13 June 2018

What we can learn from the UK’s health failures

General Practice Government

Her dad was an occasional poacher, on the Queen’s land no less. His illicit quarry, salmon, most likely some of the finest in the land given their royal pedigree.

“On occasions he used to get the biggest salmon he could catch, march up to the doctor’s surgery and plonk it down in front of him,” the woman explained. “’This is for you’, he’d say, ‘for looking after my family. I’m very grateful’. That’s how it used to be.”

The doctor accepted the scaly gift, equally grateful, with no questions asked as to the salmon’s slippery origins.

So it was in days gone by.

This story, regaled by a patient to a senior Australian doctor on a recent visit to the UK, is, it seems, reserved exclusively for the archives, an illustration of the bond that existed between patient and doctor, or rather family and doctor.

It is a bond now at breaking point in the UK.

“Under the current system of general practice there is no way you’d spontaneously take a gift to your local GP,” the doctor recalling the story lamented. “Now, you only get a few minutes with the GP, some are almost trying to get rid of you. The relationship, I’m afraid to say, has deteriorated quite dramatically.”

While such a grim outlook and nostalgic tale from the rose-tinted “good old days” may incite a degree of eye rolling in some quarters, there can be little doubt the patient-doctor relationship is under strain in the UK like never before.

As disheartening as it is, a surprise it is not. Not when you consider the over-stretched nature of the country’s National Health Service.

Aspects of Australia’s health system may be dissected and debated, fretted over and fumed about. But the scrutiny of UK’s creaking NHS is on another level. 

Everyone has an opinion. It stirs emotions few other subjects come close to, and for many Britons, the NHS evokes a sense of pride, frustration and downright anger, the former, sadly, often playing second fiddle to the more negative sentiments.

And now, it is becoming clear that general practice, historically immune from the harshest criticisms of the NHS, is facing mounting pressure, which is manifesting itself in patient unrest.

According to a British Social Attitudes survey earlier this year, public satisfaction with GPs had fallen to its lowest level for 30 years. Only 65% are now happy with their services, a sharp decline from the 80% recorded in 2009. Between 2016 and 2017 alone, satisfaction ratings tumbled by 7%.

The response from the Royal College of General Practitioners (RAGP) to this depressing picture was one of concern, resignation, disappointment and anger.

Describing general practice as the “lifeblood” of the NHS – without which other services would “crumble” – the body said such figures were “extremely distressing for hard-pressed GPs” who are working “flat-out to do the best they can for their patients in increasingly difficult circumstances”.

Significantly, the RCGP added: “While we are very disappointed in these figures, they are hardly surprising as what we are seeing now is symptomatic of the inevitable effects of a decade of underinvestment in our family doctor service and just not having enough GPs in the system to meet demand.”

Simon Stevens, chief executive of NHS England, conceded that 10 years ago anyone would have been “laughed out of court” if they had suggested cutting the share of funding for primary care and growing the number of hospital specialists three times faster than GPs. 

“But that is exactly what has happened,” he said.

ACUTE WORKFORCE SHORTFALL

It will come as a surprise to precisely no-one that British GPs are facing extraordinary pressure, particularly in a health system which is never far from financial crisis. Heck, it is in perennial financial crisis.

And Australian GPs will be all-too-familiar with, and sympathise with, their plight: under-resourced, weighed down with paperwork and struggling to cope with an ageing population and an ever rising number of people with chronic and complex conditions.

The Care Quality Commission (CQC), a body of external inspectors of general practice in the UK, branded the challenges “unprecedented”, noting how funding and size of the workforce is miles adrift of the increasing workload.

The workforce shortfall is acute. According to a recent study by The Kings Fund, a UK think tank, the UK has 2.8 doctors and 7.9 nurses per 1000 population. Only Poland has fewer of both in the 21 countries studied and Canada is the only other nation with fewer doctors per head of population.

Australia, meanwhile, has 3.5 GPs per 1000 population – fractionally below the average – and 11.5 nurses, the seventh best.

Unsurprisingly then, the major concern of UK patients is the inability to see their own GP. Another study, released last month, found the number of patients who successfully secured a timely appointment with their doctor fell by 27.5% between 2012 and 2017, a trend which researches believe is loosening the bond between doctor and patient, and potentially damaging the health of the nation. 

Having your “own” doctor stems from the UK’s registration system, where patients sign on with a practice in their catchment area, and often with a particular GP. It is a concept unfamiliar with Australians who can doctor shop to their hearts’ content.

From a public viewpoint, the freedom afforded by the Australian system would likely be the preference. After all, who doesn’t value flexibility and convenience in their everyday lives?

Yet this may not be the case, with many senior doctors unconvinced that patients necessarily want the capacity to move around and prefer continuity for most problems. 

Research published by the Australian Journal of General Practice indicates that such a view may be correct, at least partially. A study of almost 2500 Australian adults found 90% identified with a usual practice and 80% a usual GP.

Interestingly though, 25% had attended an alternate practice in the previous year, a higher figure than previously reported, suggesting many patients had a “perception” of having a regular GP.

One of the report’s authors, Dr Michael Wright, concluded that without information-sharing between practices, such patient behaviour could lead to fragmented care and, ultimately, poorer health outcomes.

Doctor shopping, or doctor hopping – patient choice is a third description for it – is highly unusual under the UK’s registration system. Although technically possible, as consumers can change practice, it is rare to jump from GP to GP. 

In any event, many practices are full to bursting point and simply do not possess the capacity to take on new patients. In the south of England, for example, there are 8,661 patients per practice, the highest in the country. 

Perusing these figures, little wonder the strain is beginning to tell.

The major concern of UK patients is the inability to see their own GP

CONTINUITY OF CARE

But if being almost locked in to one practice could be regarded as restricting choice, it does lend itself to achieving that most cherished of objectives: continuity of care, assuming you can get an appointment, of course.

One UK GP, Clare Gerada, writing in The Guardian, wonderfully encapsulated that bond, or continuity of care, that has long been valued by patient and doctor.

“It allows GPs to build a rich tapestry of their patients’ lives, woven using the strands of contacts we have had together over years, within the context of their families and community,” Dr Gerada wrote. “It allows us to deliver truly holistic care, drawing on what we know about our patients’ physical, psychological and social past. Consultations are easier and more productive.”

Moreover, Dr Gerada described continuity of care as the “single most important factor in delivering safe, cost-effective and high quality care with fewer errors”, resulting in “cost savings in investigation, prescribing and hospital referrals and admissions”.

Building on this, Melbourne-based British GP Dr Lindsay Moran, who has served on committees for both the UK’s RCGP and Royal Australian College of General Practitioners, said: “In the UK, I know everything about my patient, whereas in Australia someone can walk in to see me and they may have two or three GPs.

“I won’t know what medication they have been on, I won’t know about recent hospital admissions, I won’t know anything about them. Inevitably that means they do lose an element of care if I am not solely responsible for them.”

In addition to individual care, Michael Kidd, professor of global primary care at Southgate Institute for Health, Society and Equity at Flinders University, and an honorary fellow of the RCGP, said patient data generated through the UK registration system benefitted not only individuals, but populations.

“It’s a system that supports continuity of care which, as we all know ,is one of the core features of quality general practice,” he told The Medical Republic. 

“Having all medical records in one place allows for research and healthcare planning and allows for analysis of the patient population.

“In Australia, the My Health Record may go some way to addressing this issue. Once that reaches maturity and GPs are able to download information of visits a patient has made to other healthcare services, then we’ll have a far more complete picture.

“We have the evidence to show that visiting one GP who knows you well leads to improvements in the quality of care and to cost savings.”

Visiting multiple practices carries the risk of unnecessary investigations, over treatment, and repeat referrals, he emphasised.

Other downsides associated with doctor hopping is the absence of preventive care, according to Chris Del Mar, professor of public health at Bond University and a GP at Robina in the Gold Coast.

“It’s easier to fall through the cracks in Australia because it isn’t always clear who is responsible for preventive care,” he said. “In Britain it is. It’s the practice you are registered with. You can point the finger at someone.”

Yet that was a burden many UK GPs were struggling with, said Dr Moran, who continues to work across both countries.

Such responsibility can create a “huge amount of stress” for “snowed-under” GPs who, among other issues, just do not have sufficient appointment slots in the day to satisfy demand.

“In the UK patients can’t just conveniently walk in to see a GP when it would be better for them to do so,” Dr Moran said. “A lot of my friends in the UK are struggling with burn out, and many are resigning from partnerships because the demands of the job are just too great.”

Some were moving to salaried jobs or becoming locums, she said. Others were leaving the profession entirely.

Such anecdotal reports of worn-out partners are backed by the statistics. Figure contained in a Care Quality Commission report showed a 400% increase in the number of salaried GPs in the decade to 2012, illustrating how the pressure on general practice has been simmering for years.

In a survey by UK medical journal, Pulse, two thirds of almost 850 GPs questioned predicted the partnership model would not exist in 10 years time such is the “pressure, responsibility, admin and the future liabilities on practices in this litigious age”.

It is a sorry picture.

Interwoven with the UK’s registration system is the method of funding, a capitation system where GPs are essentially paid a set amount per registered patient, which is weighted for age.

NO SYSTEM IS PERFECT

As with Australia’s fee for service model, it is not ideal. But then no system is, according to Professor Martin Roland, Emeritus Professor of Health Services Research at the University of Cambridge.

One of the key arguments against capitation is that doctors receive the same financial reward if they see a patient multiple times or just once – or even not at all. The only way to increase capitation payments is to increase the number of registered patients, a delicate task when the practice, as already observed, is already straining under the workload.

Fee for service, on the other hand, works in reverse. GPs are only too keen to see patients walk through their door.

Professor Roland, who has studied various funding mechanisms, said perverse consequences emerged in all pay structures. To illustrate the point, he referred The Medical Republic to a table outlining the possible effects of each system if GPs did not act in line with their professional principles.  

With capitation, GPs would do “as little as possible for as many people as possible”, while under fee for service, practitioners would do “as much as possible, whether or not it helped the patient”.

Furthermore, two other methods of remuneration were also included in the table. Those paid a salary have the potential to do “as little as possible for as few people as possible” while pay based on performance could encourage a GP to perform “a limited range of commendable tasks, but nothing else”.

“There is no perfect way of paying doctors,” Professor Roland said. 

“The conclusion of this table is that all payment systems can have perverse consequences and that we therefore rely on the professionalism of doctors to minimise these adverse effects. This underlines the importance of ensuring that incentives of any type are as closely aligned to professional values as possible.”  

What seems to benefit under the capitation model, or at least work more effectively, is multi-disciplinary team-based care. Irrespective which allied health professional engages with the patient, the practice gets paid. 

Such an approach goes at least some way to easing the workload of the GP. Yet the overloaded UK system is listing so heavily that Dr Moran believes nurses are being inappropriately used as “pseudo doctors”.

“Any practice which says otherwise is wrong,” she insisted. “Nurses perform a wonderful task but they are used indiscriminately. I have heard receptionists say to patients ‘we can’t get you an appointment with a doctor but we can get you in with a nurse and they are just as good and can do everything a GP does’.

“My jaw hits the floor when I hear that. I think ‘God no, they are not the same’.”  

Steve Hambleton, a champion of Health Care Homes which is partially adopting a capitation and registration system, and team-based approach to chronic care, suggested that is one of the perverse drivers of capitation. Conversely, that notion is turned on its head in Australia.

“With fee for service, the driver is to increase the number of times you see the patient and a perverse driver not to use the practice team even though they are perfectly capable of performing many tasks,” he said, echoing the payment table produced by Professor Roland. 

“Every single patient sees a doctor every single time. Simply, if the doctor doesn’t eyeball the patient, there is no rebate, no payment.

“In the UK capitation system, the perverse driver is to see the patient for the minimum amount of time, because you get paid if you never see them. There could also be a tendency to use other members of the teams perhaps too quickly.”

Professor Roland said the UK’s capitation system had enabled the development of multi-disciplinary teams “more rapidly” than in Australia.

UNINTENDED CONSEQUENCES

While capitation remains the principal structure of funding, pay for performance has long played a major role of general practice remuneration. But as Professor Roland suggested in his table, that too, can have unintended consequences.

In the UK’s Quality and Outcomes Framework (QoF), the jury is largely still out, and has been since its implementation in back in 2004. 

Not so north of the border, however. Scotland abandoned the scheme in 2016. Its neighbours press on, albeit with reservations, with critics – of which there are many – arguing QoF is based more on activity than performance and does not appear to have driven any material improvements in the quality of care.

Robin Miller, deputy director of the Health Services Management Centre at the University of Birmingham, told The Medical Republic: “QoF helped to ensure that most GPs were meeting a minimum standard, but then failed to encourage or support people to move beyond this, and, as ever, people become very good at doing as little as necessary to get their funding.

“They also begin to see this as core, rather than extra income so it becomes difficult to administer it more thoroughly. QoF has been reviewed recently in England but looks likely it will be maintained.

Adelaide’s Professor Kidd added: “What happens when you introduce payments for specific actions is that practices focus on those actions, because they are related to payments. And that may be to the detriment of comprehensive primary care, so you have to very careful in its construction.”

It was a view supported by Suzanne Robinson, associate professor and discipline leader for Health, Policy and Management at Curtin University’s School of Public Health.

Profersor Robinson, a former lecturer at UK’s Birmingham University, said both the UK and Australia, put the focus on activity rather than value and quality.

“Whatever you put as an incentive there is always going to be a perverse incentive, and what we have seen in the UK and Australia is that they are driven by that incentive mechanism,” she said. 

“If they are being paid for certain indicators then we are going to see people behave in a certain way in order to receive income.”

In the early days, QoF payments generated 25% of general practice revenue, and cost the Government £1 billion, £300 million more than anticipated. Stung by the cost, and unable to sustain the expense, QoF has undergone several revisions and is now thought to generate 15% of general practice income.

If doctors in the UK are irritated at the administrative burden of QoF, they are positively seething at the time-consuming revalidation scheme, a process designed to ensure GPs are “up to date and fit to practice”.

Its implementation, or something similar, is often the subject of local discussion, although Australia has steered away from adopting the term “revalidation”.

The process, partly introduced in the wake of the conviction of Dr Harold Shipman, who murdered 15 patients under his care, requires GPs to supply evidence on a range of requirements relating to their performance, including feedback from colleagues and patients, quality improvement activity and a review of complaints and compliments.

They are appraised every year for five years and, assuming they have met all their obligations, recommended for revalidation by a “responsible officer”.

Dr Moran was scathing in her assessment. “It’s horrific,” she said. “The actual revalidation is not that bad. It’s the hoops you have to jump through for the appraisals that are utterly painful.”

Birmingham’s Robin Miller described the issue as a “tricky business”.

“Clearly there needs to be some way of checking that doctors are safe to practice, but equally, most of them are fine, so you do not want something too onerous,” he said. “Revalidation, therefore, gets criticised for being too time consuming, but insufficient to root out the bad apples. As it is still in place, this suggests no one currently has a better idea.”

THERE’S NO SILVER BULLET

  So what is the answer for general practice in the UK? 

Alas, there is no silver bullet, no quick fix. It was ever thus.

But the pressure GPs are facing has not been lost on NHS England. In its General Practice Forward View, it pledged recurrent funding to grow by £2.4 billion each year by 2020-21 and to add a further 5000 GPs and 5000 members of the wider workforce in the same timeframe. 

Attracting GPs at a time when many are leaving or retiring early will remain the challenge.

Additionally, there will direct funding for improvement in hours and out-of-hours access, new rules to allow up to 100% reimbursement of premise developments, and a plan to reduce hospital follow-up requests sent to GPs.

There is also optimism surrounding the closer collaboration between practices through the creation of networks, or “federations”. It is hoped this will further develop a multi-disciplinary team approach which, according to Professor Miller is “all the rage” in the UK.

“Taking a balanced view, primary care does need to be considerably strengthened if we are to achieve what we hope it will deliver in terms of preventative, holistic care, and I believe this will require us moving away from a traditional model of small-scale, doctor-owned practices”, he said.

The NHS celebrates its 70th birthday this July.

If NHS England’s pledges do become reality, and general practice is given the boost it so desperately needs, maybe it won’t be too long before GPs again start receiving gifts of ill-gotten royal-raised salmon.

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Peter Bradley
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Peter Bradley
2 months 21 days ago
Because of all the perverse incentives involved in the various systems, is why I have always felt that of them all, the fairest and least perverse system to remuneration GPs, (and other allied health professionals, incidentally), is a salary, and to be employed on the same basis as other public servants, as effectively that is what we are. Total capitation, like the UK, where they can’t even protect themselves against under-funding, (failure to inflation index being the main cause), because they are unable to levy any fee at the desk, leads to the tendency is to see as few patients… Read more »
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