Contract was a windfall for GPs but ‘not a good deal for patients’

The controversial contract to improve GPs pay and efficiency cost £1.76 billion more than the labour goverment expected and NHS productivity has actually fallen, a damning report by auditors concludes. The findings, by the National Audit Office, show that GPs who run their own practices received huge pay rises while giving up responsibility for the 24-hour care of their patients.

But GPs employed on salaries gained very little, while practice nurses actually saw a real-terms decline in pay. Hoped-for gains in productivity did not occur: productivity fell two years running, by an average of 2.5 per cent a year.

The costs of the contract were partly covered by extra cash from the Department of Health, but the primary care trusts who pay GPs were not fully reimbursed. As a result, they had to find £406 million between 2003-04 and 2005-06 from their own resources, limiting their ability to improve services.

The NAO report does not openly criticise anyone for the outcome, which enriched GP partners at the expense of almost everybody else. But when pressed, Karen Taylor, director of health at the NAO, said: “I think as far as the public and taxpayer is concerned, the benefits they should have been expecting to see have not materialised to the extent they should have done. From their perspective, it’s not a good deal for them.”
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There were some positives, she said. Recruitment and retention of GPs had improved, and the focus that the new contract brought on long-term conditions, such as diabetes, had helped patients. The average general practice appointment was longer — twelve minutes rather then eight — largely because an increasing proportion were being dealt with by nurses.

But NHS managers from top to bottom are found to have failed, by allowing the British Medical Association to negotiate a contract that enriched some of their members, shortened their hours and used up so much cash that reforms to services were stymied.

The report says that in its “business case” to the Treasury justifying the contract, the department had quoted figures that underestimated its actual cost by £1.76 billion over three years.

There were three reasons, Ms Taylor said. The department underestimated how much GPs would earn from the quality and outcomes framework, which rewards them for the number of quality points they earn; it underestimated the cost of switching out of hours responsibilities to primary care trusts; and it underestimated what it would cost PCTs to administer the contract.

GP practices are paid a gross sum, out of which the partners pay the cost of running the surgery, including salaries of nurses and other working doctors. The partners share the profits.

Perhaps the most damaging aspect of the report is the figure showing what partners did with their increased payments. They boosted their own incomes by 58 per cent over the three years, to an average of £113,614 in 2005-06. Salaried GPs whom they employ gained just 3 per cent in the first two years, to £46,905, while the average practice nurse’s income reduced in real terms, the report says.

The NAO concludes that one reason the contract has so far failed in the redesign of services is that the BMA negotiated a minimum practice income guarantee (MPIG), which ensured that no practice would earn less under the new contract than it did under the old. It meant that GPs retained the benefits of the old contract where it suited them, while gaining greatly from the new one. MPIG should be phased out, the report says.

Tim Burr, head of the NAO, said: “There is no doubt that a new contract was needed and there are now 4,000 more GPs than five years ago. But in return for higher pay, we have yet to see real increases in productivity.”

Laurence Buckman, chairman of the BMA’s GP committee, said it was meaningless for the audit office to talk about productivity because the way GPs worked had changed. “Productivity should be measured in improvements in health, not the frequency of consultations. The early evidence is that the contract is leading to improvements in clinical care,” she said.

On February 07, 2008 Health Direct posted:Alan Johnson scraps with GPs over pay and opening hours

The 2004 general practitioner contract which the labour Government is now messily trying to unpick set a new benchmark for ineptitude by the Department of Health, whose weakness in contractual negotiations is legendary.

The agreement gave family doctors lavish salary increases tied to various incentives based on preventative health measures. In its first year it led to an average salary increase of 23 per cent, in the second year 10 per cent – an extra £30,000 a year in total.

Health spending on non NHS care soars

Spending on patient care from outside the NHS has been the fastest growing component of the health service’s expenditure during the past decade and reached £5bn a year in 2006, figures from the Office for National Statistics show.

Spending on care bought from the private and voluntary sectors and local authorities has been rising by 15 per cent a year on average since 1995. That is faster than the rate of NHS growth as a whole. It reached almost 20 per cent a year between 2002 and 2006.

The proportion of healthcare bought from the private and voluntary sectors and from local authorities has more than doubled since Labour took power in 1997. It has risen from under 3 per cent of all NHS expenditure to just under 7 per cent by 2006. In cash terms, expenditure has risen from £1bn to just under £5bn.

Expenditure figures include: money spent on operations bought from private hospitals and independent treatment centres; spending on acute psychiatry in nursing homes for people with continuing care needs; and spending on community services for older people, those with mental health conditions and people with learning disabilities.

Labour has widened choice over where patients go for non-emergency operations. Also the use of private psychiatric providers (including medium-secure facilities for detained patients) has grown.

The service is now paying for heavily dependent patients who need continuing care. It had tried to shift that cost to the means-tested social care budget.

Where the growth has arisen, the ONS cannot yet say. But primary care trusts’ accounts for 2006-07 suggest that spending in independent sector treatment centres accounted for only 4 to 5 per cent of the growth.

Some 40 per cent of the increase appears to have been spent in private hospitals and psychiatric facilities. Spending on other community services, including the voluntary sector and local authorities, made up most of the rest of the increase.

The other big drivers of increased spending were extra staff, more prescribing by general practitioners, other goods and services, and capital expenditure. Payroll was the biggest destination of spending: the NHS hired nearly 300,000 more staff in the decade to 2006. Purchase of other goods and services was the next highest factor in the increase.

GP prescribing rose steeply as drugs such as statins to prevent heart attacks were prescribed much more widely.

While spending on care outside the NHS was a small proportion of total spending, it was the element that had grown most quickly, the statistics office said.


Private surgeries hurt NHS, say academics

Two leading academics claimed the government’s fast track private surgery centres for NHS patients would “contribute to NHS deficits, NHS service closure and staff redundancies”.

Allyson Pollock and Sylvia Godden of Edinburgh university’s centre for public health policy said: “There is no good evidence that independent sector treatment centres [ISTCs] have provided additional capacity, value for money or high-quality care,” while they are leading to “fragmentation and financial instability” in the NHS.

Prof Pollock, a critic of private sector involvement in the NHS, said that with the centres running below capacity, and with the Healthcare Commission saying there is inadequate data fully to compare the ISTCs’ performance with the rest of the NHS, “the available evidence suggests that the private sector is profiting at the expense of patients, the public and the NHS”.

Prof Pollock’s criticism in the British Medical Journal comes ahead of a government decision next month on whether to grant seven new contracts to add to the existing 25 centres.

The Department of Health rejected her view saying: “The independent sector has undoubtedly helped improve services for patients, speeding up treatment and reducing waiting times.” The centres had also “galvanised the NHS to raise its game”.

The first centres were set up to treat about 170,000 patients a year, with contracts awarded worth about £1.5bn over five years. The NHS committed itself to pay about 11 per cent on average above the standard NHS price for treatments. As of last September, the centres had an average occupancy of about 84 per cent.

Prof Pollock said the original assurance that the centres would use non-NHS staff had not been honoured, with about a quarter of staff being seconded from the NHS. The centres took work from NHS hospitals and “NHS beds and services are being closed to make way for the for-profit private sector,” she claimed.

The NHS Partners Network, the trade association for the treatment centre providers, said that the claims ignored “incontrovertible evidence” that patients rated the treatment they received from ISTCs very highly, with satisfaction rates of 96 per cent.

“They also miss the fundamental point of this programme, which is to use competition as a mechanism for driving efficiency improvements in the wider NHS, while giving patients some real choice”.

The health department remained “committed to a diversity of providers in healthcare” with more data on quality due to be published.

The remaining schemes would only go ahead where they met local needs, offered value for money and benefited NHS patients, a spokesman said.


Hugh Grant calls for terminal care funds and labour to keep it’s promise

Hugh Grant accused labour ministers of breaking a key commitment to the terminally ill as he called for extra funds for their care on Tuesday.

The actor claimed Labour had pledged to double funding for palliative care in their 2005 manifesto but said the money “hasn’t materialised”.

Grant, whose mother was cared for by Marie Curie cancer nurses during the final stages of pancreatic cancer, told Radio Four’s Today programme: “She was allowed to die peacefully surrounded by her family after receiving the very best attention from those helping us to support her. Everyone should have that choice.”

He is supporting Marie Curie’s latest fundraising drive.


NHS 18 week target is preventing choice

Hospitals across England are stopping patients booking advance appointments in an attempt to meet a labour Government promise of treatment within 18 weeks.

Pulse magazine said 90 per cent of hospital trusts reduced the scope for advanced booking in the past six months to help meet the target of 18 weeks between GP referral and hospital treatment.

The proportion of appointments listed as unavailable on the electronic Choose and Book system – where patients choose where to be treated – rose “sharply”.

Many of the 28 trusts polled in the magazine’s survey said that reducing the number of weeks allowed for advanced booking was “essential” for hitting the target.

Dr Andrew Mimnagh, a GP, said: “Choice is sacrificed to ensure patients are directed to the capacity available – the hospitals people do not choose to go to.”


Midwives left woman to drown in the bath

A pregnant woman lay drowning in a hospital bath just as she was about to give birth after staff left her unattended for 45 minutes – despite being told she had a history of fainting attacks, an inquest has heard.

Doctors managed to save Lorraine Maddi’s baby son, who was delivered by caesarean section after she was discovered unconscious in the bath, but the 31-year-old estate agent died eight days later.

Midwives left her unsupervised in the bath despite being told she would sometimes collapse during stressful situations.

Staff at Bassetlaw Hospital in Worksop, Notts, failed to check on her because they all assumed she would not be left alone, the Nottingham inquest heard.

Her husband Phaninder Maddi now intends to take legal action against the hospital authorities.

He was in India when his wife went into labour and was admitted to the hospital on June 1 last year.

A midwife suggested Mrs Maddi took a bath to help with labour pains and family friend Paul Guthrie, who was accompanying her, left the hospital to collect some items.

But before leaving he informed midwives of her condition and told them to keep an eye on her.

When he returned he realised she was still in the bathroom with the door locked.

Midwives knocked, but after she did not respond they opened the door and found her submerged and not breathing.

She was resuscitated and her baby Jaydem survived being born by an emergency caesarean.

But Mrs Maddi, from Worksop, later died.

A number of midwives said it was assumed she would not have been left alone during her bath, but hospital officials admitted there were no official guidelines on whether women should be left on their own.

The inquest was also told a midwife failed to investigate after knocking on the door as Mrs Maddi took her bath and receiving no reply.

Dr Nigel Chapman, the Nottingham coroner, said drowning could not be given as a cause of death because she died eight days later, after her lungs had emptied of water.

He recorded an open verdict.

Mandy Dalton, the hospital’s head of risk and legal services, said the hospital would employ new guidelines about women being left alone in its baths.

Mr Maddi said after the hearing: “ I hope they keep to their word and make the changes.”

He added: “My son will never know his mother. I don’t know what I will say to him when he grows up and starts asking about her. The word observation means to watch but obviously Lorraine wasn’t watched.”


Row erupts over NHS health trusts in centralist health dictats

A battle for the soul of NHS reform has broken out after accusations that the labour government has usurped key hospitals’ independence.

At the centre of the row are letters from the health department to all NHS hospitals, including foundation trusts, telling them to appoint extra matrons, undertake an annual deep clean to combat hospital-acquired infections and appoint infection control nurses.

William Moyes, chairman of Monitor, the independent regulator of foundation trusts, has written to NHS chief executive David Nicholson arguing that such instructions amount to line management by the labour government when foundation trusts are meant to be self-governed institutions.

“I do not believe this is consistent with the legislative framework,” Mr Moyes warned the health service’s top boss, because the department’s letter “could only be interpreted as issuing instructions”.

Mr Moyes added it was clear that “there remain different views about who is accountable for the performance of foundation trusts”.

So ministers can no longer set hygiene standards and ensure they are enforced? They can still set standards for hospital cleanliness, which the Healthcare Commission inspects. Monitor requires foundation trusts to meet these and other national standards and targets, such as reducing MRSA infection rates, and can intervene to enforce compliance. But exactly how a foundation trust achieves targets is a matter for them.

But what if there is a known best way of treating patients? Can ministers not make foundation trusts comply?
They can, but not by central direction. National service frameworks, for example, set out approved ways of organising cancer treatment and other services. Primary care trusts are expected to commission care in line with these frameworks. Monitor argues that PCTs should remove services from hospitals that they believe are unsafe or poor quality. PCTs in theory retain the ability to require a deep-clean in a contract.

Like the rest of the NHS, foundation trusts are inspected by the Healthcare Commission. They are answerable to their boards, their governing councils and to Monitor, which authorises them and has the power to direct them and replace their boards.

If problems arose over performance, Mr Moyes warned foundation trust chairmen and chief executives in a separate letter, “it will be no excuse to say you were simply operating within a framework defined by the Department of Health or the strategic health authority”.

The correspondence amounts to a battle for the operational independence of a key part of the government’s reforms, which were meant to end “command and control” from Whitehall and shift responsibility for performance to freer-standing institutions, regulators and the primary care trusts who commission hospital care.

The health department’s letter followed headline-grabbing announcements at Labour’s?party conference by Gordon Brown, prime minister, and Alan Johnson, heath secretary, over hospital deep-cleans and the appointment of 5,000 extra matrons. However, the health department later admitted it no longer had the power to order a foundation trust to appoint matrons.

Mr Moyes said PCTs should not commission care from dirty and unsafe hospitals and should specify their requirements in contracts. If foundation trusts failed to deliver that, then the right approach was for the NHS chief executive to “invite Monitor to act, using its statutory powers”.

On Tuesday, Mr Nicholson tried to defuse the row, declaring: “I fully support the autonomy of NHS foundation trusts and the role of Monitor as their regulator.

“I am also clear that every NHS board has – as part of the NHS family – a very real duty on behalf of their patients to learn lessons” to prevent a repeat of the infection scandal at the Maidstone NHS Trust, where 90 people died from Clostridium difficile.

The Foundation Trust Network, which represents the trusts, said: “It is important that Monitor maintains its status as an independent regulator able to challenge if hard-won freedoms are eroded.”


A&E patients die waiting for ambulances to meet labour targets

Seriously ill patients are left for hours in ambulances instead of being immediately admitted to accident and emergency departments to meet a labour Government target on treatment times, it was claimed.

The practice of “patient stacking” has left some waiting for up to five hours because A&E; units have refused to admit them until they can be treated within the four-hour time limit.

Unison, the public sector union, said the practice poses a danger to other patients because ambulances detained as “waiting rooms” cannot answer new 999 calls.

Mary Maguire, a spokesman for the union, said: “This happens time and time again. It is an appalling waste of resources. We should not use ambulances as waiting rooms.

“A 16-year-old terminally ill cancer patient died after waiting over an hour for an ambulance to transfer him. Three ambulances could have reached him but they were tied up waiting to hand over patients to A&E.;”

Dr Steve Field, the chairman of the Royal College of GPs, called the situation ”entirely inappropriate and unacceptable”.

Evidence of patient stacking is revealed in the official ”turnaround time” data released by seven of England’s 11 regional ambulance services.

The figures show that over the past 15 months at least 44,000 delays were reported by the ambulance services. In some cases the delays were up to five hours.

Norman Lamb, the Liberal Democrats’ health spokesman, said the situation represented ”a scandalous distortion of practice to meet a target that is meant to improve the service”.

Mike Penning, the Tory shadow health minister, said: “Not admitting people to hospital but stacking patients in car parks beggars belief in the 21st century.”

George Alberti, the Department of Health’s national director for emergency access and service design, denied the claim that Government targets are putting pressure on A&E; staff to resort to patient stacking. He said: “The four-hour clock for A&E; waiting starts 15 minutes after the ambulance arrives, regardless of whether the patient has been handed over.”

Dentists warn of future of NHS services at risk

Contract changes that have seen more than 1,000 dentists leave the health service threaten to bring about the end of NHS dentistry, MPs are warned. The introduction of financial penalties for missing targets has already seen twice as many dentists leave the NHS as the Government estimated.

Thousands more are questioning their future in the NHS because of the uncertainty surrounding their earnings, the British Dental Association (BDA) said.

Already the changes have left an estimated one million extra patients without access to a dentist. Almost one in three children do not receive any form of dental care.

The BDA will warn the influential Commons Health Committee that the future of NHS dentistry is “at risk” unless ministers scrap the system.

The new contracts, introduced in April 2006, were designed to provide better access to dentists, and to simplify charges for treatment.

But the BDA said they had driven more than 1,000 dentists – not the official figure of 57 – to concentrate solely on private practice because of the “financial penalties and uncertainty they face”.

Under the new system dentists are forced to pay back money, often thousands of pounds, to their primary care trust if they do not meet a target for the number of NHS treatments provided.

Dentists say the system is patently unfair and does not properly measure the amount of work carried out. For example, they receive the same fee for giving a patient one filling as for giving that patient five fillings.

In addition, the targets are based on the number of patients each dentist saw in 2005, meaning those with expanding or shrinking practices face having to pay back part of their salary.

Dentists also complain that they have less time to advise patients on how to prevent future dental problems because of the “treadmill” conditions they are forced to work under.

The future of NHS dentistry is “at risk”, the BDA says in written evidence to the committee, because “dentists are facing financial penalties derived from untested targets”.

The BDA also accuses the government of “chronically underfunding” dental services. Spending on dentistry in the NHS is now just 2.8 per cent of the overall budget, less than in 2002.

Dr Anthony Halperin, the chairman of the Patients Association and a dentist himself, said: ”Dentists are concerned that they are going to be even more squeezed and have to do more work for less money. Whereas many before saw the NHS as a career they are now beginning to question whether that is really the case.

”Initially their places will be taken by dentists coming in from abroad. But as they become more established those dentists will also begin to look for more salary and move away from the NHS.”

Peter Ward, the chief executive of the British Dental Association, said the new contracts would drive increasing numbers of dentists from the NHS every year.

He added: “This situation is only going to get worse. Dentists who miss their targets by small amounts are not fined if they agree to make up the shortfall the following year. But if dentists are struggling to carry out enough treatments one year it will be harder to hit a higher target the next.”


Health Minister defensive over Cerner NPfIT NHS progress

When advisers to ministers write replies to Parliamentary questions they have no legal duty to be candid. Within reason they can say what they like. So for them answering written Parliamentary questions may be no more challenging than playing tennis with the net down.

Indeed, when asked about the NHS’s National Programme for IT [NPfIT], ministerial advisers can use Parliamentary replies to make light of the concerns of clinicians and others. And this is what happened when Worthing MP Peter Bottomley put a question about Cerner sites to Ben Bradshaw, who’s the latest in a series of ministers to be put in charge of the NPfIT.

Cerner’s “Millennium” software will be used to help NHS staff administer hospitals and keep records on the care and treatment of patients. It’s due to be installed at hospitals across London and the South of England as part of the NPfIT.

Bottomley asked Bradshaw what representations he’d received from clinicians in hospitals about Cerner Millennium go-lives. Bradshaw’s reply in January 2008 suggested that clinicians are concerned only about things such as the number of keystrokes to carry out certain functions.

Bradshaw said in response to a question from Worthing MP Peter Bottomley:

“While Ministers have not received any direct representations, we are aware that users in the early deployments expressed some concerns about the system’s management and statutory reporting functionality, and some of its usability features, for example the number of key strokes required for certain functions. Action has been taken to address these concerns and to enhance these areas. This is making a positive impact. Many users who have become familiar with Millennium over time have expressed satisfaction with the system.”

There have been some successes with Cerner go-lives. Barnet and Chase Farm Hospitals NHS Trust, for example, now has near a real-time overview of when beds are vacant and where. The reality, also, is that at some hospitals where Millennium has been installed there have been protracted difficulties, not necessarily through any fault of NHS trusts or Cerner, or the local service providers, Fujitsu and BT.

The Audit Commision, in the latest annual audit report on Weston Area Health NHS Trust, referred to the implementation of what it called the Cerner National Care Records System. The Commission said that remedial work continued for months. It said:

“Significant problems with the implementation of the Cerner system have resulted in poor data quality and a lack of robust information…Weston Area Health NHS Trust was included within the first deployment of the Cerner National Care Records Service (NCRS) and implemented the NCRS system in October 2006.

However, it was soon recognised that the system was not providing the services required by the Trust and that significant remedial work would be required.Over the last nine months the Trust has been working with the suppliers and the SHA to resolve these issues…”

Bradshaw’s reply gave no hint that an independent organisation such as the Audit Commission had deemed as “significant” problems arising from a Cerner implementation.

Bradshaw’s answer did include statistics from Cerner sites including Weston. The system at Weston had 1,700 total users, 1,400 at peak times and an average of 450. Queen Mary’s Sidcup NHS Trust had 2,050 total users, 170 at peak time and [only] an average of 50. Buckinghamshire Hospitals NHS Trust had a total of 880 users, 700 at peak time and an average of 450. But do statistics mean anything?

Buckinghamshire Hospitals NHS Trust went live with the Cerner Care Records System on 25 September 2006. More than a year later, in November 2007, the trust’s board was told of some of the day to day difficulties. On the matter of keeping track of patients with MRSA and C Difficile, the Care Records System was “not working consistently” although Fujitsu, the supplier of Cerner’s Millennium system in the South of England, was working on a fix.

The trust board was told:

“CRS – which is not working consistently Fujitsu are working on a fix for this. In the meantime a ‘belt and braces’ approach is being taken by the Infection Control team to ensure patients are not missed. There is currently no functionality in CRS for flagging patients with C. difficile. “

Last month Buckinghamshire Hospitals NHS Trust categorised the risk of the Cerner Care Records Service causing disruption to clinics, targets and workforce as “likely” to materialise, and it categorised the potential severity of the consequences as “major”.

Avon, Somerset and Wiltshire NHS Cancer Services has said that “Current opinion regarding Cerner is that it will not support cancer data collection and reporting requirements for at least 5 years, possibly nearer 10 years.”

And NHS South Central reported in November 2007 that “Deployment problems at those sites that have implemented the [Cerner] system has created concern amongst those organisations in the deployment pipeline. Regular communication is now taking place to rebuild confidence and keep organisations up-to-date with progress on the contract reset.”

Health Direct Comment:

It has been said before but if ministers and officials continue to play down the problems of NPfIT implementations they’ll carry on alienating clinicians and other NHS staff whose support they need to make a success of the programme. Ministers and NHS Connecting for Health, which runs part of the NPfIT, do not need to put the programme in a zoo enclosure marked “Say kind things only – this enclosure is for the worried and nervous”.

This is the question asked by Peter Bottomley MP and Ben Bradshaw’s answer:


“To ask the Secretary of State for Health which hospital trusts have installed Cerner’s Millennium system; on what date it was installed; which hospital trusts are expected to install the system and when; what the name is of the senior clinician on each hospital IT board; which Minister is responsible for the system roll out; what representations he has received from clinicians in hospitals using the system on their experience of using it; if he will ask a chief medical officer to consult clinicians using the system in (a) Kent, (b) Sussex, (c) Cheshire and (d) Buckinghamshire; and if he will update the figures provided previously in the answer of 23 July 2007.”

Reply by Ben Bradshaw, Minister of State, Department of Health:

“Nine health communities have to date gone live with the Cerner Millennium system provided through the national programme … In addition two London NHS hospital trusts, the Homerton University Hospital NHS Foundation Trust, and Newham University Hospital Trust, had initiated procurements of the Millennium system before the national programme. To date, some 2.7 million patient records have been entered in the systems currently in use.

“Four further trusts are currently expected to go live with the existing release (release 0) of the Millennium system by the early part of 2008. These are Taunton and Somerset NHS Trust in 2007, and the Royal United Hospital Bath NHS Trust, the Royal West Sussex Hospital Trust, and Barts and the London NHS Trust in 2008. Thereafter, release 1 of the system will form the basis for other implementations across both Local Service Provider areas in 2008-09 and beyond…”

“Details of clinical representation on bodies responsible for overseeing local implementation of NPfIT systems are not held centrally.

“While Ministers have not received any direct representations, we are aware that users in the early deployments expressed some concerns about the system’s management and statutory reporting functionality, and some of its usability features, for example the number of key strokes required for certain functions. Action has been taken to address these concerns and to enhance these areas. This is making a positive impact. Many users who have become familiar with Millennium over time have expressed satisfaction with the system.

“From the inception of the IT programme relevant and experienced clinicians have contributed to the effective identification of requirements, design and testing of all systems wherever across the NHS these are being delivered. This continues to be the case. NHS Connecting for Health has appointed a chief clinical officer to lead the clinical engagement and clinical contribution to the programme.”