other practices.
Outside of the practice hospitals are struggling with the winter flu epidemic and so on. The seeds of the crisis were laid many years ago – in part by getting rid of effective small care homes – which means that many hospital beds are blocked due to a lack of community-based beds, in part due to poor understanding of doctor training and how doctors would be replaced – it now takes 2 newly qualified doctors to replace a retiring doctor ( the younger doctors are more likely to be female, work part-time and have career breaks to manage their families). We are also poor at retaining doctors in the NHS due to perceived worsening conditions and pay – younger doctors are more likely to move and stay abroad. Nurses feel similarly disempowered and have also left their profession prematurely. But the biggest issue lies with the financial crisis in 2008 which has precipitated a financial squeeze on the NHS at a time when patient expectations are higher than ever.
The back door solution to all these issues is via Accountable Care Organisations. The word to be really worried about in this Orwellian title is accountable because as I have noted many times in the Denmark Doctor government bureaucrats tend to be anti-Ronseal, what you get in the can is most definitely not what is written on the outside. The best example of this lexicographical sleight of hand is the CQC, the Care Quality Commission which does NOT provide care of any form at all; does NOT commission any service at all and does NOT measure any true quality areas. So I am anxious that any ACO will be accountable to the public in any way what so ever.
The proposal is that ACOs will be able to manage a budget which spans primary, secondary and social care. In short, they will hold the budget for local practices, local hospitals and care agencies. In some ways this may seem very sensible but as a manager of a general practice which has already had to absorb a 20% cut in funding, an ongoing reduction of funding due to an arbitrary mathematical rule which reduces the number of patients on our list from the actual 9,000 patients down to 8,000, you may appreciate that an ACO would simply cherry-pick services from GP and we would no longer be a financially viable practice. An ACO simply looking to provide basic care as cheap as possible to maximise their profits would be looking to close down all the little practices and put all the GPs, nurses etc in a central location, preferably on the same grounds as the local hospital.
You may ask why an NHS organisation would be looking to maximise profits – well the cynic in me thinks that most of these ACOs will be privately run – so their primary function will be to maximise profits for their shareholders.
Thankfully Stephen Hawking (yes the physicist, not the physician) has spearheaded a group which is trying to cut the government off at the pass before they can start the wholesale privatisation of the NHS through the back door. They have managed to get a judicial review of the whole process – if nothing else we may now be able to debate the real purpose of ACOs.