To respond to the White Paper, 'Our Health, Our Care, Our Say', GPs in England will need to take some hard-headed decisions. We are entering a new world where we will be actively competing for patients and where detailed public knowledge of practices and other healthcare providers will empower patients to register with those deemed most responsive to their needs.
The government sees closed or open lists, practice boundaries, patient services offered and opening hours as the key levers for change.
Expand the list
High-quality achievement on a broad front, for example, via the quality framework, involvement in practice-based commissioning (PBC) and the provision of user-friendly services, will become a prerequisite for gaining the support of PCTs.
Development funding and access to capital will be focused primarily towards expanding practices. So GPs cannot afford to sit back and deliver the same services as they do now. Not developing new strategies, particularly if you are in the 50 per cent of England considered under-doctored, risks commercial sector entry in direct competition with practices.
If you are in the vicinity of practices that appear to regard growth and acquisition as a prelude to selling out to the private sector, again, consider your options carefully.
When you look at the practice boundary, your options will be influenced by whether you are in a rural or an urban area. Relevant factors will include whether you share practice areas with nearby partnerships, if you can cope with an expanding list, or if you can actually afford not to expand.
Could you 'share' the community staff with nearby practices, to allow you and them to open boundaries, or would this be a danger to high-quality continuity of care? Other pertinent questions include what difference it might make if you were not responsible for home visits outside a designated area, but the White Paper says nothing on this. There are many pros and cons regarding boundaries (see box, page 44).
The issue of open and closed lists has been a bete noire for the government since before the GMS contract.
Taking on patients
At present, practices can declare themselves 'open but full', but this loophole is to be closed. Closing your list carries the penalties of letting in competitors and losing additional or enhanced services and other growth monies. Yet to open your list can be daunting.
A small practice might need to enlarge its team and increase its skill mix. Could a nurse, a healthcare assistant, or another trained staff member take over some current GP tasks?
Collaborating with local practices by sharing management, back-room, or other clinical functions should also be explored, as should negotiating with the PCT if lack of space is proving to be an obstacle.
Then there is the matter of access to the proposed expanding practice allowances for partnerships that are growing significantly and extending their opening hours. But it is likely that small practices with full lists, often clustered in areas of multiple deprivation and under the greatest pressure, need to make the toughest changes to keep their 'market share'.
Practices aspiring to put in a bid to provide services in under-doctored areas will have to show they are of 'adequate size to fill these gaps in provision' and compete in national procurement waves.
Successful bidding will entail proving themselves against a broad set of measures, such as patient surveys, open lists, responsive services, convenient opening hours, no boundaries (or 'broadly defined' ones) and high quality points achievement. The commercial sector is exempted from meeting this last requirement.
The tendering process will include a pre-qualification or shortlisting stage. The hurdles have been set high.
The DoH is clearly upset that the GMS contract changes in out-of-hours provision have led to reduced later evening and Saturday opening.
Unsurprisingly, 55 per cent of patients in the government's listening exercise said later evening opening would be a big improvement, with 59 per cent wanting a return to Saturday opening. These figures were surpassed only by the percentage wanting access to a GP within 24 hours. Future patient surveys, to be conducted independently, will ask explicitly about whether practices offer morning, evening, or Saturday appointments. Those with good results will be rewarded; there will be 'information available on practices not complying'.
The White Paper talks of not opening for longer, but perhaps dropping some morning or afternoon surgeries. But the emphasis is on more responsive and convenient opening, with fast access and booking ahead. The subtext is clearly to extend your hours.
Round the clock
The document cites as examples one out-of-hours provider that is extending to offer round-the-clock services and two practices that have restructured their staff working hours and taken on additional staff to open on Saturdays.
New providers will be expected to offer extended opening times.
Check whether your PCT can be persuaded to offer a local enhanced service for extended opening hours. Or how about using PBC to provide a range of services to suit working people, such as contraception, GUM, minor injury, insurance medicals, travel vaccinations and chronic disease monitoring, in the evenings or on Saturdays?
By doing this, you could make your premises begin to work harder for you and bring in additional revenue to reduce marginal overheads. But this kind of strategy will require planning, careful negotiation with staff over altered working practices and prior negotiation of new revenue streams.
To me, and I am usually an optimist, there seem to be more threats than opportunities in the White Paper.
But it is for GPs to use our ingenuity to make sensible modifications that will benefit patient care and sustain our practices in the future.
- Dr Phil Yates is a GP in Bristol
PRACTICE AREAS: EXPAND OR LIMIT?
TIGHT BOUNDARIES LOOSE BOUNDARIES
Controlled list size Less churn of the list, with greater
stability of practice population
Less home visiting All local family members can register
Short travel times Continuity over time
Easy for attached staff More potential for offering community-wide
Less liable to
patient allocations Riding the current wave
Might be list
size shrinkage Not in keeping with government aims. More
home visiting for doctors and other staff
High churn rate equals
more work Reduced geographical identification