How is the National Shared Care Record Project Going?

Today's FT prints a concise summary of the rise and predicted fall of the National Care Record project. You can read it here.

The FT Agrees with Me!!

Some things were ever so. As William Moyes, chairman of the foundation trusts regulator, confirmed this week, reform of the National Health Service has been slower than was hoped. The same can be said of the UK’s other wasteful state services. The Conservative party, which is likely to win the general election due by next summer, has rightly focused itself on public sector reform. But this, sadly, will not help it cope with the UK’s gruesome fiscal position.

The next government will need to close a deficit of about 12 per cent of output. The Treasury’s current plans leave the deficit at a still-cavernous 5.8 per cent in 2013-14, but even reaching that halfway house will require cuts in real terms to departmental budgets of 2.3 per cent each year. This ever-tightening fiscal straitjacket should be the salient feature of British politics. But neither main party has recognised the scale of the task.

The Labour leadership, rather pathetically, has had real trouble simply admitting that spending cuts are a necessity. And, last week, George Osbone, the Tory shadow chancellor, said that, under a Conservative government, “reforms to public services ... mean cuts on the frontline can be avoided ... ” This, sadly, is something of a fantasy.

The Tories are pointing in the right direction on schools, welfare and healthcare: they hope to drive up productivity by introducing competing private providers into these arenas. Such policies would improve public sector value-for-money. In the medium term, they would create room for savings, for example, by helping to contain the medical costs of the greying population.But, in the short term, these reforms would be expensive. During the grim years of restraint, they would be a fresh drain on the exchequer. And, even if they were costless, they could not boost productivity by the amount needed to shelter services from the axe.

Whoever wins the election – and however strong their reforming zeal – the next government will be remembered as a cutter. No reforms can save the British state from its coming resculpting: this is why both parties must unveil coherent political agendas.Labour and the Tories must both explain which functions of government they regard as sacred and which, if forced, they would sacrifice. It is absurd that we do not know what the UK’s national parties would like the British state to be doing in 10 years’ time. One now wonders whether the parties themselves even know.

Reality vs "Real Term"

The forthcoming general election - a maximum of nine months away - will generate a great deal of heat about each party's plans to preserve and improve the NHS. I can't imagine that any of them will admit to any plans to reduce spending so that's alright then ... isn't it?

Well, not exactly.

Given the state of the UK economy and the amount of debt, both government and household, that we have finally started to confront, it is more than liley that the spin will be "spending will be maintained "in real terms".

Things to ponder ...

1. Our population is growing. So maintaining spending means spending less per patient.
2. Our population is ageing and the older you get, the more you cost. So maintaining spending means there isn't enough to look after the additional elderly.
3. New and expensive drugs and treatments are constantly being added to a doctor's armoury. So maintaining the spending means there isn't any money to pay for the new stuff.

Spending in real terms is unchanged. Spending per patient is, in reality, reduced and advanced treatments will be rationed if available at all.

It's an Emergency

I first started working in an NHS GP practice over six years ago. One of the first challenges was to try and get a grip of unscheduled care of our patients; people phoning us or turning up 'at the desk' demanding immediate care usually in the form of "seeing the doctor... now". Being an 'outsider' and a novice, I reached for ... The Contract. This was, and supposedly still is the document that defines what we had to do to fulfil our responsibilities as an NHS general practice. It didn't help.

It told me that we should provide urgent care when it was needed and so I entered the wonderful Heller-esque world of Catch 22. How do I tell which patients need urgent care? I'm not a clinician. Neither are my reception team. The only people who can decide whether something is urgent are doctors or senior nurses and that's precisely what the person at the desk wants. Thus we ended up in the situation that the way to get urgent care was simply to say: "it''s urgent". Actually what they usually say is: "it's an emergency". It rarely is.

During the week, our patients can always get to see a doctor within 24 hours. They may have to wait longer if they wish to see the doctor of their choice but if something is urgent, then that's the maximum wait. It's usually less. Anybody phoning before 11 am and who says "it's urgent" will be seen that morning!! Routine appointments (which last longer) are usually in a couple of days time, and if you want an evening appointment, then it will be anything up to a week (but if you're fit enough to get to work, then maybe that's not as bad as it sounds?

The upshot is that the anxious, the worried well, the over-dramatic, the unscrupulous, and the irresponsible get to the front of the queue; whilst the sensible, the responsible, and the reticent wait until an appointment is available. It didn't seem fair then, and it still seems unfair now.

I have asked "the authorities" to define what constitutes "urgent" but they duck the issue saying it is a clinical judgement. Clearly they can't generate a list of ailments, but they could provide us with something like "an impact scale"; a description of the sort of impacts that are "emergency", "urgent" or "non-urgent". It could be similar to the categories assigned to IT problems where the severity is decided by the effect of the fault (inconvenient, etc) rather than a definition of it. We would probably end up seeing the patient but at least, if they were taking the mickey, we could then caution them about their unacceptable behaviour.

Until that happens, the usual suspects will arrive at the desk, demanding to see the doctor of their choice, because "it's an emergency".

Extra Money? I don't think so!

In 2002, our practice moved over to a different contract under which we supply 'doctoring' to our local population. I won't bore you with the detail but we signed what is, in the jargon, a Primary Medical Services ("PMS") contract. In essence, we are paid an annual sum of money out of which we have to run the practice, rent and maintain the premises, and pay the staff. Whatever is left is the partners' earnings. This is the same contract that the Department of Health propagandists have been denouncing as "too generous".

The first year (2002/03) payment was £1,106k.
This year's payment (2008/09) is £1,128k.

If annual payments had been adjusted by changes in the retail price index (RPI) , this year's payment would have been £1,374k. So inflation has eaten away 22% of our real income. At the same time, our practice list has grown by 7%.

The total amount we have "lost" through inflation is £767k over five years. By end 2010, they will have six years for the price of five.

I know, I know, I'm fat!

On UK television this evening, we watched an episode of a documentary series about Whipps Cross Hospital ( a large general hospital in north-east London). One of the featured patients was a man suffering from the usual complications of heart failure, odema, breathing difficulties, impaired mobility, etc. He was a very sick person and he freely admitted that his current plight was a result of years of over-indulgence.

At this point. a kindly volunteer arrives wheeling a mobile shop from which patients can purchase some 'treats'. Our patient buys Coca Cola, chocolate bars and other assorted confectionery that, if someone else had fed them to him, they would be at risk of being charged with attempted murder.

You might think that a rant now follows - you would be wrong! But ...

Next year, my GPs are almost certain to be given some targets for controlling obesity in our patients. I have no idea why the Department of Health thinks that we can make a difference. Who doesn't know about fibre, fat and five-a-day? Who always looks sheepish when their weight is mentioned? Who doesn't know all about eating less and exercising more?

In case you're wondering, my BMI is nearer thirty than twenty and my waist is only just surviving. Few of us do what we know to be right even when the chicken (and chips) have come home to roost like our Whipps Cross patient who confessed to sneaking into a cupboard during the night to top up his cocoa and refined sugar levels.

Alice in Budgetland

The NHS year runs from April to the following March. Over the past couple of years, we have been encouraged to take a greater interest in the cost of the medicines we prescribe for our patients. You might think that such interest would be a "given" but it is not so. The NHS relies on doctors to "do the right thing" when choosing which drug to prescribe. At the same time, these same doctors are the targets of the intense promotional activity by the drug companies. Busy doctors have little time to take a calm, measured look as the latest drugs on offer.

One positive move was the allocation of prescribing budgets to GP practices. The carrot has been the offer of allowing practices to keep a proportion of any savings they make providing these savings are reinvested in improving care for patients. At the moment, there is no "stick"; there are no sanctions for exceeding budgets but it is hard to believe that won't come in due course. Last year we saved £70k from our budget. We look forward to using these savings to add to our services. An in-house physiotherapist; an acupuncture clinic, and the like. Our budget this year is £1.33m. That's our share of a total budget of £32m for the PCT as a whole. We have worked hard to make further savings and at about the half-way point (the latest figures available) we have increased our savings to an annualised £130k. Great! We can continue to offer these extra services and add to them.

This week I received a letter from our PCT. They have finally incorporated the changes in payments to community pharmacies. These changes will have to be funded from this year's budget. It means that £1.8m additional funding has to be found. Thats about 5% of the total budget and it will have to come out of all our budgets.

Let me see. Five per cent of our budget is £66k. Gone! Half the savings we have worked hard to achieve. It is the end of month nine of our financial year. What is the point?

It's raining money

You might remember the "shock/horror" headlines of a couple of years ago when many NHS organisations were finally forced to declare their hidden deficits. Our then illustrious leader, the glorious Patsy Hewitt, forced trusts to do all the unpleasant things they had tried to avoid such as getting rid of surplus staff, becoming more efficient, etc. However, the knee-jerk actions of the NHS bureaucracy reached all the dark corners of the service and we had "realignment of services" (ward closures); "streamlining" (nursing staff were made redundant); and "financial re-focus"(budgets were suddenly reduced). Our own primary care trust was one of the few that had stayed within budget up until then. Suddenly, their budgets were "top sliced" and abracadbra - we were £30,000,000 in the red.

That's the good bit! Next, because the trust couldn't work out how to recover all this "overspend" a pack of management consultants was forced upon us (at our trust's expense) to tell us how to run more efficiently. (I don't know why but it reminds me of the old army joke: "all leave is cancelled until morale improves".

Life has moved on. Our trust has now had much of that top-sliced money suddenly returned. It is falling out of trust headquarters by the day. On my desk are three new incentive schemes that seem amazingly generous after the recent sparse past. I am trying to work out how to recruit (expensive) agency staff so I can grab this dosh before the meter stops (March 2009). My primary care management team was reduced to two people during the lean times. There are now at least ten of them floating around, some of whom are tasked specifically to help me spend money.

Meanwhile, back in the real world, we are hurtling towards a recession. This government is forecast to borrow £100,000,000,000 next year. somehow, I don't think that the next cuts are likely to be another unpleasant top slice. They are more likely to be financial castration.

I'm keeping everything crossed.