Read the full transcript of Pulse's exclusive interview with the GPC chair.
Don't forget you can watch the full-length video of Pulse reporter Gareth Iacobucci's interview with Dr Laurence Buckman by clicking here.
Does the GPC support the proposal for it being compulsory for GPs to join commissioning consortia?
I think most doctors would prefer to be part of something that was universally applicable than find that there was a fast stream and a slow stream.
I think a lot of us would worry about the presence of favourites and people who were less favoured. You could only do that in a situation that's compulsory. What worries everybody about compulsory is 'what am I being compelled to do, if I'm compelled to join a consortium, as much as I'm compelled to live in a particular borough, or drive on the left,' I don't see that as a problem. If I'm compelled to do particular things, than that's more of a problem. So we don't know what we're being compelled to do.
I suspect that most GPs are going to be compelled to be part of a consortium and to engage with it rather than to actually be the managers of it. There will be some who will be the managers, some who will be very senior, but an awful lot of people will merely have to observe the consortium rules. Since they'll be set by themselves and other GPs, I don't see that as anywhere near as much of a problem. I think there is a great risk of individual doctors either being chosen for stardom for chosen for not being wanted for various reasons.
I think its much better that you are part of a consortium and so the consortium can't cherry pick who it has and doesn't have. I think there is a risk of both victimisation and favouritism, and you avoid those by saying that everybody is part of the same structure. We never complained when we were part of the same PCO, so why should it be such a problem to be part of the same consortium, which is after all, another version of a PCO in many ways.
Is it just practice-level responsibility i.e. writing commissioning responsibility into the GMS contract that the GPC is opposed to?
We don't think the contract is the place to put this. We think the best place to put this is in the NHS Act. The reason for that is, if it's in the contract, it would be very difficult to maintain a UK contract in the face of 3 countries not having commissioning in quite the same way.
Whereas if it's in the NHS Act, of which there are already four, one for each country, then it's quite easy to make it just as compulsory without it being part of a contractual obligation. It's a legal obligation. As far as the Secretary of State is concerned, as long as it's somewhere and we don't mind if it's somewhere as long as it doesn't mess up UK contracting.
If a new commissioning DES was introduced, would the GPC want that to be in addition to existing contractual payments?
There are different kinds of contracting. There are the people running the show, clearly that's a management allowance that's not part of a DES or anything else. And there's all the practice level activity, much of which is new and has never been done.
We'll need a lot of time, effort and probably staff hours to support the preparation for commissioning. Then we'll need a lot of effort in carrying out commissioning. And this work has to be funded somehow. It is not part of GMS at the moment, and even if the secretary of state wants it to be part of GMS, it'll have to be funded somehow, because if I'm doing this I'm not seeing patients, therefore I'm going to need support for that either to provide the care for patients or to provide the commissioning activity. That's going to need funding somehow.
A DES is the obvious way of doing it, it doesn't have to be that but that's the most obvious, and we would be encouraging the secretary of state to consider some form of payment structure within the contract to enable doctors to participate in commissioning.
And the NHS Act, would that be the legal enshrinement of what the Government wants?
The sort of statement I expect is 'GPs shall be involved in a commissioning consortium in England.' You only need that sentence and not much else in the NHS Act and that's it, that's the law, GPs can't get out of that. Then you have to create a structure for supporting it that goes inside the contract. But of course if its preparation for commissioning, the other countries also want GPs to commission in different ways, and it's possible to create a generic practice activity DES (there isn't a name for it). A thing related to commissioning, we certainly could look at that.
If, as has been suggested, the GPC proposes that commissioning is done as a DES, how would you get GPs to sign up to it?
You don't have to take up a DES in order to have something required of you. If you're required to take part in commissioning, you don't have to have the DES, you could not do it. In which case, you won't get any money for it, so you'll be doing it for nothing. I think most people would take the opportunity of doing it for something.
So it's their choice. A DES has to remain voluntary. You can't have a compulsory DES, but you don't need it compulsory. If people see that there's a workload involved, and there is a resource they could get for delivering that workload, most people would take the money.
People who decide they don't want to take that, will still have to be part of a commissioning group, and will still have to be involved with commissioning, but they won't received the money. That's their choice.
If the commissioning changes are only implemented in England, could a DES be available to GPs across the UK, so that all GPs had the same menu to choose from?
I can see a way of having an Enhanced Service for improved prescribing, improved referral, better monitoring of what you do, better monitoring of what goes on in hospital. Those things are country independent, and you could see a way of having those things across the whole of the UK that wouldn't be dependent on particular England-forms of commissioning. If the secretary of state doesn't want that, then we'll obviously have to think again. But that's clearly an option we're considering.
At practice level… David Colin-Thome told us a few weeks ago that the DH wanted a portion of practice income tied to reducing inappropriate hospital admissions. Do you think that's appropriate or is that overstepping the line in terms of demand management?
That's the most bizarre idea for demand management. Emergency admissions are performed by hospital doctors, hospital doctors see patients typically in casualty, and then decide to admit them or not. I refer people to hospital in an urgent situation to be seen, not to be admitted. I don't have admitting rights so the emergency admissions rate is almost entirely down to hospital doctors deciding someone's sick enough to be admitted. GPs refer for admission those people that they think are sick.
I understand why the DH wants to reduce emergency admissions, and that's a perfectly reasonable aim, but GPs are not responsible for those. There's always the accusation that if you manage people better, they wouldn't get sick in the first place, and I suppose there might be a few patients that applies to. But I would predict that is a tiny percentage of the total number of people admitted in emergencies.
Are we suggesting that everyone who falls over and breaks a leg, it is somehow the GPs fault because we didn't provide rubber mats on the pavement. What is it we're meant to do? Whilst the problem for the state is obvious, GPs are hardly liable for most of the urgent stuff that goes through hospitals.
Overall, to what extent are you happy with pay mechanisms being attached to budgetary constraint?
I think the wording here is quite critical. If there is a suggestion that if I under refer, under investigate and under prescribe, somehow I will benefit from that financially, I think that is a very dangerous path. Ethically I think that's very doubtful, patients would get the idea that I was somehow under managing them, in order that I would receive a financial benefit. I don't think we want anything to do with that at all.
However, there is no doubt that a consortium that manages to save money will have money to spend on patients in other ways. I think that's absolutely reasonable. But that's not the same thing. Contractual obligation sounds like a suggestion that we get money for it. I don't like that idea. I'm happy to be paid money to do it, but I don't want there to be a direct link between what I save, and what I ultimately receive as payment. I think when you start blurring commissioning and practice budgets that's a very dangerous path and I don't think many GPs would want to go down that.
At consortia level… the Government has outlined its proposal for a quality premium to be funded out of existing resources. What do you understand this to mean?
Existing resources means what I'm paid now.
But quality premium? We've had almost no mention of it in our discussions with departmental officials. So I'm actually not sure what it means. I've read the paragraphs and I can't interpret them. Paying doctors to do better or have proven that they've done better in whatever regard is perfectly reasonable. But since I don't know what is meant by a quality premium, I'm not sure whether it fits into a model of contracting we have now, whether this is some brand new thing, I don't know.
Could it be that although there is no new money, some practices could earn more because of the way the consortia distributes the money, but some would therefore earn less?
I think we wouldn't like that. If we're having a situation where practices are treated equally, at least on a per capita basis, and possibly reflecting on the needs of their population, then I certainly don't think we start with another system that says, 'if you're super efficient and potentially mistreat patients, then somehow you benefit from it. I don't like this idea of practice income and commissioning income having any connection with one another. I think we should steer right away from that.
So far, the Government has refused to rule out the possibility that PCTs debts could transfer to GP consortia. Would the GPC agree to a deal that could see GP consortia inheriting PCTs debts?
I think we don't understand yet precisely what debts we're talking about. There are several kinds of debts. There's the debt that inevitably occurs as a result of managing patients. That debt is something that has a present level, we know what it is, and we can argue whether it should or should not transfer to the new consortia. I think if it did transfer its something we would have to manage and cope with and I think the way the health service works, I don't have a huge problem with that.
Where I do have a problem, is where for example the body of GPs opposed things and are now having them visited on us, like Darzi centres, PFI schemes that the vast majority opposed, and we're now going to be faced with that debt, well I don't see why we should be.
Even more so, there is a whole series of things that were brought in by the previous Government that this Government is now reversing, and we're going to be saddled with that debt too? I don't think so.
So there are those debts that we would want to see played off the field. The final bit of debt that would worry people enormously are the brokerage arrangements, where money is moved from PCTs that weren't in deficit to those who were in order to stop the deficit PCTs from being in such a bad position. Now, I don't see why my patients, my practices, my area should suffer because someone else wasn't very good at managing theirs.
Why should we have brokerage arrangements? That's not the same as stop loss insurance, risk pooling, management of risk, contingency funding, all of those things are quite different. Here we are talking about areas not in debt and making them in debt.
Unless the Government can sort out all of those different kinds of debt, I think that GPs will not want to be involved as much as they would be if they thought the debts were written off, moved around, taken off somewhere else. The debts won't go away, we can't pretend they're not there. But if they are part of the consortia problem, and you're told you've got to sort out all the debts that have accumulated before, then I think GPs will say, hold on, I'm a GP, I commission services, that's not the same as how I solve millions of pounds worth of debt, much of it politically motivated and historic. How on earth can we be involved in that?
And at the beginning of this consultation period, we asked all those questions. We're now coming to the end and we still have not had answers to those questions. I'm hoping that when the Government published its response, we'll get an idea if how debt will be handled because it's one of the main topics that GPs ask me.
The policy will not get off the ground if debts are not sorted out. They are the biggest issue. The treasury has to sort this out for itself. You can't ask GPs to participate in something when they start from a position of very serious debt, some of it almost unachievable. It may be that there will have to be special measures in some parts of the country where primary care organisations are so indebted that they cannot function.
You've advised GPs not to rush headlong into the changes until the plans are more fully developed. From reports you're hearing on the ground, is this advice being heeded by a) GPs, b) PCTs.
Largely, yes to both, but not completely.
We are in the middle of a consultation process. What on earth are people doing getting legal advice on setting up consortia? We know nothing about that. What are people doing spending money on lawyers, why are some PCTs - very few actually- telling practices how they will configure, who will run them. Which practises have been chosen to lead - how on earth can they do this?
We don't know anything about the structures that will be employed. So I think we have to say, at this stage, we should be talking to people, finding out which hospital colleagues will want to be involved, getting involved across LMCs and local negotiating committees in hospitals, talking to each other, getting managers to talk to each other both at PCT and hospital level. Asking what configurations will work. Don't start going to lawyers, don't start listening to PCT saying 'you must do it this way or else'.
At this stage, GPs should be talking to each other - can we work together - because invariably there will be people that say they can't work together. But you might have to, so you're going to have to think of structures that you can work with. How you can do that, NOT let's start creating an organisation, particularly if that bears an amazing resemblance to the PCT that was there before. That's what a lot of the rushed structures are going to look like.
This is a different world, and you don't need the same structures. You do need some of the management skills, in fact quite a lot of them. But you want to encourage the local managers to stick around, some of them are really good and should be retained. You also want to make sure that those who have caused mischief in the past aren't able to create problems now. You particularly want to get an endeavour where the present management structure and the present GPs are working together as one body with other contractors, with other unions, with other professions and across the primary secondary divide. This is a talking time, not a business set up time.
Do you have any examples of PCTs who have not been co-operative with GPs since the changes were announced?
I'm not going to name names, but there are a number of PCTs who seem to have taken some very eccentric decisions to tell their GPs how they will be in their consortia. These PCTs need to be told to back off a bit.
And there are a few GPs who have been very much involved in commissioning up til now, and obviously we need their talents and expertise, but they are not, as PBC leads or PBC activists, suddenly going to be running the consortium.
A consortium is a completely different structure, involving a lot of other people, many of whom will not be enthusiasts, and it may well be that the PBC groups do not have the kind of democratic legitimacy that they are going to need in the new world. That's not to decry PBC which I am very supportive of, but it is a different world.
It has been suggested that the Government could use the patient survey as a bargaining chip with the GPC during negotiations. How big a priority is it for the GPC to get rid of those patient survey questions attached to QOF?
At this stage nothing is high or low on the agenda. It most definitely is on the agenda. It's something many GPs would like to see the back of.
We won't care who asks a survey of whom, what we do care is that the current survey doesn't ask patients, it asks the public, and we don't think it is as good as the surveys we had before. We think they should be reintroduced, and we certainly don't like PE7 and PE8 being visited upon GPs. We think that's turned out to be a big mistake, we will certainly be asking the Government to get rid of it.
The present Government are nowhere near as enthusiastic for it as the previous Government, although I suspect that's more to do with costs rather than because they don't like the survey itself.
Has the GPC had any indications from Government that the extended hours DES will be removed next year? If it were to go, would the GPC want that money to be re-allocated, and if so, how?
We're talking to the Government about access in its broadest forms and what we can do to make access better for patients without driving practices mad.
The extended access material is obviously part of that. If anything is removed, we always want it back, and this is no exception. We'd obviously have to negotiate with the Government to see what we could do with the extended access money, the Government is not going to want to see, nor would it be politically acceptable for them to have extended access being abolished, because that looks very strange to the public, after the Government spent years forcing GPs to do it.
I don't think it has shown to be great value for money and I think we would will to look very critically at it. I think many GPs would like to see it go but I think it would be difficult for us too, as doctors, to argue that we want patients to have worse access. The question is whether extended access is better access or not.
Could it be a situation where there would be more flexibility?
Obviously that's what we would like, because that's what we campaigning for before the start of all of this. Whether the Government will listen to that I don't know.
Does the GPC support the decision to scrap NHS Direct, and how would you like the service to develop under the new 111 number?
I can't suggest that we're sorry that NHS Direct is no more. We always believed it was a waste of money, it was a service which was popular and was presented as such but actually has achieved very little for the NHS and I think the money could have been spent much more widely in a variety of other ways.
NHS Direct of course is not just an answering service, it also provides triage, and the triage, in our view, has delayed care rather than improved it.
They also have an information service that is partly online and a variety of other bits and pieces that have added on to the service. I think the information bit of it should survive and be encouraged, because enabling people to get more access to information is a good thing.
The 111 service is going to be primarily a signposting service, like when you phone 999. You are now going to be offered a series of alternatives by a lay person who is not providing the service, just like when you talk to a 999 operator. They are signposting you, not offering you an ambulance or whatever. You then talk to them, the experts in the service. 111 will do the same thing, providing information for non-urgent matters and enabling you to get access to the service. Much better that patients will talk to a GP out-of-hours service or be told to go to hospital rather than be triaged on the spot.
Triage should be by doctors and nurses, not by lay people, not by using algorithms that are prone to suspect error. This is an opportunity. 111 I think will be a much better service or at least, it sounds like it would be. There are three pilots going on at the moment, they will have to report and then I think we will have a better idea of what comes next.
Back in February you outlined your lines in the sand on GP out-of-hours in letter. Are you confident that these will hold firm and not be breached?
Yes I remain confident.
The secretary of state has reiterated more than once that he is not intending GPs to actually go back to working out-of-hours, unless they choose to work for an out-of-hours service, or they provide it themselves. But the vast majority of GPs will go through something which looks remarkably like the co-op they had before, and will be responsible for commissioning the service.
That's part of the commissioning consortium anyway, so it'll just be, the out-of-hours will also be for GP commissioners, and I imagine will be much better for it. And certainly, we will do our best to keep out doctors who shouldn't be working for the service, to make sure the service is fit for purpose, doesn't overwork people and does pay people properly, isn't paired down to the last penny to save money. You can't have a service operating in out-of-hours that is so constricted that it can't actually deliver.
Some GPs will have been concerned about the funding. Is that something that is being reflected in the talks you're having with the Government?
Once you're commissioning, then it's just part of that. It's not 'the out-of-hours money is not enough therefore…', the out-of-hours money spent by PCTs may not have been enough, but well, we are going to have consortia now, and the consortia will decide how much money is spent, and it can take money from other bits of the service. It isn't restrained to one lump. If it were restrained, then I could understand why people are worried. But it's not, there's no suggestion it should be.
Does the GPC expect the changes to practice boundaries to be negotiated at the same time as the commissioning changes, or does it anticipate that the boundaries proposals may come later?
We don't know.
There is an internal inconsistency between having consortia scattered across the country. And there is a suggestion that the consortia not necessarily be purely geographical.
So you could have a mosaic of consortia, so I could be in a consortium and my next door neighbouring practice might be in a different consortium. I have to say, I think that's unlikely, but if that were the case, that any GP could be in any consortium anywhere unfettered, then if any patient could be anywhere as well, who is buying care for whom?
The argument was if you lived somewhere else, it would be the home consortium that purchased care. What if there is no such thing as home as far as consortium is concerned? Who then purchases care for you. And what happens if you consortium where you live, or work has taken a contrary view to another consortium about purchasing care or drugs for example. What is available for you in hospital?
Do you just change consortium until you get the GP you want what happens if one consortium suddenly starts making Viagra available. Will every patient who wants it start flocking to that GP or that consortium?
There are so many questions you ask once you say there's no such thing as home, as boundary. I understand what the secretary of state is saying, but I'm sure it has been thought through adequately. So when we see the result of the consultation (on boundaries) we will then have a lot more questions I guess.
If there is a Government insistence that there will be no such things as boundaries, ok, we and the Government will have to live with the consequences. I'm not sure it will be a better service for patients, there is a point where competition doesn't work and I think we're fairly close to that point now. Competition between neighbouring practices is something we can accept and are not so worried by. Competition between any practice anywhere seems futile. How will that help the vast mass of patients, who don't change GP?
Can the boundaries proposal and the commissioning plans be pursued alongside each other, or is there too much tension between what they are both looking to achieve?
The tension between them is the very reason why they have to be negotiated together, because you have to solve that problem of conflicts between the two. They are internally conflicted so we clearly will be talking about it with Government officials and the Secretary of State. If that's what we wants then ok, but it's going to look very odd alongside commissioning.
There is some evidence that PCTs are tightening up their criteria for funding approval for procedures like hip and knee replacements. Is this a problem that has been raised with the GPC in feedback from LMCs?
PCTs that have contracts with private organisations to provide hip surgery have for a long time had very restrictive criteria given to them by the private providers. So much so that you've got to be an Olympic athlete to get your hip replaced in some places. I think those criteria are stupid, and all that will happen of course is in the commissioning world, GPs won't commission from services that put that level of restriction on referral.
If we are saying that you have to be at a particular weight, not smoking status, alcohol status, fitness, and other health issues in order to get hip or knee replacements, that's good commissioning and I don't see that as a difficulty. What it means is that there are several people who presently are offered treatment for various illnesses who may not be offered treatment in the new world.
If there's evidence to show that that's actually better for them, that the treatment is worse for them, then that's not bad care, that's good care. Where restrictions are put in merely to save money, I don't think any of us would accept that. But where there is clinical evidence of harm from pursuing particular treatment or route, then we have to listen to that. You have to understand the motives of why people get things done.
What have been your initial impressions of the coalition Government after the first 100 days?
I think the first 100 days have been interesting. They've hit the ground running and have wanted to do all sorts of things, some of which weren't in their manifestos of course. And we're in a consultation phony war period where you don't know what anything's about. I can't really judge how it will be when they've finished consulting. Then we'll go into a long period of negotiation when who knows what will come out of that. Inevitably, negotiation ends up somewhere different from where it went in, and I imagine GPs will be very nervous about all of that.
The first 100 days haven't given me enough information to know what I think. We have had many meetings with Mr Lansley in his previous guise, now he's the Secretary of State we're still in contact but in a different way.
I think it's too early to judge the Government on its health plans. It's very nice that they're supporting the NHS by saying the finance won't change. It's not very nice though that they've told the DDRB that there will be no pay rise for GPs, and they've taken away the remit of the DDRB. We think that's quite wrong, we think the DDRB should have offered us due process and that we should know what the DDRB thinks we're worth.
The Government has said there will be efficiencies. I'm not sure how you can impose efficiencies on tiny businesses, where uniquely GPs will bear the brunt of those policy, whereas hospital colleagues faced with efficiencies don't have personal efficiencies, the efficiencies are taken from the provider for whom they work. And we think that's unfair.
At this stage I don't think we can judge what the Government are up to. We'll have to see where negotiations get us.
Dr Laurence Buckman
