The Future Forum’s second bout of listening

Education and training

The Future Forum’s report on education and training has some important recommendations on the structure and duration of training for junior doctors.2 Firstly, the forum recommended that the training pathway should be made more flexible to allow doctors to move between specialties more easily and also allow the workforce to be more responsive to changes in the needs of the population. The government, in its long awaited response to the white paper Equity and Excellence: Developing the Healthcare Workforce,3 suggests that a more flexible model would encompass higher education institutions, training in the community as well as in acute settings, and better supervision, particularly at nights and weekends. Secondly, the Future Forum recommended that the length of general practitioner (GP) training should be extended from the current three years, although the government warned that any increase in the length of training should be affordable and sustainable financially as well as “the right thing to do educationally and in the interests of patients.”

The Future Forum also set out some proposals to make sure that fully trained doctors continue to receive education and training. Employers should ensure that a minimum proportion of staff have development plans, and local education and training boards should allocate a minimum percentage of their funding to continuing professional development. The proposals for minimum funding for continuing professional development could be a problem, given how stretched education and training funding is already, said Tom Dolphin, chairman of the BMA’s Junior Doctors Committee. “There’s not a big pot of money somewhere that is not being used or is being used sloppily,” he said. “Deaneries are incredibly tight organisations, they’re very lean, there’s not any fat to cut. All that really leaves to cut to allow for that CPD [continuing professional development] percentage is going to be the training posts.”

The Future Forum’s report on education and training spelt out some of the detail on the proposed new system for medical education and training. Through an authorisation process, local education and training boards will be required to demonstrate robust and transparent governance and will need to prove to the NHS Commissioning Board how the functions of deaneries will be continued. The BMA in particular was concerned that details on the structure and governance of local education and training boards were not forthcoming and has welcomed the “clear focus” of the Future Forum on identifying and dealing with competing interests in the new set up.

Health Education England, the new organisation charged with providing national leadership and strategic oversight of the healthcare workforce, will encourage scrutiny of the quality of education and training provided by employers; and those organisations that provide top notch education and training will be rewarded with a quality premium. “It’s interesting that [the Future Forum] went for the quality premium approach rather than something punitive,” said Dr Dolphin. “There should also be a range of penalties for employers who don’t manage to provide decent training, where the training’s not so bad that you would remove trainees but still not very good.” The reward received by the education provider, the hospital, or the general practice should ideally be ploughed back into education rather than spent on services, he suggested.

Public health

The Future Forum made three key recommendations on public health,4 the first being the proposal that healthcare professionals should “make every contact count” by aiming in every contact with a patient to offer advice and support on four lifestyle risk factors: diet, physical activity, alcohol, and tobacco. Despite being broadly supportive of this plan, Lindsey Davies, president of the Faculty of Public Health, has warned that doctors should beware of being seen to badger patients on the same old issues. “We don’t want healthcare professionals to be telling off ill people,” she says. “Professionals do need to think holistically about the needs of the person in front of them and taking appropriate opportunities to help them get healthier—and stay that way.”

The Future Forum’s second proposal was to improve the health and wellbeing of the NHS workforce. Occupational health in particular should be a focus, says Richard Jarvis, co-chairman of the BMA’s Public Health Medicine Committee. “In general doctors are healthier than the average person, but there are a few things that they trip up on,” he says. “It’s very important that these things are recognised and that appropriate healthcare is offered at the most appropriate time.” Doctors in primary care in particular often do not have access to occupational health, adds Richard Vautrey, deputy chairman of the BMA’s General Practitioners Committee, whereas most hospital trusts have a whole occupational health department.

Returning to the health of the general public, the Future Forum thirdly considered how commissioners can use contracts and payments to support prevention of poor health and promotion of healthy living. The forum suggested that the Quality and Outcomes Framework (QOF) and the commissioning for quality and innovation (CQUIN) payment framework should be used to reward acute providers and general practices for improving the local population’s mental and physical health and wellbeing and for reducing health inequalities. The government jumped at this idea, suggesting that at least 15% of the value of the QOF should be devoted to public health and primary prevention from 2013.5

Dr Vautrey, however, believes that enhanced services might be a better way to deliver this goal in general practice, as QOF is applied to the whole United Kingdom, but enhanced services can be tailored to local needs. “There are other mechanisms for providing resources to enable people to engage in primary care activity, it doesn’t have to be just QOF,” he says.

Integration

Many of the Future Forum’s recommendations on integrated care hinge on making the most of general practices as providers of care.6 One rather controversial suggestion is to start tinkering with the General Medical Services contract to drive better integration between general practices and community services. The government doesn’t need to turn to contractual mechanisms to incentivise integrated care though, says Dr Vautrey. “To go down that route I think risks the independence of individual practices, and I think that’s something that both practices and patients would not want to see happen,” he says.

Another suggestion to drive integration from the primary care side of things is for general practices to collaborate more closely with their neighbouring practices by coming together in federations. The view of the Royal College of General Practitioners is that federations will be provider groupings in which practices will work across practice boundaries,7 setting them apart from clinical commissioning groups, which will be responsible for designing services. This approach will allow practices to share ideas and infrastructure, as well as make savings from economies of scale, and to coordinate service development to avoid duplication.

One big problem with all these grand plans for integration is that the health service in England is not set up to be integrated, says Paul Flynn, deputy chairman of the BMA’s Consultants Committee. “The separation of primary care and secondary care does not lend itself to integration, in that anything that is currently done in hospitals but might perhaps be done in primary care is seen as a threat by secondary care organisations,” he says.

It is generally believed to be easier to deliver integrated care if you are part of the same system, says Rebecca Rosen, a senior fellow in health policy at the Nuffield Trust and a GP in southeast London. “But being part of the same organisation is not essential, and you can deliver integrated care across organisational boundaries,” she counters, citing the success of the US Kaiser Permanente and Veterans Affairs systems in integrating care across several cooperating entities. Instead of thinking of themselves as working in isolation in their practice, GPs should see themselves as working as part of a multiskilled team where the community services aligned to their practices are an extension of what they can do, she adds.

Information

One of the key recommendations from the Future Forum’s information group was for patients to be given online access to their GP records, a proposal the government has said it will make reality by 2015.8 However, the Future Forum warned that this plan would present a financial and a time burden for general practices, a theme that the BMA’s General Practitioners Committee has picked up on. The workload isn’t just an issue for the practice or the GP, it’s also an issue for patients themselves, says Chaand Nagpaul, a negotiator for the committee. “Patients may be looking at clinical information about themselves that they don’t understand, which can cause anxiety for patients, and they naturally want to have access to a consultation with their GP to explain the content of their records,” he says. “We need therefore to build in the logistics and practicalities of enabling patients not just to access their records but also to seek an explanation and an understanding.”

The Future Forum’s information group also recommended that hospital discharge summaries should be made available to GPs and the patient at the point of discharge and that GPs’ referral letters should similarly be made available at the point of referral. The government has supported this plan and agreed to put it in place as soon as next year.5 The best way to put this plan into action would be electronically, as already happens in Wales, says Dr Flynn. “This is a simple and straightforward thing to do that doesn’t really require a huge amount of money but does require some investment in infrastructure,” he adds. “A lot of healthcare organisations are going to have difficulty finding that investment at the moment.”

A lot of the progress in integrating care and in improving information sharing is going to come down to re-establishing the type of relationships that existed 20 years ago, where it was much easier for a GP to pick up the phone to a consultant, says Dr Rosen. “A lot about integration is about rekindling those relationships and getting them back on track again,” she says. “There will be new things that are needed and it will be challenging, but some of it is not rocket science, it’s just basic human relationships that have been dislocated and need to be brought back together again.”

Conclusions

Despite all this “listening,” and several concessions from the government, many organisations, most recently the royal colleges,9 are still not happy with the NHS reforms. The BMA has been particularly strident, stating that it remains opposed to the Health and Social Care Bill, and it believes that “most if not all of what is being suggested in these papers could be delivered without the need for expensive and destabilising legislation.” In many ways the Future Forum’s reports are needed to try to rectify many of the problems with the bill, it says. But as the chairman of the Future Forum, Steve Field, says, “the NHS cannot stand still. It must adapt to meet the challenges ahead.”1