NHS payment system in England is “completely illogical,” says national director

BMJ 2014; 349 doi: (Published 19 November 2014) Cite this as: BMJ 2014;349:g6978
  1. Nigel Hawkes
  1. 1London

Payment systems in the NHS in England will have to change if urgent and emergency care are to be successfully reformed, a senior manager from NHS England told a meeting in London on 18 November. Keith Willett, national director for acute episodes of care, said that the present system was “completely illogical.”

In the current system GPs are paid on a capitation based contract, inpatient care on an activity based formula, emergency department visits on a payment by results tariff, emergency admissions on a tariff with different rules, and community services and social care on a block contract. “We’re stuck with financial allocations that don’t work,” he said. “We have to change the payment system before the money moves the way we want it to.”

Willett was speaking at a Westminster Health Forum seminar on delivering the seven day NHS. In addition to reform of the payment system—the subject of a consultation by NHS England and Monitor—he said that much better information sharing and improved skills in the workforce were also needed. He said that despite its difficult introduction the NHS 111 advice line had begun to make a difference and was getting a million calls a month. “It works but it doesn’t really satisfy,” he said.

He said that its usefulness would be transformed if the team taking the calls had access to the callers’ medical records. But that would need better information systems and greater clinical competence in those taking the calls. The ideal situation would be that callers could get advice and, if necessary, arrange an appointment for the next day during the same call. That would reduce the chances of patients pitching up at emergency departments, he said.

But he admitted that, although NHS England had worked hard to produce a new model for urgent and emergency care, the role of the GP remained poorly defined. Other speakers at the seminar presented widely different views of primary care. Richard Vautrey, deputy chairman of the BMA’s General Practitioners Committee, argued that it was underfunded, low in morale, and unable to attract new recruits, whereas David Colin-Thomé, a former national director for primary care at the Department of Health, said that in some respects it was better than people recognised.

Colin-Thomé said that, despite the criticism it had sometimes faced, out-of-hours care was generally good, a view confirmed by a recent report by the National Audit Office. He said that he had participated in a review by the Care Quality Commission of 30 out-of-hours services covering 36% of the population of England and had found that they were safe, effective, well led, caring, and were not having any trouble recruiting GPs. “Out-of-hours care faces challenges but no more than other parts of the system,” he said. One challenge was increasing its visibility—26% of people surveyed by the National Audit Office were unaware that such services even existed.1

The forum heard examples of general practices getting together in groups to offer extended opening hours by sharing IT facilities, making records available online at any of the participating practices. Mohammed Jiva, medical secretary of Rochdale and Bury Local Medical Committee, said that the future of general practice lay in such collaborative arrangements. But Vautrey warned that the proportion of NHS funding going to primary care had declined—a trend that had to be reversed.

“Before promising the Earth, we have to be sure that we have enough money, that we have the right premises, and that we have the GPs,” he said. “The seven day NHS is possible, but we have to put the building blocks in place.”


Cite this as: BMJ 2014;349:g6978


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