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Oldham: Tackle problem GPs to improve primary care in poor areas

Under-resourced primary care in poor areas could be improved by tackling practices currently providing a bad service, a senior GP adviser has said.

Sir John Oldham, national clinical lead for the Department of Health’s quality, innovation, productivity and prevention programme, said commissioners should tackle a minority of practices that were not providing good value for money.

Sir John chaired an international review of primary care held for the Global Health Policy Summit held in London last week. The review found GP services in many countries required more investment. Speaking to HSJ after the summit Sir John said in the UK there were not enough good primary care services in many poorer areas.

He acknowledged additional funding was unlikely to be available but said the NHS Commissioning Board – which will contract primary care services from next year – and clinical commissioning groups could improve access and release resources by together identifying and tackling poor providers.

Sir John said: “This doesn’t need additional investment but it needs looking at what return we get on existing investment.

“We need to make sure provision in less well-off areas is as good as in well-off areas. Most of us recognise the minority [of poor GPs] need tackling, not least to make sure patients receive a good level of care, but also to make sure they are contributing to CCGs’ commissioning aims.”

The government previously promised national incentives to attract GPs to poor areas, but this appears to be on hold. A commitment to “develop incentives to improve access to primary care in disadvantaged areas” - which was also in the 2010 coalition Programme for Government - was dropped from the DH’s monthly reform timetable in June 2011.

Sources involved in primary care policy development said increases for poor areas would have to come from reductions elsewhere, which the British Medical Association would not accept.

The DH and commissioning board face calls to overhaul the GP contract from some senior commissioners, who believe it is currently too difficult to change funding and performance manage poor providers. But changes to the GP contract for 2013-14 are expected to be minor and HSJ understands the board has no clear plans for major shifts the following year.

One senior commissioning source close to policy development said: “It is absolutely fundamental we do something about this.” A PCT cluster chief executive said: “If we push this into the long grass because it is politically too difficult, it will be really unhelpful.”

Readers' comments (6)

  • An anecdote to shock you all: accompanied a friend to a CENTRAL MANCHESTER GP visit only to witness GP drinking from a glass of whisky during the 'consultation'. When he was challenged, he threw us out. The matter is being dealt with. I couldn't agree more with the sentiment above "It is absolutely fundamental we do something about this".

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  • They could start with the large proportion of GPs who are below average. I heard the other day that this is as high as 50% - one in two GPs! Shocking. Then, they could make sure that the lowest 25% perform as well as the best 10% currently do. Maybe release a slide pack which claims that primary care could save billions of pounds over the next five years...

    Seriously, though, this looks like action for its own sake. It's pretty obvious that primary care in poor areas has to cope with a disproportionate set of problems, because of the massive effect that poverty has on health.

    More money in recognition of this is the sensible answer, but this doesn't appear feasible. Now, rather than do nothing, they'll go after the 'underperforming' GPs.

    If this means identifying which GPs are outliers even after adjusting for relevant factors such as local deprivation - good. This should be done anyway, by every CCG, and I'd be very surprised if these outliers are concentrated solely in poorer areas.

    If, however, it's a case of pointing at a GP in Toxteth and asking them why their 'outcomes' are so different from one in Windsor, that's a different matter entirely.

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  • Two points

    Cassander you have clearly never noticed that people in posh areas tend to complain more, get listened to more and change practice if their issues are not addressed. This tends to drive up the quality of GPs in posh areas (note the word tends).

    Two years ago the inner city PCT near where I work had finally managed to get approval (including LMC approval!) for a serious quality and performance management system. This included opportunity to improve followed, if necessary by contract sanctions. They had started the first round of visits, under-performing GPs had been given a deadline to produce a development and improvement plan.

    The secretary of State announced that we were all useless and were going to be sacked. GPs would run it all and managers had better suck up to GPs if they wanted to keep their jobs. Result - the good people left, the performance frame work was dropped, the GPs identified as underperforming have done nothing about the quality of their practice.

    It will take another two years for the LOAs to get themselves sorted and strart performance managing those practices again.

    If improving general Practice is so important, what a shame we will have lost 4 years of making it happen

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  • Actually that anecdote doesn't shock me as much as I thought - my mother reminded me that as a child when we went to our GP he was often several sheets to the wind. Alcoholism and substance misuse is surprisingly common. After I read the impact assessment of the Bill I thought it was about reforming primary care but as previous posters have said GPs have just torn my PCT apart with no sensible plan or alternative to QIPP other than childish "not doing it, I'm in charge now, HAH" and most of us have left. Let them play, the trusts practically do all the commissioning and re-design anyway.

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  • On the contrary, Anon @ 14:13, I'm quite aware of how sharp-elbowed affluent patients are more likely to get what they want. Whilst I'd expect this to drive up the patient satisfaction measures of GP 'quality', I'm not so sure that this will improve clinical outcome indicators - what the patient wants and what is clinically appropriate will not always overlap.

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  • Harry Longman

    Point one: please stand up for your views. I'm fed up responding to "anonymous".
    Point two: demands for GPs do differ a great deal depending on age and deprivation. Some of this is already reflected in capitation formulae. Whether it's the right amount is an endless debate, but should be informed by the best evidence.
    But point 3, a vision of hope. We know a number of practices in the Patient Access movement are providing a superlative level of access and clinical quality in very deprived areas, and have been able to take this on despite the pressures. It's the system - the practice system, which can be so quickly and so simply transformed.

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