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General practice in the UK : a new dawn?

Dr Roger Chapman, Head of the UEMO Delegation

In his article in the 1998/1999 UEMO reference book, Simon Icnkins described with a considerable sense of optimism a 'new dawn' for British general practiced In the period which has elapsed since that was written, and during which Simon has sadly had to leave the medico-political scene through illness, it is clear that while some of the issues which had troubled general practice and were responsible for divisions in our discipline are being resolved, new problems and dilemmas are facing the profession, the regulatory bodies and indeed government. This article will describe some of those areas of difficulty and will consider the reform of the National Health Service (NHS), clinical governance, workforce issues, devolution, rationing and occupational health for primary heath care staff.The General Practitioners Committee (GPC) of the Britis Medical Association (BMA) has spent considerable time an energy in trying to ensure that the proposals are introduced in way which will facilitate the active co-operation and participc tion of GPs, with some success.The organisational vehicle which will be used to deliver the go\ ernment's objectives is the Primary Care Group (PCG). PCGs ar to be geographically based and will involve all general practice within the area. Originally the size of the PCG was to be base on a population of around 100,000. In the event the final size c groups varies from 40,000 to 200,000 plus. Management c PCGs is to be in the hands of a board and negotiation secure the option for GPs in any PCG to be in a majority on the boar and to occupy the position of chair.

...the government has shown great reluctance to provide the resources necessary to support GPs and others who will be actively participating in the work of the PCG board...

The GPC of the BMA has spent considerable time and energy in trying to ensure that the proposals are introduced in a way which will facilitate the active co-operation and participation of GPs...

Reform of the NHS
The United Kingdom (UK) government published its proposals for reform of the NHS in England in December 1997.2 Subsequently, in line with the UK government's commitment to devolution. White Papers for Scotland,3 Wales4 and Northern Ireland5 have also been published. Against a background of common themes, there are distinct differences in the proposals for all four countries. For ease of presentation this section will consider only the English situation. The differences between England and the other nations are described in Section 4 on Devolution.The English White Paper was entitled The New NHS Modern and Dependable and proposed that the following principles should underpin healthcare reform:

to abolish the internal market in healthcare and to end the system of general practitioner (GP) fundholding;

to move to a system based on co-operation rather than competition;

to focus on improving health;

to move towards long-term service agreements and away from the bureaucracy and cost of an annual contracting cycle;

to eliminate inequity in healthcare;

to address the problem of unacceptable standards where they exist;

to aspire to raise standards progressively across the board. The principles attracted widespread professional support but concern about the details of implementation as they affect GPs has continued despite, or perhaps because of, the publication of a whole series of subsequent policy and guidance documents.

However, PCGs are not just about general practice and GP' and PCGs boards will include nurses, a lay representative, a nor executive member of the local health authority and a representa live from the social services department within the PCG's area.The reforms are placing a new statutory responsibility on th chief executives of health authorities to secure an improvemer in the health of the local population. The health reforms charg all health authorities with producing a health improvement pro gramme (HIMP) and all PCGs are required to contribute to th development of the HIMP and to commit themselves to playin an active part in its delivery.Other key functions of the PCG include:

focusing on the performance and development of primary care

playing a progressively increasing role, following the end c fundholding, in the commissioning of secondary care service'

participation in the function of clinical governance, considere later in this article.

Many GPs have found their support for the principles of the gov ernment's NHS reforms compromised by anxiety about the practi cal implications:

active participation is going to require the commitment of sip nificant time and energy by many doctors, taking scarce clini cal resources away from patients;

the PCG will be progressively responsible for the use of a bud get which merges the traditional funding streams. The GPC ha negotiated protection for that part of the budget currently alia cated to infrastructure support for general practice, however ii the longer term concerns remain about protection for this fund ing, which supports practice premises, computing and ancillar staffing;

the government has shown great reluctance to provide th resources necessary to support GPs and others who will b actively participating in the work of the PCG board;

guidance from the government on details of the implementa tion of the reform proposals has been very slow in coming am has usually been worryingly short of the details required;

many colleagues are concerned that their participation wil involve them in rationing decisions to a degree with which the' are uncomfortable. This issue, also, is addressed later in thi article.

However, at the present time PCGs have been established in all areas, shadow PCG boards are in post for all PCGs which will begin their active lives on 1 April. In most PCGs GPs have taken the option of a majority on the board and of occupying the chair and are committing themselves, albeit with varying degrees of enthusiasm, to making a success of the new structures and processes of the NHS.The government has just published a Bill6 which, depending on its passage through Parliament, will provide the necessary legal framework for some aspects of the reform process, including the abolition of fund holding. The government has made it clear that we are embarked on a five to ten-year programme of reform and the Health Bill provides for the implementation of the next stages in the process. Unfortunately this is also extremely short on detail and the climate of uncertainty this producing is not helpful either to morale within our discipline or to recruitment to it.

Clinical governance
One of the main policy thrusts contained in 'The New NHS Modern and Dependable' is the continued improvement of the quality of care and the systematic implementation of systems of quality assurance. Underpinning this move are the steps the government is taking to make chief executives of health authorities and healthcare trusts legally responsible for the quality of care delivered. PCGs will have similarly accountable officers. The term 'clinical governance' has been adopted by the government to include all the initiatives aimed at improving and maintaining quality.From the perspective of general practice there are a number of elements to this:

every PCG will have a named leader responsible for clinical governance;

every practice will identify a clinician with a special interest in implementing clinical governance within the practice and with responsibility for communicating on clinical governance issues with the PCG lead.

the government is setting up two new bodies: the National Institute for Clinical Excellence (the remit will include the development and dissemination of clinical guidelines and protocols), and the Commission for Health Improvement (whose functions will include local inspections, where necessary, to address and resolve problems of continued poor quality).

Clinical governance sets out to ensure that:7

systems to monitor the quality of clinical practice are in place and are functioning properly;

clinical practice is reviewed and improved as a result;

clinical practitioners meet standards, such as those issued by the national professional regulatory bodies. Whilst the term 'clinical governance' caused initial confusion, it is becoming clearer that, in broad terms, it represents a gradual and incremental approach to introducing quality assurance systems into all aspects of care, across the NHS. Realisation that in large part clinical governance can only work through building on and developing the existing good practice of many GPs is helping to demystify the process.

The systems included under the umbrella 'clinical governance' will include:

clinical audit;

effective management of poorly performing clinical colleagues;

risk management;

evidence-based clinical practice;

implementation of clinical effectiveness evidence;

development of clinical leadership skills;

continuing education for all clinical staff;

audit of consumer feedback;

management of the clinical performance of colleagues, developing guidelines and protocols;

accreditation of hospitals, community providers and primary care groups;

continuing professional development for staff. There will also be systems to ensure lessons learnt are implemented, plus a mechanism to ensure all systems are in place and functioning effectively.

There is widespread recognition of the drive to improve quality and to be seen to do so, particularly against the background of a British press that seems to thrive on the bad news stories about doctors. However, this support in principle is compromised by concerns about a lack of clarity, little evidence of a commitment by the government to provide the resources which will be needed, concerns about the ability of clinicians to devote the necessary time to clinical governance, and the impact this will have on the delivery of clinical care.

Workforce issues
British general practice is facing major and developing problems with the recruitment and retention of GPs. They are problems which, to a varying degree, apply right across the country, but there are particular difficulties in special areas.Practices in very rural areas are experiencing difficulty in attracting new recruits, one reason being a rejection of the out-of-hours commitment which is still required in areas which do not have access to either commercial deputising services or to GP out-of-hours co-operatives.The inner city areas of the major conurbations are also experiencing particular difficulties in attracting enthusiastic new entrants to general practice. Out-of-hours cover is not generally the issue in UK cities, but long-standing problems of large lists, poor premises, difficulty in achieving good access to secondary care for patients, and poor provision of community support are major considerations. In addition, the additional expense of living in some of the conurbations and the increased threat of abuse and violence, often related to the problems of substance abuse and the heavy workload required by its socially deprived population, all serve to deter recruits.Unless the UK begins to acknowledge the existence and scale of the problem, and unless prompt action is taken, the situation is set to deteriorate. Already there are some 800 GP principal vacancies in general practice. Certain trends will increase the gap between the demand for GPs and the availability of new recruits. We are experiencing a significant trend towards part-time working; already 15 per cent of British GPs have a contract with the health service which is for a less than full-time contract8 and demands for part-time and flexible working are increasing. Whilst these trends in themselves represent a healthier approach to working patterns, they are undoubtedly presenting problems in terms of sustaining an adequate workforce.We are currently seeing a rejection of general practice as a career option by junior hospital doctors. A recent report from an ongoing BMA survey into the career intentions of junior doctors.9 demonstrated that only 18.9 per cent of doctors in their first full year of registration planned a career in general practice. In broad terms, UK general practice requires 50 per cent of the graduate output to sustain the workforce.A further trend in GP career pattern in the UK is not yet fully understood, yet it has major implications for the established pattern of practice. Large numbers of fully trained British GPs seem to be rejecting entry into practice as a self-employed principal, which is the traditional manner. In sharp contrast with the difficulties practices face in recruiting permanent self-employed partners, there may be as many as 7,500 GPs currently working, albeit with a very variable commitment, as locums and assistants at the present time. It is not yet clear whether this trend represents a long-term rejection of traditional practice. Some commentators believe it represents a new generation wishing to contribute, and to experience, in different ways before finally settling down to a stable career. Others believe it is a long-term development. There is an urgent need to determine which is the case; the latter scenario will compel a major rethink of the whole of the organisation of general practice in the UK.The inner city problem is going to become much worse over the next few years. General practice in the inner cities has been delivered largely by doctors who entered the UK, often from the Asian sub-continent, in the 1960s and 1970s and who are rapidly moving as a group towards retirement within the next few years.10 Unless urgent steps are taken to make inner-city practice much more attractive to recruits, many areas will be facing a breakdown in the traditional delivery of GP services.Finally, the UK is experiencing the common trend towards early retirement, a trend which has been facilitated by the introduction of improved pension arrangements for GPs. The radical and continuing pace of change in the UK health service is undoubtedly serving to increase this trend as many doctors feel exhaustion and disillusionment.

Devolution
The Labour government was elected in May 1997 committed to the implementation of devolution for Scotland and Wales. The necessary legislation is now in place and elections for the Scottish and Welsh assemblies will take place in May 1999. The assemblies themselves will begin their work shortly after. As part of the government's commitment to devolution, Scotland, Wales and Northern Ireland all have their own separate proposals for reform of the NHS and separate papers on all the consequentic changes, including those relating to quality assurance.There are a number of common themes, for example, th abolition of fundholding although this will not happen i Northern Ireland until one year after the rest of the UK However, there are also significant differences. Scottish GPs wi not be able to influence the commissioning of secondary car for their patients to the extent that their English and Welsh col leagues will. Primary Care Groups in England and Local Healt Groups in Wales, although titled differently, will have broadi similar functions, whereas the Local Healthcare Co-operative and Primary Care Trusts in Scotland will be significanlly diflerer in structure and purpose.The profession is concerned that this development represent a move away from a UK-wide NHS and towards increasingly dil ferent healthcare systems. If this is so we will logically also se a move away from the UK national contracts, terms of servic and payment structures for doctors towards different systems i' the four countries of the UK.There is, of course, a range of views on the desirability c devolution in general and the devolution of healthcare in partic ular. However, its implementation is undoubtedly causing dilemma for many UK institutions, not least the BMA, its Generc Practitioners Committee and the Royal College of Gener;Practitioners (RCGP). The GPC is actively working to ensure the its structures and processes adequately reflect the fact of devc lution, whilst maintaining a strong and coherent UK voice fc general practice with the UK government and internationally.

Rationing
GPs in the UK see and experience increasing pressure on th resources allocated to the NHS and are increasingly frustrated b the refusal of successive governments to conduct an open an honest public debate about rationing. The profession believe such a debate needs to acknowledge the existence of rationin and should seek to establish an agreed set of priorities for th first call on limited resources. The licensing of sildenafil (Viagra) and its implications for the healthcare budget might have pro vided a sensible, if difficult, example on which the govcrnmer might have focused. Unfortunately at the time of writing, som five months after the licensing of sildenafil, the UK Departmer of Health is still only at the stage of consulting on proposals fc its use in the health service. The BMA in any event finds the prc posals unacceptable and they contain no definite commitmer to a deadline for the introduction of definitive measures.Sildenafil is, of course, only one example of a whole range ( expensive new drugs, often both effective and cost-effectiv< which are currently licensed or are proceeding through the development and licensing phases. Other examples are th newer treatments for dementia, for fertility problems and fc multiple sclerosis. The profession believes that the introduction of these products is being handled in a way that is most unsatisfactory, places invidious pressure on doctors, and that considerations of effectiveness and cost are being confused in a way that risks misleading both public and profession.In the context of PCGs, many GPs remain concerned that their involvement in the groups, and particularly in board membership, will involve them in rationing decisions with which they are not comfortable. GPs holding this view, and particularly those who are declining to participate actively in the establishment of PCGs, believe that such involvement inevitably leads to the end of advocacy on behalf of the patient and threatens to undermine the doctor-patient relationship. The contrary view is that participation in the debate on rationing, and contributing to decisions on rationing, is a legitimate part of the function of the profession collectively and of doctors individually, provided the process takes place in an open and honest manner and provided the public is fully involved and retains ultimate ownership of the decisions.

national blueprint for an occupational health service for GPs and their staff.11 Following this, and as part of the implementation of a wider human resources strategy, the Department of Health is now in active dialogue with the profession and with other interested parties about how such a service for GPs and their staff might be implemented. The dialogue is based on the BMA/RCGP blueprint. There is, as yet, no commitment to funding such a service without detriment to the provision of patient services, but the profession is encouraged by this process and is determined to continue to work towards the introduction of a full occupational health service for GPs and their staff.

Conclusion
Simon jenkins was looking forward to a new dawn for British general practice, how does it feel now? Unfortunately the goodwill of British GPs is being sorely stretched. There is widespread support for the aims of the latest series of reforms to the NHS, but despondency at the rapid and continuing change which has been a feature of our lives for the last ten years. The profession feels under attack by the media and unsupported by a government which continues to refuse to acknowledge such self-evident problems as the current difficulty in recruitment, the poor morale of so many colleagues and the clear needs to make some explicit rationing decisions.However, most GPs are determined to make a success of the reformed NHS in the interests of their patients and the future of their discipline. Doctors are a resilient group and are becoming increasingly aware of the need to take care of themselves and their distressed colleagues. The dawn may yet arrive. The profession needs to acknowledge that under the system which is about to be dismantled, fundholding GPs are either actively involved in this debate or would soon have become involved as the pressure on resources continued to grow. Similarly, GPs who were not fundholders but who were actively participating in the commissioning of healthcare through involvement with their health authorities were also indicating their acceptance of the need to participate in this difficult area. The PCGs rationing function, and few believe that they will not have this function, at least serves to remove the decision-making process away from the individual consultation and indeed away from the individual practice, unless practices choose to retain a budgeting mechanism which leaves them with this function. Many GPs believe that this offers an appropriate balance between participation in debates about the allocation of resources and maintaining the individual doctor-patient relationship and the advocacy function.

Occupational health
Although British GPs are self-employed independent contractors, an overwhelming majority of their time, commitment and energy is devoted to the NHS. Evidence, both published and anecdotal, clearly indicates that the stress of this work is increasing. This sadly includes the increasing exposure of many GPs and their staff to abusive and violent patients. It has long been a source of frustration to the profession that the Department of Health has consistently declined to make available funding to support access of primary healthcare staff to occupational health facilities.At last we have some positive movement on this front.

References

1. S jenkins: 'UK general practice in the NHS prospects of a new dawn' European Union of General Practitioners Reference Book 1998-99 pp91-94, London, Kensington Publications Ltd

2. Secretary of State for Health: The New NHS: modern and dependable Department of Health (Cmnd 3807), London, 1997

3. Secretary of State for Scotland: Designed to care renewing the national health service in Scotland Stationary Office (Cm 3811), Edinburgh, 1997

4. Secretary of State for Wales: NHS Wales Putting patients first Welsh Office (Cm 3841), Cardiff, 1998

5. Secretary of State for Northern Ireland: Fit for the future the Government's proposals for the future of health and personal social services in Northern Ireland Department of Health and Social Security (Northern Ireland), Belfast, 1998

6. United Kingdom Parliament, House of Lords: Health Bill 1998 (HL Bill 15) The Stationery Office, London, 1998

7. British Association of Medical Managers: Clinical Governance in the new NHS 1998

8. Department of Health Statistical Bulletin: Statistics for General Medical Practitioners in England: 1989-97 Department of Health, 1998

9. BMA Health Policy and Economic Research Unit: Third Report of Cohort Study of 1995 Medical Graduates. Career Intentions of 1st Year Senior House Officers BMA, London, 1998

10. DH Taylor, A Esmail: 'Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?' BM) 318, pp306-10, 1999

11. R Chambers: Occupational health service for GPs a national model RCGP/GMSC, London, 1997