AFA FIAB MIHM
Independent Healthcare Consultant
Director of Primary Care, National Services for Health Improvement
Steve is a former Royal Navy Officer, and joined the health service as a chief management accountant in 1984. He has worked at all levels of the NHS. He was an associate tutor at the Institute for Health Policy Studies at the University of Southampton and has worked for the professional development committee of the Institute of Healthcare Management
"Modernising education, training and opportunities for learning are essential. In the future, education will be more flexible and based on transferable competency-based modules."(1)
Continuing professional development (CPD) is a significant part of lifelong learning. Working in general practice, you will be only too aware of the daily experiences that contribute to the working profile of a modern manager. The CPD requirement of this article reflects this diversity and the difference in the levels of understanding expected or needed.
The 10-year NHS plan has provided many opportunities for primary care and, without undertaking CPD, these opportunities could be overlooked. In today's busy environment, knowledge can be the key to success.
By experiencing the policies introduced as part of the 10-year plan, individuals can show the systematic maintenance and improvement of their knowledge. This will enhance their skills and level of competence, and add to their lifelong learning experience.
When the NHS 10-year plan was announced, its fundamental message was about sustained increases in funding for the NHS.(1)
We are now nearly at the end of the implementation of this plan, and the NHS appears to be in a financial crisis as the global recession takes hold. The plan was designed around the results of a public consultation that revealed the public wanted more and better-paid staff with different methods of working. They wanted waiting times to be reduced and high-quality, patient-centred care. They wanted to see a general improvement in the quality of local hospitals and surgeries.
Obtain a copy of the 10-year plan and list the five key areas that have affected your practice most, and explain why.
The plan recognised the NHS was not achieving its potential due to underfunding, which had resulted in too few clinicians and other key staff. However, the Department of Health (DH) also wished to divert attention from the funding issue to that of the NHS being fundamentally outdated.
In other words, the NHS of 1948 was trying to operate in the same way in 2000. The plan identified a shortage of national standards and several barriers that existed between staff, which impacted on the delivery of services. It identified a complete lack of incentives to drive forward performance standards. It said the service was too centrally controlled and that patients themselves lacked influence.(2)
What do you consider the biggest incentive for your practice, and what is the biggest disincentive?
Agenda for Change
In March 2000, the government's budget stated that the NHS would significantly grow in real cash terms in just five years, and that extra investment would follow for the next five years. This cash injection has been openly reported, so why does the NHS still seem to be in such financial difficulty?
The answer is obvious if we look at how the investment is being spent. In the last few years, there have been three key areas of investment in the NHS: the consultant contract, the GP contract and Agenda for Change. These initiatives involved heavy investment in salary costs.
The decision to reduce the number of primary care trusts (PCTs) by almost half and the restructuring of the strategic health authorities resulted in a number of redundancy and settlement payments to staff. The increased earning potential of GPs and consultants has meant an increased cost in national insurance costs and pension contributions by the employer.
This is not to say that these staff do not warrant such salaries, but this money is taxed by the government and the majority of it will be at the higher tax rate of 40%. Therefore money is coming into the NHS, but a big percentage of it will be returned to the treasury.
Has your practice adopted the principles of Agenda for Change? If yes, how has this benefited you? If no, what are the reasons why you have not adopted this route?
Local health economy
The NHS plan promised financial investment. It announced 500 "one-stop shop" primary care facilities. It stated that more than 3,000 GP premises would be modernised and 250 new scanners would be available.1 Both hospitals and GP practices would benefit from investment in modern IT systems and an investment in staff.
Hospitals would expect to see 7,500 more consultants and there would be 2,000 more GPs, more than 20,000 extra nurses and 6,500 additional therapists. Medical schools would offer up to 1,000 more places for students. The NHS would also be able to benefit from childcare facilities provided from more than 100 onsite nurseries.(1)
This was an impressive vision for the future and could only be delivered if reform took place. Critical to this process was the devolvement of the decision-making process from central government to the locality. PCTs would hold more than 80% of the potential NHS spend, and there would be a pooling of resources between social services and local health.
Consider your local health economy. How does your PCT fair? Is practice-based commissioning (PBC) established, and how do you feel it is working?
The GP contract was extended to create a quality-based framework and the opportunity for developing local enhanced services. Consultants could expect to receive an increased additional discretionary payment for providing increased productivity for the NHS. Newly qualified consultants would be restricted in the amount of private work that they would be able to undertake upon initial qualification. The Quality and Outcomes Framework (QOF) was designed to improve patient services, reduce inequality and provide incentives to general practice. Since its inception, it has undergone a variety of changes that many say have now devalued the amount paid for the work done.
How is your practice performing under the QOF? Do you think it is easier to obtain this level of funding now compared with when the scheme first started?
Also linked to staffing was the greater role to be played by nursing staff and the creation of new support roles. Nurse consultants would be increased to number more than a thousand, and therapists would also be able to aspire to a new consultant level.
All of this development was being met by the new contracts or by Agenda for Change. Interestingly, practice managers and their support staff are actually excluded from Agenda for Change, but still have to work towards the demands set by the core competency framework that underpins the GP contract.
The new contract also introduced a core competency framework for managers. Can you list these core competencies?
As we reach the completion of the plan's implementation, we are starting to see the impact of efforts to ensure that patients have a true opportunity to say how they would like to see services being delivered. Patient involvement has become one of the most critical aspects of the decision-making process. Being able to demonstrate how patient involvement has been achieved is moving higher and higher up the agenda.
The obvious impact on general practice has been patient choice, Choose and Book and the patient survey. The introduction of PBC has also meant a requirement to ensure that commissioned services truly reflect the needs of the local population.
We have seen practices that have opted to belong to an out-of-hours service and those opening later in the evening and at weekends to reflect the type of service local patients want.
The disappointing aspect of extended hours is that most feel that it was introduced as the lesser of two evils. It is strange, but not inevitable, that 60 years on from the conception of the NHS, general practice faces ultimatums rather than consultation on change. Patient empowerment will be a critical aspect of the NHS that will need to be managed effectively and sensitively.
The health improvement plan tells us how "any willing provider" will be able to offer services to the NHS.1 This means the relationship with the private sector will develop more freely. It will break the monopoly in the provision of health services and help to drive improved quality and costs for the NHS.
Has your practice been affected by any new services provided by your PCT? Do you consider such developments to be a positive or negative development to local healthcare provision?
Guaranteed access to a GP within 48 hours has been introduced, although many patients complain they are still unable to obtain appointments suitable to their commitments. It is estimated that more than a thousand GPs with specialist interests will be receiving referrals as part of PBC.(1)
Are there any areas where targets are not being met? Do you have any specialities where the minimum waiting time is still being exceeded?
Addressing health inequalities
Certain clinical areas, including cancer, heart disease and mental health, were to be tackled. Under the 10-year plan, cancer-screening programmes would be significantly expanded. Chest-pain clinics would be established nationally, which would be coupled with reduced waiting times for heart operations, and there would be a substantial increase in the number of mental health teams available.(2)
There would be a concentration of the development of services for the elderly, which would include free nursing in nursing homes and the development of an intermediate care service worth in excess of £900m. This was designed to allow more elderly people to live more independently and be secure about what services would be available to them. Breast screening would be extended to cover all women aged between 65 and 70 years.
Lastly, the purpose of the plan was to reduce inequalities in the NHS.(2) While a number of the issues raised by the plan have been addressed, the most recent upheaval in the restructuring of the NHS has meant that much of the plan has been achieved, but with costs being felt elsewhere within the NHS.
As a manager, it is not beneficial to criticise what has been successful or not, but instead you need to adopt the flavour of the overall plan and ensure that your actions, taken at a local level, achieve, wherever possible, the overall aims of modernising our NHS.
One of the biggest challenges to be faced by primary care now is the introduction of polyclinics or GP-led health centres. Contracts are being terminated or varied, and individual practices must take a pragmatic approach to ensure their individual survival in the current market place.
What is your PCT doing? Is it planning on having a GP-led health centre, and do you know where this is to be situated? What will be the impact on your practice as a result of such developments?
1. Department of Health. The NHS Improvement Plan: putting people at the heart of public services. London: DH; 2004.
2. Department of Health. Delivering the NHS Plan: next steps on investment, next steps on reform. London: DH; 2002.
Applying the principles of the 10-year plan in practice …
Jackie Henderson is practice manager of the Tudway Road Surgery in Kidbrooke, London. Her surgery caters for about 3,200 patients and is in a particularly deprived area.
Are you aware of the current 10-year plan?
I know about all of the changes that have occurred over the last few years, but I was not aware that we were working towards the same plan.
What has been the biggest change in your practice?
I suppose the biggest change has been the new contract. While the staff and I have continued to work for the same employer, our duties have changed enormously.
Is there anything you do not miss as a result of these changes?
Yes. Before, there was always so much paperwork to deal with, and if claims were not made on time money could be lost or you would have to spend a lot of time chasing up queries.
So what have been the benefits?
In theory, it is meant to be less bureaucratic. For the first couple of years, this seemed to benefit the practice, but now the PCT has introduced a performance management framework, which has meant an additional workload for us.
Do you think the Agenda for Change policy was a good idea?
Anything that looks at better pay and working conditions for staff is a good idea. Unfortunately, practice staff are excluded from Agenda for Change and must rely on their doctors to make the decision about pay rates. Fortunately, I work for a good GP, but I would like to see practice staff included in Agenda for Change – especially when you see the rates of pay paid to PCT staff.
Do you think the concept of Choose and Book is a good idea?
I suppose that, when you look at the concept of Choose and Book as a whole, it is a sensible idea. However, we have a very socially deprived population, many of whom live in poverty and cannot afford the luxury of internet access and computers. Therefore, the majority of patients rely on the practice to decide for them which hospital is best.
Do you think services have improved, and do you believe that the Quality and Outcomes Framework (QOF) is an effective way of rewarding performance?
I would like to think that we are always looking to improve our services to our patients. I think the constant changes to the QOF have started to act a disincentive now, because more work is being requested of the practice team and it seems we are just doing extra work each year with the same resources. I would like to see things being left alone, just for once. That might give us all a bit of breathing space. When you consider the time taken to monitor and audit the QOF, in addition to the annual review/visit, you can understand that sometimes it does not feel it was really worth it.
How well have your local services developed recently?
As a practice, we have continued to offer the core services and a number of enhanced services. While we have put forward commissioning plans, very little has taken off in our area, which means that enthusiasm gets stifled. When I worked for the practice as a fundholding consortium, we were much more advanced in our approach than we are now.
Why do you think this might be the case?
Before, we were in direct control of our actions and we could make decisions. The current process is led by the PCT and, as such, there tends to be more and more meetings, which leads to a lot of talking and not a lot of doing.
What would you like to see happen in the next 10 years?
I would like to see better pay for practice staff and a recognition of what we actually do. I want to see the traditional values of a practice like mine being retained and built upon. I believe that we already listen to and value our patients.