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Changing practice

Changing practice

Feature: Policy
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The health reforms have yet to impinge on the many frontline clinicians. But the message from the top is that, while the minority of GPs will be involved in taking the lead in creating commissioning consortia, everyone will need to change their professional behaviour pretty significantly.

For NHS Alliance Chairman Dr Michael Dixon, the reforms are the embodiment of the Prime Minister David Cameron's so-called 'Big Society', with both patient and doctor taking responsibility for the financial health of the much-loved institution that is the NHS.

The health reforms have yet to impinge on the many frontline clinicians. But the message from the top is that, while the minority of GPs will be involved in taking the lead in creating commissioning consortia, everyone will need to change their professional behaviour pretty significantly.

For NHS Alliance Chairman Dr Michael Dixon, the reforms are the embodiment of the Prime Minister David Cameron's so-called 'Big Society', with both patient and doctor taking responsibility for the financial health of the much-loved institution that is the NHS.

"We need to lose the idea of a maximum use of resources. The 'Big Society' is then a more realistic idea, localising what's national. It's about people having that element of altruism, the rich giving to the poor so no one needs to worry about being ill, not seeing the NHS as something you get the most you can out of."

Dixon, who has a practice in Cullompton, Devon, admits that this might be "a bit idealistic", but believes GPs, nurses and other primary healthcare professionals are well placed to influence patients to change their view of the NHS. In this capacity, the GP will have to take on new responsibilities. "We are independent advocates for our patients, but we will need to keep an eye on the [whole] population – on the patients not in the room. So there is a possible conflict but it's also complementary, as GPs get to draw up new goals for the population as a whole.

"This is a grown-up role for general practice to play. Rather than simply being seen as 'tinkers'. GPs have more knowledge than we recognise, as we are commissioners of care when we refer patients. Consortia will expand this role for the whole population," he said.

Cost decisions
The first way to effect this change, Dr Dixon believes, is by looking at prescribing habits that, he believes, "will absolutely" change.

"For example, not using expensive drugs in favour of another drug, which is made as well but costs less. When I am responsible for the budget for all my patients, I'll think about the cost of expensive drugs in terms of delaying the next patient from going to hospital earlier," he said, adding that public support could be won for that sort of decision due to the strength of the doctor-patient relationship.

"Think of it as going into a restaurant, and you've got a menu from which you can see how you can maximise good care for a patient with the budget you have got. The important thing is that GPs don't feel under pressure to prescribe inadequate drugs for their patients. I don't want GPs to feel they can't offer the best, but maybe they should not refer as quickly if there is no need."

GPs will need to effect change in another way: careful reflection of referral habits. In Dixon's practice, half an hour is spent during a coffee break reviewing referrals and seeing if there is an alternative route of care. He urges other GPs to take time to do this.

"It's easy to say to patients, 'Here's a drug and a referral,' but if GPs spent a moment of time to counterbalance that, they could avoid a referral for something that can be treated in practice without specialist intervention," he said.

Rules of engagement
For Dr James Kingland, President of the National Association of Primary Care and Clinical Commissioning Network Lead for the Department of Health, GPs who refuse to engage with the reforms are risking the viability of their business, and underperforming, over-referring practices could be asked to leave consortia and therefore lose the ability to practise.

A long-term advocate of GPs having control over the cash, Kingsland says: "It's a misunderstanding within the service if a GP practice thinks all they need to do is choose which organisation they belong to and then continue as they have always continued.

"If that's the case, why on earth do you need primary legislation if you're just creating something that the primary care trust (PCT) does, minus its provider arm, minus public health? We would just recreate the bureaucracy we are trying to get rid of and create a system that would fail the public."
For those GPs who say, "All I want to do is clinical practice", Kingsland has little patience.

"You're an independent contractor – I'm sorry, but that means you're self-employed. You manage estates, have to be a fair employer and have good HR practices, employ staff, manage overheads and run contracts as a self-employed person of a for-profit business.

"Whether you like it or not, that's who you are. When you write a prescription you are spending taxpayers' money. If you don't want to do [commissioning] don't write a prescription, don't make a referral. That's a commissioning act that, conscious or unconscious, you are inherently involved with, and what you're telling me is that you have had no responsibility for it and therefore you are not accountable for the budget. The legislation says you have lots of opportunities to manage the budget differently, but you become accountable for it."

According to Kingsland, who has a practice in Wallasey, the legislation is trying to change clinical behaviours so that in the consulting room GPs are accountable for both outcomes and the NHS spend.

"The only reason the consortia will be better than the PCT before them is if in every single consultation, in every practice, there is a behaviour change".

'Groundless' fears
Taking a more sceptical stance of the reforms is the British Medical Association's GPs' Committee chairman Dr Laurence Buckman, who believes we have seen this all before.
"[Consortia] look and smell very much like a family practice committee before they were thrown out for having a conflict of interest," he says.

The idea that the Health Bill will pull clinicians out of the practice is based on a misunderstanding, as all three leaders agree. In terms of time spent on consortia work, Dixon, Kingsland and Buckman believe that a small minority, from 1% to 4%, of GPs will be affected.

"I think a lot of GPs are walking around thinking they are going to be running the health service, and that clearly is not so. That fear is a groundless but almost universal fear," says Dr Buckman.

"Most GPs are going to get up in the morning, go to work and see their patients and that'll be it," he adds. "Once every so often they will go to a meeting with their consortia representatives and they will talk to them about what's going on, and I think that will impinge on them but not a lot. Ask them, 'How much does the PCT impact on you?' The answer is: 'Not much'. It does now and again, when you want money, but most of the time it doesn't touch the sides."

This also filters in to conflict-of-interest fears of the GP being both commissioner and provider, which Buckman says "will affect relatively few people", as, although "there is a lot of talk" the numbers involved will be "pretty tiddley".

So, for Buckman, the day-to-day of a GP will change little. "I think they will notice they can get patients seen in a greater variety of places and that waiting times lengthen, and the government says it's ok with that."

He believes the real fear for GPs should be that "they are going to [have a] health service that doesn't look like the one they are used to.

"What GPs are worried about is change. There is a deep cynicism as they fed up with change. This was not in any manifesto, although anyone that had spoken to Andrew Lansley, as I did for many years, can't be surprised at it. He's done exactly what he said he'd do, so it's no big surprise."

 

Victoria Vaughan
 

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