Commissioning-apathy of the silent majority.

Commissioners must focus on workforce planning to engage GPs By Dr Kamal Sidhu | 26 Jul 2012As Pulse recently highlighted, it is now very obvious that on many CCG boards GPs are not even in a simple majority. Yet supposedly the greatest change under the new Health and Social Care Act was that GPs would lead the NHS. Are grassroots GPs really involved in commissioning? Or is it still an old boys club where the few who have always been active remain at the forefront, along with management? The answer in most places seems to obviously be the latter. Clearly, widespread apathy is a major factor as we saw in the pensions action fiasco too. Some feel that GPs are being made scapegoats by being put in charge of commissioning in the current economic climate. Despite this, one of the most important factors is the capacity of practices to allow their workforce, mainly GPs, to go out and engage actively in commissioning-related work. Most practices are already burdened with increasing demands on their time by an array of organisations, whose names constantly keep changing. Evidence suggests that not only have the number of consultations per patient risen significantly over the last decade, but that GPs are providing increasingly complex treatments as well.1 The Office for National Statistics suggests that the proportion of elderly patients have risen and will continue to rise.2 Hence, the complexity and burden of an ageing population can only head northwards. QOF managers ask us to do more every year to achieve the same reward. We are increasingly expected to refer less, reduce admissions and reduce prescribing budgets. At the same time, the unfair and disproportionate pension reform inflicted on the profession does not improve a discouraging picture of the future of general practice. It remains an indisputable fact that practices do not have any spare capacity to proactively and meaningfully engage in commissioning. In many areas, the remuneration for CCG work does not even cover the cost of a locum, which has soared dramatically and has become difficult to organise as the locum workforce has dwindled. Remuneration rates vary widely, as highlighted by Pulse in the past.3 In deprived areas like ours and many others, even finding good salaried GPs is a big problem – it is extremely difficult to attract candidates into areas that have been highlighted in the report GPs in the deep end.4 Unfortunately, these are the areas where clinical leadership can make the biggest difference. Many of our colleagues rely on a few enthusiastic GPs to work for CCGs out of their own goodwill. But we hardly have any of these type of doctors left, given how overstretched we are. Hence, many practices – especially small or single-handed ones – find it extremely hard to have their voice heard, while other practices end up having inequitable and excessive involvement in commissioning. Both lose at various levels. If you really believe that putting GPs at the very centre of commissioning creates efficiency and innovation in the system, it is grossly short-sighted to discourage practices and GPs from becoming involved – whether because of inadequate capacity, remuneration or both. These problems affect partners, true, but they are also particularly off-putting to salaried and sessional GPs. Engaging GPs across the board was supposed to be the whole point of commissioning and, as the saying goes, you are unlikely to get different a dish from the same recipe. It is high time that CCG leaders started to look at workforce planning to create capacity for GP engagement. It may be that CCGs need to employ extra workforce to help practices cover the lost time. It may be that practices start to get equitable involvement with support. I understand that it is sinful these days for GPs to ask for any pay increase, but it is only fair to ask for appropriate remuneration to reflect the time committed to commissioning as a partner – or sessional doctor, or locum. The NHS Confederation, it must be said, has already called for this.5 It is also time for our colleagues to stop expecting us to work on commissioning out of pure goodwill. This expectation risks losing our trust. As was the clear emerging theme from the LMC conference this year that 'no new work without new pay', it is only fair that we stand our ground at all levels. Dr Kamal Sidhu is a GP in Peterlee, Durham and is involved in commissioning work in his locality References 1. NHS Information Centre. Trends in consultation rates in general practice, 1995 to 2006: analysis of the QRESEARCH database. 2007.http://tinyurl.com/cghebo3 2. Office of National Statistics. What are the chances of surviving to age 100? 2012. http://tinyurl.com/cwdwa3r 3. Iacobucci G. GPs expected to do commissioning group work for free. Pulse 2011, online 30 September. http://tinyurl.com/ccvoxc6 4. University of Glasgow. General practitioners at the deep end. 2009. http://tinyurl.com/c3rkxle 5. NHS Confederation. Deciding how to pay: remuneration for clinical commissioners. 2012. http://tinyurl.com/bp6wb75

CSA is failing international trainees.

The CSA is failing international trainees 23 Jan 2012 If you are an international medical graduate, your chances of failing the clinical skills assessment (CSA) are about 50%, compared with 10% for UK graduates.1 These startling statistics shock me every time I see them. General practice is currently the only specialty that has an exit examination, which implies your career is over if you fail the now limited number of attempts for the CSA. This has led to discontent among international graduates as well as the training community in general. Such high failure rates for a particular subgroup raise questions about the exam's validity and fairness. This has brought the role of the RCGP under scrutiny. Raising its bar for examination standards when it clearly expected more international candidates to fail – as Pulse revealed last year – hardly gives the impression of a fair organisation. Even though it did issue an advisory paper on the CSA, it remains guilty of introducing an exit examination without appropriate support for the subgroup it knew was likely to struggle. This rings alarm bells about revalidation too, in line with the concerns expressed by the BMA.2 The test is not just meant to examine communication but clinical skills, and yet all the explanation being given is about communication. Anecdotal evidence suggests that many candidates who fail the CSA appear to be safe and effective doctors. But why do international graduates struggle disproportionately? The common reasons given for candidates failing the CSA include not listening, not exploring ideas, concerns and expectations, and problems with diagnosis and treatment. But that is virtually all of the consultation. It also makes me wonder how they passed the PLAB exam and GP recruitment. Or did the system let them in to fill posts? Also, consultation skills are learned skills. We expect a qualified GP to be able to adapt their consultation style and yet we do not adapt our teaching style for trainees with different cultural backgrounds lacking in so-called ‘linguistic capital'. Biases and prejudices We all know that despite the UK being one of the world's more tolerant societies, there remain biases and prejudices that increase the pressures on overseas graduates. There is a plethora of evidence that suggests ethnic minority students fare less well in entry to UK medical schools, in final examinations, in job applications, in disciplinary action before the GMC and in the granting of merit awards.3 The reasons for such differences are far from clear. We need more research as to why international graduates, who constitute about one-third of the workforce, do less well. Any suggested predictive factors then also need to influence the demand-supply cycle at the recruitment stage. Most deaneries are now actively looking at ways to tackle this problem head on. Encouraging trainees to have mixed study groups to foster more social integration is laudable – integration works both ways. But being an international graduate is an immense pressure in itself. Setting very high standards to reassure the public is all very well, but the standards that have been introduced will not make the public any safer. A poor doctor with good communication skills can still pass the examination. The relationship between the non-UK workforce and the NHS has to remain symbiotic. Otherwise, we will end up causing damage to the very patients we seek to reassure. Dr Kamal Sidhu is a GP trainer in Peterlee, County Durham Competing interests: Dr Sidhu is an international medical graduate References 1 RCGP. MRCGP Clinical Skills Assessment (CSA) Information Paper. 2011. http://tinyurl.com/74dldbf 2 BMA. Health committee enquiry into revalidation. 2011. http://tinyurl.com/78l55nf 3 Woolf K, Potts M and McManus C. Ethnicity and academic performance in UK trained doctors and medical students: systematic review and meta-analysis. BMJ 2011. http://tinyurl.com/6ulgbyv

We must face up to the cause of so much waste – our patients

13 Sep 2011
Amid the gloom of budget squeezes and low morale, the big question is what can be done to save one of the finest health systems in the world?

There has been a huge amount of research into shifting specialist services to the community, the use of referral management centres, reclassifying low-priority procedures and even incentives to reduce referrals and admissions, as potential solutions to the shortfall in NHS funding. But something seems to be missing.

We all blame many of the current constraints on it, but are afraid to talk about it. It is politically unpopular to look at some of the patient-related factors that waste billions.

Most patients are careful and use the NHS when needed and appropriately. But there are a small fraction who do not appreciate the system that so comprehensively looks after their health and is free at the point of use.

Having worked in another healthcare system where you pay for each and every contact, I still find it amazing I can go and see my doctor and receive, usually, world-class treatment, without worrying about the cost. In many cases, even transport is provided. The NHS is the envy of billions around the world.

But who has not come across frequent callers to surgeries or out-of-hours services and patients who have numerous attendances at hospital for trivial reasons? Sadly, a minority of patients would be happy to call the doctor out in the winter, claiming their car is too cold for them to come in. Who has not heard about abuses of 999 services? What about those who refuse to listen to smoking cessation advice while their child keeps getting asthma attacks? Or those who get drunk and sober up at A&E? Abuse of the sick note system (or now, the fit note system) is no news to any of us.

There have been some efforts to tackle wasted resources as a result of missed appointments, mainly in hospitals. Even the potential savings from these are staggering – NHS North East, for example, puts the cost of missed appointments at around £20m a year. But there appears to be little research on missed appointments in primary care.

In our own surgery, during the last month, we have lost the equivalent of four days' work from a doctor. There are many other related areas of waste that have hardly been looked at – re-referrals after missed hospital appointments, wasted prescriptions, wasted treatment plans and requests for over-the-counter medicines on prescription.

Who is to blame? We, as doctors, either do not have time to carry out patient education or are afraid to do so.

But patients have to take the blame to a degree and accept that if this system has to improve, all of us have to improve. Patient empowerment can only be a good thing and I completely agree with ‘nothing about me, without me' – but power is accompanied by responsibility.

Sadly, there is little emphasis on patient factors amid all the commissioning talk. There is an urgent need to involve patient groups to find ways to reduce abuses of the system if we wish to make it work effectively. If charging patients when they fail to attend without prior notice is not acceptable, then we need to bring forward other solutions.

I would like our commissioners to take a lead on patient education and awareness. Otherwise, the question of whether we can afford the NHS risks fading away as we are left with an alternative system altogether.

Dr Kamal Sidhu is a GP in Blackhall, Cleveland