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Politics, practice and people: changes at the heart of primary care

1 November 2007

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Kieran Sweeney

Senior Lecturer in General Practice
Peninsula College of Medicine and Dentistry

Kieran works three days a week as a GP in the sixth doctor–nurse partnership to be set up in the NHS, based in Exwick, a deprived ward in Exeter. As senior lecturer in the new medical school in the southwest peninsula, his research interests are in professional development of medical students and the application of complexity theory to primary care

Mention Choose and Book in our practice, and the managing partner and her team will fall silent and withdrawn. Mention Choose and Book to my GP colleagues in town, and their responses would be unprintable in an upstanding publication like Management in Practice.

But mention it to John McTiernan, Tony Blair’s recently resigned political secretary, and he will wax lyrical about the Labour party’s agenda since 1997.(1)

And if you really want to kill a good lunchtime meeting in our practice, introduce the topic of GP commissioning. Many GPs in the town would simply shrug their shoulders at the thought of this, thinking: “Well, whatever the really big practices in town want to happen will happen – the smaller ones just won’t have the clout.”

And when we, in our small nurse-led practice, talked to our bank manager about the vague possibility that we might seek better premises, the limo taking us to lunch was outside the door before I even placed the receiver back onto the phone.
Ever wondered why the private sector wants to fling money at GPs?

What’s happening here is profound, serious, and will change the way general practice works in this country. These three examples – Choose and Book, practice-based commissioning, and the role of the private sector – are just the most obvious examples of how healthcare, and at its heart, primary care, has been politicised recently.

Health is the forum upon which politicians contested the last, and will contest the next, general election. All three of the major parties are jostling to see who can produce the most radical policies, while still appealing to where voters’ hearts lie, with the cherished values of the NHS.

Choose and Book keeping
Few understand the truly radical thinking behind Choose and Book. For many, including our long-suffering administrators, it is merely an operational nuisance, which will, in time, probably get sorted out.

But underpinning this policy initiative is committed thinking on behalf of the disadvantaged, lower social class in the country. In the past, the poor got just what they were given in the way of healthcare: the educated middle-classes could wind their way creatively around the system, using it (without any hint of deceit or impropriety) to their advantage.

Now, policymakers want to make sure that less able groups get what their more able and better off countrymen have had for years: choice. No longer will the doctor decide your gall bladder needs to come out, and then send you to his mate, whom he was at medical school with, and who’s pretty good at this sort of thing. The patient and the doctor will jointly come to a decision about the wisdom of having a cholecystectomy, and then the patient will choose which hospital to go to.

Right now, this is as tricky for patients as for the doctors and practice management staff. But the real, inherent value in the policy will become apparent in time – perhaps quite a long time from now – as the system gets slicker, and more importantly, as more and more information becomes publicly available, mainly through the Healthcare Commission, about surgeons’ success rates and case mix.(2)

Many specialists feel threatened by Choose and Book. Patients are no longer referred to them individually (although this is not impossible); rather, patients are referred to a department, and allocated by middle management to one of a team.

The individual specialist, then, could be forgiven for feeling a little aggrieved that his or her skills are not being valued in their own individual right. This is not by chance either, but is equally part of healthcare policy aimed at redeploying power within the health service, destabilising the pivotal position of senior doctors.

Commission impossible?
Some think commissioning is the last-chance saloon for doctors. Politicians generally haven’t been impressed with primary care trusts’ (PCTs) ability to shift commissioning away from its power base in hospitals. The previous configuration of PCTs was simply too puny to take on the big guns in secondary care. They lacked not only pure financial clout, but many thought they also lacked leaders of sufficient calibre.

Commissioning entails a great deal of understanding of the nuts and bolts of healthcare planning and delivery. At a minimum, commissioners have to understand and anticipate needs in order to plan and prioritise; they have to be able to define services to meet these needs and contract them from the most appropriate providers; and they have to monitor the contracts they have drawn up and agreed.

The Department of Health is hoping that this generation of bigger, wealthier and better-organised PCTs will do better. But will they?

There is little evidence that commissioning in any form has had a substantial effect on secondary care services, although in fund holding, at least, it did seem to secure shorter waiting times and some improvement in information flow.

There is evidence that commissioning has made its biggest impact on primary and intermediate care, for example in developing a wider range of practice-based services, stimulating new forms of peer review (for example, in prescribing, where the most convincing evidence in favour of commissioning was found by the Health Foundation report).

This may have indirectly led to the evolution of some new forms of specialist primary care. In total purchasing consortia, there was evidence that some longstanding working practices could be changed. However, there is always the tension of local priorities and innovation to be balanced against national targets and “must dos”.(3,4)

But, like many contemporary healthcare policies, commissioning has been introduced with a flourish, is a “must do” for PCTs and strategic health authorities, and is here to stay – at least until the policy changes.

The QOF factor
Of course, the biggest policy shift affecting how general practices work has been the Quality and Outcomes Framework (QOF), which we see every time we turn our computer screens on.

It seems so obviously a good thing: experts give you a template to remind you what to do about the commonest conditions you will see and treat. And, five years on, there are discernible improvements in the care of patients with diabetes and asthma.(5) While the care of coronary heart disease was already improving before the contract came in, the improvements in care for that condition have been maintained, too.

Concerns about cheating – always a threat when a system of financial inducement is introduced – have largely proved unfounded. The most obvious way to “cheat” would be to exemption report as many of the blighters as you could. Martin Roland’s recent review, however,  reported a rough rate of exemption reporting of about 5–6% (one practice Roland describes exempted 86% of its patients in the first year – I’m not entirely sure what they were thinking of!).(5)

Others have criticised the QOF for not being rooted firmly enough on evidence-based criteria, and for tying practices into tedious process measures when, really, what they should be doing is talking to patients about how their life is, to what degree they feel they are suffering, or simply what it is like to live with the condition they have.(6)

Well, not “condition”, actually – more like “conditions”. The vast majority of patients over the age of 65 will not actually have just one condition, but rather two or three conditions.
A recent paper has taken a swipe at this single-disease modelling, arguing that what doctors can do now isn’t anything to do with stopping us dying, it is more to do with selecting out certain causes of death, and influencing the manner of our dying.(7)

In this study, the researchers re-examined the PROSPER trial, which definitively set out the value of treating older people (those in their late 70s to early 80s) with statins, for the secondary prevention of cardiovascular disease.(8)

Bags of benefit, said the PROSPER authors, definitely statistically significant for men, and very nearly statistically significant for women. A clinical policy was established: statins were to be prescribed for the increasingly large population of very elderly people.

What interested the researchers in this paper wasn’t the primary result – the reduction in heart disease outcomes – but the overall mortality in the entire study group: this was unchanged. So, on the one hand you had an intervention decreasing mortality from one cause – but, overall, no change in mortality. Something must be balancing the gain from reduced heart-related deaths.

Within the paper, the original study authors had noted that cancer diagnoses had increased. Their interest, however, was simply to exclude the possibility that statins might cause cancer (they don’t). But Mangin and her colleagues, reflecting on the study’s findings, plotted the cancer figures, and noted that cancer diagnoses were, in fact, statistically significantly increased. Cancer deaths had also increased, though not
statistically significantly.

What you had to conclude from this study was that, while the statins could reduce the heart-related deaths, they simply allowed you to live longer to develop a diagnosis of cancer: the study had lasted long enough just for people to get their cancer, not die from it. One is reminded of the aphorism from the philosopher Lionel Trilling: “Any proposition conveyed without a hint of doubt about its validity is a form of bullying.”(9) Makes you think, doesn’t it?

The astute reader will have noted my deliberate mistake in the opening to this article. OK, we don’t have a bank manager now, we have a relationship manager. Actually, we don’t really have a bank, in terms of a wood-panelled building with sniffy attendants in black jackets. And, yes, I think we have a cheque book but, to be honest, most transactions we undertake are deployed electronically.

Know how long it took for the entire face of banking to change? Ten years. April 2007 was the tenth anniversary of the first online bank. Many think general practice will change just as rapidly, and just as radically. If we don’t understand how policy affects our practice, we’ll all be wandering about Tesco looking for our stethoscopes.

1. McTiernan J. An insider’s view of Labour’s record, and its importance for health. Presentation to ODP Network Westminster Hall; July 2007.
2. Healthcare Commission. Independent sector treatment centres: a review of quality of care. London: Commission for Healthcare Audit and Inspection; 2007. Available from:
3. The Intelligent Commissioning Board steering group. The Intelligent Commissioning Board: understanding the information needs of SHAs and PCTs. London: Dr Foster Intelligence; 2006. Available from:
4. Higgins J. Health policy: a new look at NHS commissioning. BMJ 2006;334:22-3.
5. Roland M. Quality and Outcomes Framework: too early for a verdict. Br J Gen Pract 2007;57:525-6.
6. Mangin D, Toop L. The Quality and Outcomes Framework: what have you done to yourselves? Br J Gen Pract 2007;57:435-7.
7. Mangin D, Sweeney K, Heath I. Preventive care for the elderly needs rethinking. BMJ 2007;335:285-7.
8. Shepherd J, Blauw GJ, Murphy MB, Cobbe SM, Bollen EL, Buckley BM, et al. The design of a prospective study of pravastatin in the elderly at risk (PROSPER). Am J Cardiol 1999;84:1192-7.
9. Delbanco P. Night vision [review of Tilling L. The moral obligation to be intelligent: selected essays]. New York Review of Books 2001;48:1.