NHS organisations are increasingly interested in our work, particularly based on the evidence that it is linked with lower A&E demand. We have set out the general terms on which we wish to help. Our vision “To transform access to medical care” guides the policy.
1. We welcome the support of NHS bodies for practices to go through change
One of the most frequent barriers to change is that practices don’t want to pay for support. This means that they either wait (many are still waiting after more than a year), or in some cases they DIY, which has a high failure rate and provides little opportunity to optimise their systems.
The rationale for outside support for change is savings from reduced A&E tariff payments, typically in the range £4 to £6 per patient per year (based on 20% A&E reduction). An investment of around £1 per patient is therefore highly attractive. We recommend that support is in full or not at all, simply from the experience that a part funded programme has been found to have very low take up.
2. We call for the removal of any disincentives against the new method
Practices have been penalised for the number of face to face consultations offered, and number lasting 10 minutes. The system cannot be properly measured in this way as face to face is a clinical decision based on a phonecall, and the duration is irrelevant, so long as the problem is solved.
3. We do not support the use of incentives to pay for adopting change in any way, beyond direct payments to third parties for services supplied.
The reasons for this are:
- Pioneering practices invented the method to save time as well as improve service. Its sustainability bears witness to its success in saving time. When optimised, it is less work than a traditional system, costing less to operate for a given workload.
- Practices have a legal responsibility to provide medical services to their listed patients. We are helping them to do this and no more. There is no legal or economic case to offer extra payment simply for fulfilling the contract.
- We want GPs to continue the method for its own sake, because it is the right thing to do professionally and for patients. The offer of a financial reward on top will undermine this motivation. Extrinsic rewards have the effect of reducing intrinsic rewards (A Kohn, F Herzberg etc)
- Any payment made would be interpreted as payment for extra work. This begs the question of how much extra work, and for what rate of pay. It will never be right. We want GPs to continue the journey of improvement, to save time and money by doing the work better, not calculating whether the incentive is enough.
- Many practices have paid us directly from their own funds as they see the value for themselves in the intervention. Any further self paying business would be undermined if some practices received an incentive.
- We must assume that any incentive offered would eventually reach the public domain. Imagine the headline, “NHS doctors paid extra not to see patients.”
4. The question of QOF
We are often asked whether the system reduces QOF points from fewer face to faces, but this has not generally been a problem. It is the business of the practice how they decide to run QOF. We do not support QOF points linked to specific access models including our own as this would undermine the patient service and professional motivation for adopting it, and distort the economic benefits of the model in itself.
5. We support the use of measures, not targets
Measures relating to service, quality and efficiency are crucial to understanding and improving general practice. They are an integral part of our work. We share these measures with practices, and also with the body which is paying for the work. We seek to make them relevant, accurate, clear and objective.
We do not support the imposition of any targets. There is no theoretical basis for how targets should be set (Deming), and we have seen the damaging effect of targets on quality and integrity in the NHS (Francis). We have seen innovative GPs achieve service standards, for example access to a GP within a median of 30 minutes or less, which are around 100 times faster than the one time govt target of 48 hours.
We want practices striving for the best, not satisfying an arbitrary number. The NHS needs commitment, not compliance.
Harry Longman, Chief Executive.
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