Medicopolitical digestBMJ 1994; 309 doi: http://dx.doi.org/10.1136/bmj.309.6966.1444 (Published 26 November 1994) Cite this as: BMJ 1994;309:1444
- Linda Beecham,
- Jennifer Dixon,
- Naomi J Fulop
BMA issues guidance on removing patients from lists
The General Medical Services Committee is recommending to general practitioners that they should consider writing to patients when they remove patients from the practice list giving a brief outline of the reason. If they are in doubt about the wording the committee suggests they discuss it with their partners or the secretary of the local medical committee. It was also suggested at last week's meeting of the committee that doctors should consider telling patients if they are misusing the service and give them an opportunity to discuss the situation. This might lead to a change of behaviour and obviate the need to remove them from the list.
General practitioners have a right to ask that patients should be removed and there is no contractual obligation to give a reason. They must tell the family health services authority or the health board, who notifies the patient. Similarly, patients have a right to change their doctor. They do not have to give a reason or even notify the doctor.
Many of the removals occur because the patients have moved away from the practice area or have died. But there has been increased publicity recently about patients who have claimed that they do not know why they have been removed while some patients believe that they have been removed because of their clinical condition or because their care was too costly.
SIZE OF PROBLEM
The size of the problem has varied according to the source of the information. There are 34000 general practitioners in Britain and approximately 250 million consultations each year. The 1994 annual report of the Association of Community Health Councils in England and Wales claimed that about 30000 patients a year were being removed from lists, but the association admits that it does not know how many of the removals were voluntary. A recent parliamentary written answer gave a figure of 78000 for England but this includes patients who had moved away or died.
Dr Eric Rose, secretary of Buckinghamshire Local Medical Committee, who helped to draft the guidance, said that the patients' organisations would be satisfied if doctors gave reasons for removing patients.
The guidance points out that in the majority of cases the sole criterion will be the irretrievable breakdown of the relationship between doctor and patient. This may happen when there has been a scurrilous attack or unfounded allegation. The Association of Community Health Councils is concerned that patients may be removed from the list for making a complaint. The GMSC believes, however, that a complaint made in a reasonable manner may sometimes help to improve services.
Occasionally patients are violent or threatening, and under changes to the terms of service which came into effect in April doctors can request their immediate removal. In these cases the doctor must inform the police and notify the FHSA or health board and the patient in writing or via the police. The GMSC believes that doctors will use their clinical judgment to determine those rare cases where a patient's violent behaviour results from a medical condition and does not warrant removal from the list.
The guidance says that there are no grounds for removing patients from practice lists because their treatment is too costly. Practices which find that their fundholding or drug budgets are being stretched by an individual patient or group of patients should seek the help of their local medical committee to negotiate improved local funding arrangements.
MPs warned about local pay deals
The BMA has warned all members of parliament that local pay deals will be “a further nail in the coffin of the idea of a NHS in which doctors work for the service as a whole and not for individual competing businesses.”
The chairman of council's letter to MPs followed reports that the government was urging the doctors' and dentists' review body not to recommend a national pay rise for doctors but to let NHS trusts make deals locally. Dr Sandy Macara was also responding to a briefing document on locally negotiated pay which the minister for health, Mr Gerald Malone, sent to MPs last month (5 November, p 1236).
The letter points out that, although the government was anxious to drop the term performance related pay, local pay posed just as big a threat. Dr Macara tells MPs that the public is worried about the idea of doctors having to follow managerial objectives based on the trust's business needs rather than deciding priorities according to patients' needs. The public fears there will be a greater emphasis on numbers of patients treated and less on the care of individual patients.
The BMA believes that local pay deals will cause variations in doctors' pay by specialty and by geographical location. Some trusts will not be able to afford pay increases while others may reward only those specialties which bring in most business. There will be recruitment difficulties in some specialties and some trusts and particular problems for junior doctors who move at frequent intervals during their training.
The BMA points out that, although the health minister quoted from the 1994 review body report, he omitted some important comments—for example, “We urge the Departments to take note of the professions' concern that in developing performance pay schemes, regard should be paid to the quality of the work provided.” The review body's role, the BMA tells MPs, is to assess the appropriate pay levels for doctors on the basis of agreements about terms and conditions that have been reached between the profession and the Department of Health. No agreement has yet been reached and yet the government has asked the review body to recommend no increase for this year on the assumption that local pay arrangements will be in place.
“We remain determined,” Dr Macara says, “to persuade the government that insistence on local pay will be an expensive distraction to NHS trusts, a divisive force in the NHS, and a threat to the integrity of patient care.”
Government decides on “acquired rights” for GPs
When the European Community directive on specific training in general practice comes into effect on 1 January 1995 doctors working in general practice have to be either vocationally trained or have an acquired right to practise (29 October, p 1163).
The NHS Executive has now confirmed that doctors eligible to work as general practice principals will be protected when the directive is implemented. Other doctors who have worked as an assistant (including on the Doctors Retainer Scheme) or as a deputy (including as a locum) on either 10 separate days in the four years or 40 separate days in the 10 years ending on 31 December will have an acquired right to work in either of these capacities but not as a principal.
This will largely preserve the status quo for many doctors. Any other doctor will have to be vocationally trained. The executive says, “We consider that the arrangements for limited acquired rights strike a fair balance between the interests of individual doctors practising now, and the need to ensure quality of care.”
The General Medical Services Committee has asked for clarification about the evidence that assistants and deputies will be required to provide to qualify for acquired rights. It is concerned that doctors who have worked sporadically as deputies may not have sufficient evidence. The committee has also asked whether doctors who have not been vocationally trained will be able to take part in the retainer scheme. They may be able to work in hospitals but not in general practice.
The committee will take up the matter with the general practice subcommittee of the European Commission's Advisory Committee on Medical Training and with the committee of European public health officials.
NHS Executive defends measles campaign
General practitioners have been critical of the current measles immunisation campaign among schoolchildren, particularly about the delay in providing information. But the NHS Executive believes that it has provided very full briefing to doctors. In a letter to the chairman of the General Medical Services Committee, a senior medical officer at the executive, Dr A Cameron, points out that the chief medical officer has written three times to general practitioners and distributed a memorandum Immunisation Against Infectious Diseases. The health information service and regional freephone helplines have received this briefing material but Dr Cameron admits that there are some instances where the only proper course is to refer inquiring parents to their general practitioners because only they will have the necessary details of the children's medical history. The GMSC had criticised the campaign's advertising and has been given an assurance that the NHS Executive would carry out a full evaluation.
Unions criticise blood authority's proposals
Plans to reorganise the national blood service have been criticised by joint staff unions of the National Blood Authority. In August the authority announced a restructuring of the service in England, including the closure of one third of the 15 regional blood transfusion centres (10 September, p 630). The unions fear that the proposals, designed to cut £10m from the authority's £135m budget, will undermine the effectiveness of the service.
In A Formula for Failure: Our Blood Services Under Threat the unions accuse the authority of going against good practice, reaching misleading conclusions unsubstantiated by facts, and failing to offer any explanation for why the centres were chosen for closure. The union secretary, Mr Kevin Green, said that the plans imposed a market mechanism on collecting and supplying blood which would alienate donors, put patients at risk, and end in donated blood or blood products being sold for cash.
Applicants to general practice fall
The number of applicants to general practice has fallen according to a survey by the Medical Practices Committee but there are still enough of quality for good appointments to be made. In the first survey it had conducted the committee contacted 96 practices in random urban and rural family health services authorities in England and Wales. Sixty practices had taken an additional or replacement partner in the previous six months and 36 had taken a partner in the past five years. There was an 89% response rate.
The responses showed that, although doctors were being recruited throughout England and Wales, there was a core of cases where recruitment was difficult in deprived urban areas. About 26% of the filled posts were not advertised and appointees came from local vocational training schemes, by local recommendation, or from locums.
The survey highlighted different working patterns for women. More worked part time and did not want to provide out of hours cover or become involved in practice premises and development.
Trusts earn interest on cash flow
NHS trusts are earning substantial amounts by investing their cash turnover and keeping the interest. In 1992-3 the 156 trusts then in existence earned £42m in this way, according to a report last week by the National Audit Office (NAO). There are now 419 trusts.
The NAO commends the NHS Executive for providing a firm foundation on which trusts can build their investment management policies. The executive specifies the categories of investments that trusts can make and provides guidance which takes account of the lessons learnt from the collapse of the Bank of Credit and Commerce International, in which local authorities lost £82m.
The cash which trusts can invest on a short term basis is derived from their temporary surplus in the period between the receipt of contract income from health authorities in the middle of each month and the payment of salaries and bills at the end of the month. The NAO investigated a sample of 10 trusts.
Almost all investments were with banks or building societies. One trust had invested with a local authority and another with a discount house. The average interest rates obtained ranged from 4.2% to 5.6%. All the trusts visited operated adequate financial controls.
The NAO says that trusts should consider adopting a wider investment approach to maximise investment income, while monitoring the credit risks involved and setting limits on the amount to be invested with each organisation.
Health secretary says reforms are “virtually complete”
Launching the 1993-4 NHS Annual Report, the secretary of state for health said that the NHS reforms were now virtually complete and patients would increasingly reap the benefits. This meant that the NHS and those who worked in it could look beyond organisational change and concentrate on the delivery of services to patients.
Mrs Virginia Bottomley said that in 1993-4 there had been a 5% growth in the number of patients treated in NHS hospitals, taking the total to over eight million; the number of patients waiting over 18 months for hospital treatment fell to 3394 and all would be treated this year; there had been a 34% fall in the number of hard pressed junior hospital posts contracted for over 72 hours a week; and over 90% of family doctors were meeting targets for immunising children.
The NHS's chief executive, Mr Alan Langlands, welcomed the report but said that the NHS still had a great deal to do and he cited the need to improve services for mentally ill people, to reduce the length of time spent waiting for an outpatient appointment, and to reduce the burden of bureaucracy on general practitioners and other frontline staff.
But an officer of the health service union, UNISON Mr Bob Abberley, said that Mrs Bottomley was living in wonderland if she believed the rosy picture. He said that beds and casualty units were closing, the number of nurses was falling, and hospital services were being cut back.
Labour's health policy
Labour's last thoughts on health policy appeared in Health 2000.1
Several areas were discussed including public health, primary care, community care, and mental health. The document also included a pledge “to consult on our clear commitment to abolish GP fundholding and the operation of the internal market.”
As part of this consultation process a conference was held earlier this month. This was attended by members of the new shadow team headed by Margaret Beckett. The aim was to listen to party representatives, members of health unions, health care workers, and other interested individuals. Contributions from conference participants and others, such as the Commission on Social Justice,2 will be used to shape a second health policy document. This will be published next spring and debated at the Labour party's annual conference later in the year.
The principles guiding a future Labour policy will be equity, efficiency, and patient choice. The growing disparity in economic and health experience between rich and poor and between young and old was highlighted and calls were made for Labour's economic policy to be central to health policy. As Professor Richard Madeley, professor of public health at the University of Nottingham, put it, “A deregulated society is a divided society is an unhealthy society.”
IMPACT OF REFORMS
There was a lot of criticism about the impact of the NHS reforms. Speakers gave examples of decreasing cooperation between trusts, the duplication of services, two tierism generated by general practitioner fundholding, and the mounting bureaucracy to maintain the purchaser and provider split. Less predictably, the brave few who gave examples of benefits resulting from the reforms also received applause.
The meeting discussed solutions for the skewing of board membership of trusts and health authorities towards those with affiliations to the Conservative party. These ranged from directly electing board members to coopting representatives of patients or the community; no consensus emerged. On the future relationship between health authorities and local authorities, the most prevalent view was that the two organisations should remain separate but ollaborate more on areas of obvious mutual interest such as housing, transport, and community care.
Speakers recognised the relevance of some current policies: knowing more about the effectiveness of treatments; the importance of efficiency; using information to compare the quality of care between hospitals; and a stronger focus on prevention and primary care. There were calls to reinstate free eye tests and dental checks, but few calls for more money for health care.
Turning the clock back to before the reforms is acknowledged as not an option and this will be the biggest challenge for the Labour party. It will have to deal with a continuing upward pressure on Britain's health bill; the legacy of gross inequities in health experience and needs of different social groups; challenges of new technology; the interests of powerful groups of health professionals; and an increasingly informed public. With demands elsewhere on public spending, a significant injection of funds into the is unlikely.
The challenge for Labour will be to show that it is different, but it should resist the temptation to make radical change too quickly. It should draw up a balance sheet showing the pros and cons of current policies including those which the party finds least palatable.
—JENNIFER DIXON is an honorary lecturer and NAOMI J FULOP is a research fellow in the Health Services Research Unit, London School of Hygiene and Tropical Medicine, London
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