A year in the making, the final report of Lord Darzi's Next Stage Review of the NHS has finally landed on practice managers' desks.
There is a lot to digest – the main report, High Quality Care for All, and its accompanying primary and community care strategy outline the new direction of travel for the NHS.(1,2)
The last 10 years of NHS reforms have focused on building capacity. Now the buzzwords are quality, personalisation, patient choice, user empowerment, equity, integrated care, clinical leadership and more responsive services.
The raft of new measures include: reforming practice funding to reward GPs who take on new patients; extending the rights of patients to choose their GP; a new focus on keeping patients healthy; the introduction of care plans and personalised budgets, and an emphasis on strong GP-led commissioning and
The review confirms the provision for 150 new GP-led health centres, already dubbed "Darzi centres".
Lord Darzi's vision heralds a shift away from a top-down era and central targets to a health service that is more accountable to empowered and informed patients and the public, and which is measured and funded according to the quality of care delivered.
Costly crunch time?
Darren Pritchard, Business Manager of the Croft Surgery in Gateshead and the new primary care sector chair at the Institute of Healthcare Management (IHM), says the review has given him a lot to worry about for his practice.
The primary and community care strategy promises fairer rewards for practices that attract more patients. This will involve removing the historic minimum practice income guarantee (MPIG) and replacing it with payments based on the numbers of patients registered with each practice, their level of need and quality of care.
Mr Pritchard says abolishing MPIG would remove up to £40,000 of his practice's income at a stroke. Further income will be lost if some of their patients migrate to one of the new Darzi centres planned for his area.
Proposals to give patients a greater choice of which GP they register with are another concern, as this means the practice will be forced to serve patients outside their existing practice boundary, making home visits more time-consuming and costly.
"We are going to have to adapt, but it is worrying as we could potentially lose patients and practice income," says Mr Pritchard. "This is frightening when you add in the impact of the credit crunch, expenditure costs – such as gas and electricity going through the roof – and the freeze on GPs' pay. GPs are going to be paying out more and taking home less income."
He takes issue with Lord Darzi's concept of quality, which he says is subjective and vague. Quality, maintains Mr Pritchard, is providing patients with continuity of care with the same GP, something he claims they will be unlikely to receive at the new Darzi centres.
"A number of things in this review are simply revamped ideas, and a lot of practice managers and GPs are asking whether there is a hidden agenda of a drive towards privatisation and to make all GPs salaried. One wonders where the reforms are going to stop – even whether general practice will exist in the form that we currently know it in 10 years' time."
Mr Pritchard says there has been no stability in the NHS for many years, and he fears that this latest review could have a detrimental effect on the careers of practice managers. He says some former practice managers have already been lost to posts in primary care trusts (PCTs) and to other jobs outside the NHS. The Darzi reforms could speed up this exodus.
"At one time, practice management paid a reasonable salary and was a safe job with a secure NHS pension. But everybody is now very twitchy, and a lot of practice managers are asking whether general practice is going to be a safe environment for the next 10 years.
"They are looking over their shoulders and wondering, 'How can I protect my patients, my staff and my own job? What do I need to do to move this forward?' Or: 'Do I really want the hassle and should I jump ship?'."
Mr Pritchard is planning to start sending out IHM newsletters to encourage practice managers to feed back their views and network more. "I fear that some practice managers may simply be burying their heads in the sand," he warns.
New critics, added pressures
John Lyne, practice manager of the Unsworth Medical Centre in Bury, is similarly pessimistic. He fears that the loss of MPIG, which forms a significant part of his practice's income, could force them to reduce the number of medical consultations because there is a limit to the extent to which further admin costs could be cut.
He also dislikes the idea of their income being dependent on patients' perception of the service the practice provides: "If someone doesn't like you and ticks the wrong box, then we don't get paid and if we don't get paid we can't then provide services and we go into a downward spiral. All payments should be based on hard fact."
Mr Lyne says he can understand what Lord Darzi is trying to do in being a "voice of the people". However, he says some of the suggested reforms do not reflect the reality of what patients say they want.
"Like surgeons, GPs train for a long time in their specialty to become experts," he says. "It is therefore difficult to understand how a surgeon in a hospital can dictate reform in primary care. I would like to know what he would think if we sent a GP in to sort out theatre sessions?"
Mr Lyne says the challenge for practice managers is to read all the documents, decipher them, make sense of them, then work out how they will impact on the practice and present the conclusions succinctly to GPs.
He says his doctors are already under pressure to hit Quality and Outcomes Framework targets and work longer hours. "We never really have an upbeat practice meeting where we talk about any of the really good aspects of the Darzi review," he says.
Response from healthcare experts
Niall Dickson, Chief Executive of healthcare thinktank the King's Fund, points out two significant omissions in the review: "There are no estimates of how much all this will cost and no indication of just how different the government expects the quality of health services to be in five or 10 years' time," he observes.
The British Medical Association (BMA), tinged by bitterness at recent confrontations with the government, has given a lukewarm response to the review.
Dr Laurence Buckman, Chairman of the BMA's GP Committee (GPC), says: "There are lots of opportunities to improve general practice within this report – unfortunately the government's recent behaviour towards GPs has destroyed any trust they had in the government's ability to run the NHS."
The BMA welcomes ideas such as personal plans for patients, faster and simpler access to a wider range of community-based services and early intervention to improve long-term outcomes for patients. It says choice of GP is a good thing, but warns that unnecessary and potentially destructive competition would waste NHS resources.
Dr Buckman says the GPC is pleased that Lord Darzi recognises the talents and professionalism of GPs and wants them to have the freedom to provide the services their patients want and more control over how they do it.
Professor Steve Field, Chairman of the Royal College of General Practitioners (RCGP), says they are delighted that the review has endorsed the voluntary accreditation scheme they have been piloting in 40 GP practices. The scheme is designed to improve safety and quality of practice, and will be rolled out nationally by 2010.
"The majority of care in this country is good or excellent in some areas, but we acknowledge that there are some small pockets of poor practice that need to be addressed," says Professor Field.
Dr Michael Dixon, a Devon GP and Chair of the NHS Alliance, describes the review as a "charter for renewed and refreshed general practice". "The principles and values upon which it is based – such as the registered list, quality and personal care, and continuity – are those that matter most to good GPs," he says.
Dr James Kingsland, a Wallasey GP, chair of the National Association of Primary Care (NAPC) and an adviser to the primary care strategy, says he sees a very strong future for general practice and for general practice management.
"One of the most important messages from the review is that practice-based commissioning (PBC) is here to stay. Whether the strategy is strong enough on developing PBC we will have to wait and see, but it certainly tries to give more momentum to it and is signalling that the future of general practice lies in expanding the service that it delivers, which I find very exciting."
He says practice managers will need to upskill to help their practices deliver PBC, and will have new opportunities to manage the commissioning consortia that will develop around the country.
"Most practices in our NAPC network are saying it is about time these ideas were introduced, while others are saying they are challenging but interesting, and as long as they get the resources and support they need they will take ownership of them.
"For some, it is cataclysmic and they are saying, 'It will never work, we hate it', and these are the practices who will have an uncertain future because they don't want to change and adopt the goals that most good general practice aspire to already.
"But," Dr Kingsland concludes, "I believe that the vast majority of general practice, which is fantastic in England, will adapt and evolve and take onboard the principles of the new primary care strategy."
1. Darzi A. High quality care for all: NHS Next Stage Review final report. London: Department of Health; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. Department of Health. NHS Next Stage Review: our vision for primary and community care. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...