A gentlemen’s agreement, or a gentleman’s excuse-me?
Round 4,371 of the BMA-Government row over access to primary care. Seconds out.

Richard Vautrey, David Stout and Michael Dixon discuss what can be done to make progress between the Government and the BMA.

by Andy Cowper

Ben Bradshaw is the Hugh Grant of the NHS. It’s not just the whole floppy haired, well-spoken, good teeth thing he’s got going on. No, Bradshaw is now engaging in political Tourette’s akin to Grant’s most famous character from Four Weddings And A Funeral in his dealings with the British Medical Association.

The latest bone of contention on which the Government and the BMA are chewing is about access to primary care - again. Bradshaw told the BBC News Online (http://news.bbc.co.uk/1/hi/health/7475985.stm) “I think there’s also no doubt that there are some areas where gentlemen’s agreements operate that mitigate against lists being open to new patients, and therefore work against real patient choice”

Attacking fixed funding for patients, he said that fixed practice funding with the Minimum Practice Income Guarantee funding (MPIG, agreed in the new 2004 GP contract to stave off potential income losses) "dampens any incentive a practice might have to expand their list".

Bradshaw also said that "it's the patient who pays the salary ... all too often in the heath service, the approach has been a kind of patronising 'we know best' one, when actually you're being paid by your patient, so your patient should be in charge. That’s still a cultural challenge that we still need to crack". So not only are GPs conspiring to keep lists closed, the Minister considers them paternalists into the bargain.

Buckman: Minister’s claims “absolute nonsense”
The BBC’s story reports that Dr Laurence Buckman of the BMA's GP committee dubbed Bradshaw's claims as "absolute nonsense ... it just doesn't happen".

Buckman is also reported to have said that he is not opposed to moving the funding basis from MPIG lump sum to one based on practice list size, but that GPs were not going "to compete for patients, that is not the way general practice works".

Head them off at the impasse
It’s like déjà vu all over again, isn’t it? The new row is, in truth, of a piece with the ongoing row over access to primary care, both in terms of hours open and the new polyclinics – or as they have been rebranded, GP-led health centres.

These public rows make for easy copy for journalists. However, they are generating much heat and very little enlightenment.

How can both sides be persuaded to sit down, have a few deep breaths and a nice cup of tea – and then try to move beyond this sterile impasse? How can we park the mud-slinging?

Dr Richard Vautrey, deputy chair of the BMA’s GP committee, is clear that the BMA “would like to see an end to it. We’ve been making repeated approaches to Government to engage with us and we’re more than happy to join negotiations over some of the issues that have developed as a result of the new contract. I’m sure we’d all like to move on to deliver fair allocation of resources to individual practices”.

How would he see this working, given that Lord Darzi’s review has signalled the end of the road for MPIG? Vautrey says, “we need movement back to what was the original intent of the new contract (until the Government intervened, against our advice). That intent was that the core payment, global sum, would cover essential services, and the quality element under QOF would be for specific priority areas on top. The Government shifted existing resources out of the global sum into the quality pot.

“Moving forward, we need the global sum payment increased to a level that’s fit to deliver the essential services. Now that sum is £54 per patient annually. If you aggregate this and correction factor payments, together with PMS basline payments and growth funding, (not discussed by Government, but a real issue –PCTs look at PMS baseline and growth funding as well as GMS payments and correction factors), then if you then re-divide the total based on a population basis, you end up with a new global sum figure that’s much higher: certainly into the £60s and maybe £70 per patient. That’s a much more realistic figure per patient, and we need to develop a system which works to that target. It’s eminently possible if there’s the political will”.

“If practices can work towards that with confidence, it’ll provide stability; it won’t undermine current services; and it could be done without a huge amount of new resources. But it needs to happen over years, as changing the inequities in PCTs’ funding has done. The disadvantaged PCTs are being gradually given additional resourcs over and above the average and thereby working to a target level over years, it is not done by taking from some and giving to others: but by giving some proportionately larger increases, but increasing funding to all.”

Those are technical fixes, but despite the Darzi review’s emphasis on quality, the row seems to indicate a cultural divide between the BMA and Government. How can the two start to work in common?

Vautrey suggests that “the key is that Government needs to increasingly talk up the benefits and value of British general practice, and celebrate its success. I think the frustration of GPs and patients in recent years is that following any success with targets, the rider is always about how GPs have acted so as to cause lots of problems. GPs have acted to provide good services to patients. GPs are looking for a period of stability and positive support from Government - and not undermining.”

Parking the money debate and driving with Darzi
David Stout, director of the primary care network of the NHS Confederation registers a wry smile when asked how the Government and the BMA can move on from this latest confrontation. “I think everyone would like a way out! I’m not sure it’s helpful for the government and the profession to appear constantly to be arguing and bickering - at least in public.”

What does he regard as the potential ways out of this impasse? “The primary and community strategy part of the Darzi Review that’s just been published could present a positive way forward for the service – it’s full of good things to talk about in terms of improving patient care. It would be good to move on to them”.

How real does he think the issue of Bradshaw’s suggested “gentlemen’s agreements” are? Diplomatically, Stout says that “the real issue to what extent there’s choice in general practice. Behind the noise, is there a real choice for patients in general practice?

“Historically, practices have not competed for patients: that’s not how they’ve operated. Partly as a consequence, the theoretical choice to change GP is hard to operate in practise. The NHS Confederation believes that patient choice is one of the drivers for service quality improvement – not the only driver – but it should be made more real”.

How? “Firstly, look at the new GP-led health centres, offering an opening to alternative providers as well as existing providers. Secondly, by adding capacity across country, we will add patient choice in terms of new practices in localities, and within their 8-8 opening hours, some sort of drop-in will give patients another option.

“You don’t need huge amounts of competition to generate effects on practices’ responsiveness. Where APMS has been used (which has been on a very small-scale), there have been knock-on effect on existing practices to increase choice at the local level, but also responsiveness.”

Richard Smith wrote a piece for The Guardian (www.guardian.co.uk/commentisfree/2008/jul/03/nhs.nhs60) about the UnitedHealth UK (his ex-employers) effect in Derby, when they took a practice over, he states that practices nearby opened their previously closed lists. Stout agrees: “it’s that kind of effect. The same principle we have seen with choice in the acute sector: not a lot of people do shop around, and we don’t anticipate they will with GPs. But the fact they could do it has an effect”.

He concludes that “the Darzi strategy is full of stuff for clinicians, means something to them, not just doctors. meaningful discussions, and that might be a way of moving past adversarial debate, to true mutual interest in better patient care, better ways of incentivising quality (QF a start, but keep moving). If you can park the money debate (and there always will be one) and engage in what really want for patient that something profession would engage with.

Growing pains to replace MPIG
Michael Dixon, chair of NHS Alliance, is circumspect whether Bradshaw’s alleged “gentlemen’s agreement” is a real problem. “I haven’t heard of it, but I’m a rural practitioner, so I probably wouldn’t as I imagine it’s a city thing. I’m not sure why you’d want to close your list. Is it so you can’t be picked off?

“Whatever the truth, the overview within Darzi’s strategic review has a commitment to associating pay with the patient list. At the moment, the payment system is not sensitive, so it doesn’t reward practices who track patients or take on when other words. It’s self-evident that need to build these factors in, which would be better for patients and for practices.

Dixon suggests that the whole issue “becomes non-existent when a successful practice attracts pay with new patients. It’s not an issue if we get a fairer funding system, to which most GPs are committed including saying goodbye to the MPIG. The disagreement is over how fast: some say 3 years, others 5. What’s crucial is for the minimum number of practices to lose out. If practice income growth is relatively fast, we’ll get there sooner; if it’s slower growth, MPIG will have a longer phase-out”.

Why have the BMA’s and Government’s reactions to one another become so entrenched? Dixon suggests that “a lot of progressive GPs feel they’ve got nowhere to hide because the two sides have become so polarised. A lot of GPs feel they can’t turn their back on their union in the dispute.

“It’s been a very unfortunate interlude, which we need to lay to rest. Progressive GPs are much more about patients and patient care than they are about pay”.

How does Dixon think they can stop the row? “I think it’s easy. The aspirations behind the Darzi review of primary care are good, so now we need to move the rhetoric to reality, with proper decision-making, front-line clinical involvement and patient involvement over access, availability and continuity of care.

“Once local clinicians and particularly patients have those active roles, there’s no problem any more and no need for national debate about how to weight funding. We need localism, patient power and clinicians leading change.”