Month: May 2018

NHS England’s ‘high-risk’ decision to outsource primary care support services to Capita in a £330m seven-year deal left patients in danger of serious harm, according to a damning report by the National Audit Office (NAO).

NHS England did not understand primary care support services well enough to set contract targets and failed to assess adequately the risk that Capita would fail to provide the service to a good standard, a report published on Thursday by the NAO warns.

The £330m contract awarded to the private outsourcing giant in 2016 did not contain performance measures for the full range of services Capita was expected to deliver, and NHS England had no contractual mechanisms to intervene in some service changes, the report says. The NAO warned that NHS England’s ability to hold Capita to account remains limited because ‘basic principles about the contract are still not agreed’ – two and a half years after the contract began.

GP leaders said the decision to press ahead with outsourcing Primary Care Support England (PCSE) as part of a ‘massive cost-cutting’ exercise despite opposition from within general practice was scandalous. They warned that Capita’s failings had increased the burden on GPs, left doctors unable to work during a chronic workforce crisis and put patients at risk.

GPonline has reported on delayed pension payments, problems with patient record transfers and delayed payments that have left practices facing cashflow problems among other concerns.

GPs are continuing to experience ‘widespread failures’ with primary care support, the NAO report warns, despite some recent improvements. It says that Capita ‘underestimated the scale and nature of the task and the impact of closing sites and losing local knowledge’.

As part of its winning bid for the service, Capita said it would slash staff involved in primary care support from 1,390 to 314 to reduce the cost of the service by 69% – well above the 40% saving required by NHS England. While NHS England has ‘largely achieved the financial savings it expected’ – with £60m saved in the first two years of the contract – Capita has ‘absorbed significant additional costs’.

GPC chair Dr Richard Vautrey hit out at ‘two years of chaos’ for GP practices, warning: ‘This damning report lays bare the scale of the failures impacting patients, services and GPs due to this poorly thought-out and woefully-run programme delivered by Capita.

‘That NHS England ignored the BMA’s serious concerns and went ahead with massive cost-cutting by commissioning Capita to take charge of PCSE – with the expectation that they’d have to strip resources to the bone – with no thought of the consequences is nothing short of scandalous.’

Damning report

RCGP chair Professor Helen Stokes-Lampard said: ‘This is a damning but fair account that highlights how NHS contracts have been awarded to private companies, such as Capita, for work that is substantially more complex than had been assumed, and that they have failed to deliver effectively as a result – with GPs, our teams and our patients suffering the consequences.

‘The long list of failures made by Capita have been incredibly frustrating for GPs and our teams, and we are still dealing with the fallout.’

House of Commons public accounts committee chair Meg Hillier MP said: ‘Trying to slash costs by more than a third at the same time as implementing a raft of modernisation measures was over-ambitious, disruptive for thousands of doctors, dentists, opticians and pharmacists and potentially put patients at risk of serious harm.

‘Neither NHS England nor Capita properly understood the scale of the challenge before agreeing the contract and are still in dispute over future payments. Yet again this is poor contracting by government with one of its major suppliers and it must learn lessons.’

Doctors in Unite chair Dr David Wrigley said the union was ‘appalled but not surprised at the damning report’. He added: ‘GPs have been saying for a very long time that the service from Capita is not fit for purpose, is impacting negatively on patient care and causing unacceptable administrative burdens for practices are already struggling with the unprecedented funding squeeze imposed on the NHS by this government.’

Dr Wrigley demanded that ‘primary care support services should be brought back into the public sector immediately’.

Complex service

A Capita spokeswoman said: ‘As today’s NAO report concludes, the complexity of the support services being let by NHS England was not fully understood when the contract was signed.

‘The report notes that several organisations and legacy issues all contributed to underperformance. It has been acknowledged that performance has improved and Capita will continue to work with all parties to address the remaining service issues. We have accepted accountability for not meeting our high standards of service previously.’

An NHS England spokesperson said: ‘While not without its difficulties, by making this change over the past two years the NHS has successfully saved taxpayers £60m, as the NAO themselves confirm. This £60m in lower administrative cost has all been successfully reinvested in frontline NHS patient care, and has helped fund the equivalent of an extra 30,000 operations.’

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Doctors have good reason to worry about GMC complaints. Receipt of a letter from the GMC informing you of a complaint can often come as a terrible shock. The whole experience can be very traumatic.

Recent data issued by the GMC shows GPs are more likely to face sanctions than colleagues in Secondary Care. The percentage of General Practitioners sanctioned or warned between 2012-2016 was listed at 0.7%, whilst the percentage of the 88,143 Secondary Care Doctors sanctioned or warned was 0.4%

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Whilst shocking, it’s worth bearing in mind the public accounted for nearly 70% of complaints hence figures become slightly more understandable when considering the number of interaction with patients a GP will undertake when compared to a Secondary Care Doctor.

Statistics become more concerning when looking into compliant rates amongst BME Doctors. The GMC issued data states “GPs who graduated outside the UK were at an increased prevalence of receiving a sanction or warning.” Whilst data does not delve into specifics it’s certainly demonstrates a worrying trend. The GMC have promised to launch a ‘very serious’ review into the alarming statistic. However, with confidence in the GMC at an all-time low for many a review simply is not swift enough nor suffice with most fiercely pushing for further reforms into the way complaints are handled by the GMC.

An independent review of the GP partnership model announced earlier this year by the health secretary will be led by Wessex LMCs chief executive Dr Nigel Watson, the government has revealed.

The review, announced in February, will look at how the partnership model needs to evolve to meet the needs of a modern NHS.

The GP appointed to lead the review is a current GPC member, a long-standing chair of one of the largest LMCs in England – and has been heavily involved in developing emerging new models of care.

Dr Watson is the former chair of a multispecialty community provider (MCP) that established musculoskeletal practitioners and fully-funded pharmacists in GP practices and implemented an electronic consulting service in more than 80% of Hampshire practices.

He has also played a leading role in developing the voluntary MCP contract – which aimed to bring GP practices into a ‘multi-year contract with payment operating on the basis of a whole population budget, a new pay-for-performance incentive scheme and risk-and gain-share agreement with the acute sector’.

New models of care

The Wessex LMCs chief has since taken on a leadership role in the Hampshire and Isle of Wight sustainability and transformation partnership (STP).

Dr Watson said: ‘It is a great honour to chair the review and I plan to engage widely with organisations, as well as frontline clinicians and practice staff, to identify the challenges and will make a number of recommendations about how the partnership model can work in the future.’

Commenting on the review, health secretary Jeremy Hunt added: ‘The GP partnership model has benefited patients over the years but in an ever-evolving NHS environment we need to consider new ways to reinvigorate the current model.

‘Dr Nigel Watson will lead the review and work closely with partners to explore how the partnership model can continue to benefit both GPs and patients.’

The BMA has backed the review, but has made clear it should be about ‘reinvigorating’ the partnership model rather than replacing it. GPC chair Dr Richard Vautrey said the GP partnership model ‘is the foundation on which the rest of the NHS is built’.

Partnership review

Mr Hunt’s commitment to a joint review of partnerships comes after official data reported by GPonline last year showed that the profession lost almost 2,000 partners between September 2015 and September 2017.

BMA leaders have said the review must deliver incentives not only to keep existing partners in post, but also to persuade younger doctors to take on the role.

The DHSC, NHS England, the BMA and the RCGP are currently working to finalise the terms and conditions of the review.

NHS England chief executive Simon Stevens, said: ‘With around 1m patient appointments every day, GP practices are the frontline of our health service. The great strength of British general practice has been its diversity and adaptability. So in the year the NHS turns 70, this review will help shape new options for future generations of family doctors.

‘That means keeping all that is best about the here and now, while also asking thoughtful questions about how the partnership clinical, business and career model might evolve for the future.’

Dr Vautrey added: ‘We know that our independent contractor status and GP partnership model are good for doctors, our staff, patients, communities and the wider NHS, but we also know that many practice partnerships are struggling to recruit new GPs as doctors raise increasing concerns about rising workload pressures, premises liabilities and indemnity risks.

‘Valuing and building on the partnership model is at the heart of our Saving General Practice report and we are glad the health secretary has listened to us and commissioned this review into reinvigorating the model. On the year the NHS turns 70, we look forward to working with Dr Watson and other stakeholders to ensure the core principles behind general practice are preserved for the next seven decades and beyond.’

RCGP chair Professor Helen Stokes-Lampard said the GP partnership model had been ‘a trailblazer for innovation in the NHS’ but that recruiting partners was proving increasingly difficult. The college has backed the review as a way to ‘invigorate’ GP partnerships for the future.

‘Dr Nigel Watson is an incredibly experienced GP, with an excellent understanding of the NHS and the challenges it faces,’ she said. ‘We look forward to working with Nigel constructively to feed into this review.’

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At a time when GP recruitment is probably harder than it has ever been, the need to retain staff and keep those valuable assets happy, healthy and ready to work is paramount.

Whether staff departures are voluntary or involuntary, it can be problematic for practices due to the costs involved in finding replacement workers. Plus, once one employee leaves, a chain reaction often occurs and several other staff members will follow suit. Morale inevitably suffers too if turnover is too high or absence levels are too high.

Here are ten ways you can avoid these problems and ensure staff retention is increased

Ensure your employment packages for your GPs are competitive in-line with current market offerings

A competitive employment package is comprised of a number of elements. There are of course the financials – It’s essential you pay GPs fairly and in-line with current market rates, GP employment contract should be reviewed and amended where required. With Practice Budgets already Salary increases may seem somewhat counter intuitive however slight increases will work wonders for practice spirit and motivation.

Additionally, ensuring adequate levels of staffing will go a long way to improving retention. Many Practice Managers overlook the domino effect poor staffing levels have. Poor staffing levels often lead to increased workload on GPs and eventually burnout and ultimately depart the from the practice. Ensuring a suitable number of GPs at the practice from the get-go is crucial.

Be critical of yourself

As Practice Manager you along with GP Partners are the practice kingpins! It’s therefore important to be honest with yourself about how you’re managing staff.

For example, do you treat everyone equally? Do certain members of staff always end up dealing with those awkward patients? Do the same people end up with the dull jobs? Do you always say thank you? It’s often the small things that often help create a desirable professional environment and help retain staff.

Engage staff

Staff that feel engaged with the overall practice aims and an integral part of the team stay longer. By involving staff in decisions and communicating clearly with them, you can maintain and improve staff morale, even during periods of difficulty and change.

Flexibility helps

Could flexible working patterns help to retain staff? Of course, any flexibility has to fit within the restraints of your practice and regulations but parents, those studying for qualifications and older members of staff are just three examples where being flexibility can retain staff who would otherwise leave.

We hope the tips listed above assist with retention. Have you got tips you’d like to share? Leave a comment using comments section below.

 

With Primary Care facing a recruitment crisis that’s pushing practices to breaking point, NHSEs recent recruitment initiatives have left practices in London in no mans land as millions of pounds are invested into recruitment of GPs in more acute areas.

London Practices have found themselves at the back of the list in terms of assistance with GP Recruitment despite 24 out of 32 London CCGs having Patient to GP ratios exceeding 1500 Patients per GP.

NHSE have ploughed funds into 3 major recruitment initiatives, only one of which has encompassed London. The Target Enhanced Recruitment Scheme (TERS) / Golden Hello Scheme, The International GP Recruitment Scheme, and the GP Retainer are scheme. However, only the GP Retainer Scheme sees London Practices as beneficiaries.

Is the GP Retainer Scheme even benefiting London practices?

The GP Retainer Scheme is marketed as a ‘package of financial and educational support’ designed to help retain doctors who might otherwise leave the profession. The scheme has had mixed reviews since inception a few years back. However, looking in retrospect the numbers are abysmal. Recent NHS Digital Data lists 36 GP retainers in the entirety of London. We’ve crunched the numbers below:

Assuming all 36 GP Retainers are working 4 sessions – The maximum number of permissible sessions as a GP Retainer – the total number of session coming from Retainer GPs across London would be 144. This translates to 72 days’ worth of cover. With there being 1,330 practices across the capital, the Retainer Scheme has provided on average an additional 0.108 sessions per practice per week!

Ultimately, NHS England are failing practices in the London leaving Practices and Practice Managers in a complete recruitment crisis prompting a domino effect on CQC Scores, Patient Feedback Scores and other key performance indicators. It’s clear Practice Managers are going to require some ingenuity to ensure their practice is adequately staffed and running smoothly as NHSE obviously aren’t to be relied on!

The Care Quality Commission (CQC) is understandably a controversial body. Its usefulness and ability to improve care standards is often called into question. Inspections are generally comprised of satisfying bureaucratic requirements rather than assessment of anything of real merit. A recent Pulse survey brought to light to extent of the lack of confidence in the CQC, with nearly half of the 2,361 Primary Care Workers surveyed indicating they feel the way the CQC inspects and regulates doesn’t necessarily improve quality of care for the patient.

However, despite the industry wide distaste for the CQC one thing is unfortunately for certain. It’s here to stay. In today’s Newsletter we’ve developed a CQC checklist designed to reduce the burden of your next inspection, and ensure your practice scores ‘Outstanding’ next time the dreaded inspector arrives:

Defining ‘Outstanding’ practice in an all-encompassing way is challenging. Making judgments is inherently subjective and the wider context must be considered. However, Professor Steve Field Chief Inspector at the CQC advises on some common traits linking all CQC outstanding practices, we’ve taken a look at those below.

“Find innovative solutions to inequalities, problems, or unmet patient needs”

Feelings of inequality, problems, and unmet patient needs often arise from inadequate staffing levels. A recent GP Online report confirmed what was already known – larger practices tend to fair better at CQC Inspection than smaller practices.

Ensuring a full, motivated and stable workforce will help address issues.

Reducing reliance on AD HOC locums in favour of long-term cover is a simple step that can be taken to improve scores. Continuity is as important for practice as it is for patient. Use of regular GPs in favour of AD HOC GPs will allow familiarisation with referral pathways and other nuance associated your practices whilst in most cases simultaneously improving patient feedback.

“Show tangible improvements for patients”

Whilst improvements to practice are obvious to Practice Managers who are at their given Practice day in, day out; They’re not so easy for a CQC Inspector to see. Inspectors are at typically only at a practice for a number of hours hence you’ll need to demonstrate tangible improvement quickly and concisely.

Primary Care Medical Chambers (PCMC) recommends regular audits to demonstrate improved outcomes for patients or improved access to services. You should be able to quickly draw upon these audits when required.

“Be scalable, sustained, and robust”

Examples are not just about delivering good care to one person, but showing good care is regularly delivered to a range of patients there should be processes in place to demonstrate this.

Workforce statistics issued by NHS Digital highlights an unsustainable reliance on locum GPs throughout the Midlands and East of England.

The recent report has placed locum usage in the region under the spotlight. The damning report looks into the workforce demographic, bringing to light severe shortcomings  throughout the Midlands and East of England.

The report lists 806 GP locums across the Midlands and East of England, translating to roughly nearly 10% of the GP Workforce in the area. This is compared to 1.5% in the South of England, 2.5% in the North of England, and 4.3% in London.

There have been three large scale recruitment initiatives to increase workforce capacity across the area. The International GP Recruitment Scheme, The GP Retainer Scheme and The Targeted Enhanced Recruitment Scheme (TERS) more commonly known as the ‘Golden Hello’ scheme. However, the effectiveness of the aforementioned schemes is questionable.

The International GP Recruitment Scheme has come under heavy fire due to issues with the speed at which GPs are being onboarded, earlier this year Pulse reported only a fifth of the EU GPs promised for April had been recruited. Far fewer than the numbers needed to address workforce issues.

Similarly, The Golden Hello Scheme – which offers Junior Doctors £20,000 to take up a training place in an area facing severe GP shortages-  has been heavily criticised due to the first beneficiary of the scheme not receiving their ‘Golden Hello’ GP for another 3 years yet.

Whilst in the early stages the GP Retainer Scheme was commended for being a proactive approach to recruitment, looking in retrospect the numbers are abysmal particularly in the Midlands and East of England. NHS Digital Data from December 2017 lists the number of  GP Retainers in the Midlands and East of England at 62, meaning the Midlands and East of England currently have the second fewest number of GP Retainers of any area of the country with only London having less.

Taking a look into a breakdown of the numbers highlights the extent of the shortcomings with the retainer scheme, assuming all 62 GP Retainers are working 4 sessions – The maximum number of permissible sessions as a GP Retainer – the total number of session coming from Retainer GPs across the Midlands and East of England would be 248. This translates to 124 days’ worth of cover. With there being 2,378 practices across the Midlands and East of England, the Retainer Scheme has provided on average an additional 0.1042 sessions per practice per week.

Ultimately, NHS England are failing practices in the Midlands and East of England leaving Practices and Practice Managers in a complete recruitment crisis prompting a domino effect on CQC Scores, Patient Feedback Scores and other key performance indicators. It’s clear Practice Managers are going to require some ingenuity to ensure their practice is adequately staffed and running smoothly, as NHSE clearly aren’t to be relied on!

 

Speaking at Londonwide LMCs’ conference on Wednesday, Professor Martin Marshall said: ‘The 10-minute consultation is a disaster, essentially. I’m not sure it was ever adequate, but it certainly isn’t adequate now when we know consultation rates are going up and the complexity of what we’re dealing with is going up as well.’

He said that GPs should be focused on triage and complex health problems, which offered an ‘exciting career choice’ for junior doctors.

‘There are essentially two things GPs are really good at. One of them is triage – we’re really good at making quick decisions about whether someone is ill or they’re not ill, what they need, what they don’t need. The other job is dealing with complex problems which involve at least 20-minute, probably 30-minute consultations, like they have in Sweden or Denmark,’ Professor Marshall said.

10-minute model

‘The stuff we don’t need to put our efforts into is the stuff in the middle – probably the 60% of stuff in the middle – the 10-minute consultations for relatively simple, relatively straightforward things.’

He said this model was proving very popular with younger doctors, but ‘slightly less popular with older doctors’.

‘When I say this to junior doctors they really buy into it,’ Dr Marshall said. ‘If you want to do the triage stuff or the complex stuff that’s a really exciting career choice – depending on your own inclination you can choose what proportion of each you want to do.’

‘But we need to find a way of not doing the stuff in the middle,’ he added. ‘And that way needs to be more systematic and faster at delivering than it is at the minute.’

Complex patients

Both the BMA and RCGP have said repeatedly that 10-minute consultations are inadequate in the face of rising demand and complexity of patients,

Earlier this year research published in the British Journal of General Practice found that patients with multimorbidity account for around 53% of GP appointments in patients over 18.

Research published in BMJ Open last year linked shorter consultations with lower quality care and found an association between shorter consultations and physician burnout.

The BMA’s 2016 report Safe Working in General Practice said that introducing 15-minute appointments ‘would allow improved decision making and case management, and should reduce the administrative burden outside clinic times’.

 

 

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There are many benefits to being part of a chambers if you are a locum GP, but what can you do if there is no chambers in your local area? Dr Richard Fieldhouse provides some advice.

The concept of GP locum chambers was first pioneered by the National Association of Sessional GPs (NASGP) in 2002. Chambers are generally small locally-owned and run collectives of self-employed freelance GPs, working together as a team with mutual professional support and a shared group identity to support local practices.

Outside of a chambers, working as a regular freelance GP locum can be a thoroughly isolating affair; you have to work out how to go about booking sessions, deal with issues related to working in struggling practices, and manage last-minute session cancellations on your own. You also may not have colleagues readily available to offload about a vexatious complaint you’ve had or work through case reviews for your next appraisal.

So working as part of a locum team, with support on-tap for any issues relating to locuming, and meeting regularly with colleagues who all share a similar professional identity, can lead to a greater sense of belonging. This is where being part of a chambers can make all the difference to a happy and fruitful career as a GP.

According to a 2016 NASGP poll, over 90% of members of GP chambers agree that the main reason they’re still a GP at all is because of the chambers. In fact, over half of members say they’re living where they live because of the support the chambers gives them.

How do locum chambers work?

Locums within chambers remain self-employed and able to contribute to the NHS pension scheme. The practice pays the full session fee direct to the locum, who then pays the chambers a management fee. This fee is anywhere between 3% for NASGP’s LocumDeck chambers and up to 15% of the original session fee for some traditionally-run chambers, depending on its staffing costs and the level of support provided.

It is important to realise that chambers are not agencies. In contrast, agencies are seen as employers and locum work via agencies cannot be pensioned on the NHS scheme. The agency typically retains around 30% of the fee they charge practices, paying the locum around 70%.

Some newer practice-facing online platforms sidestep being defined as agencies, allowing the locum to remain as self-employed, and undercut traditional agencies by typically charging the practice 15% of the locum’s session fee.

Benefits of chambers

In areas where agencies and online platforms are dominant, a chamber could therefore financially benefit both practices and locums. Even if the locum charges a session fee that reflects their chambers’ management fee, this is still likely to be cheaper for the practice than using an agency or a practice-facing online platform. Furthermore, the full fee is being fed back into the local health economy by paying the locum and investing into the chambers’ running costs.

Locum GP chambers also offer a unique opportunity to retain GPs in the workforce. They are ideal if you are a recently-retired partner wanting to retain elements of teamwork and equally necessary for newly-qualified GPs, allowing them a support structure that was so important during their training years.

Chambers also allow GPs the potential to ‘collectivise’ and work under the protection of terms and conditions that are designed to protect safe working boundaries. This is key in an environment of rising complexity, workload, risk and litigation.

Ironically, as the need for GP cover rises, there has been a growth of commercial companies seeking to place GPs in practices, but often under terms that are not under the control of the GP locum. Chambers can be an antidote, offering a locally professionally-led umbrella for flexible GPs.

Joining a chambers

If being part of a locum chambers is something that appeals, a good option would be to join an existing one local to you – a quick Google search should find you your nearest. If there isn’t a chambers in your area then there are two choices: either to ask an existing chambers network to help set one up in your area, or set one up yourself.

 

Credit: https://www.gponline.com/