Written evidence submitted by Dr Liam O’Hara (FGP0108)

 

Thank you for setting up this opportune inquiry into the current state of NHS General Practice. I write from the perspective of a recently retired GP Principal, having been in practice for three decades.

 

In order to address any of the questions posed in the Terms of Reference one really ought to understand the current structure of the NHS General Practice business model. The salient ingredients of what I consider provider alienation I shall describe, then potential remedies.

 

1.Superficially NHS General Practice is said to be a regulated market, scratch the surface and you quickly realise its a rigged market. This rigged market is the elephant in the room no one wishes to speak of. Partnerships of GPs hold contracts of provision with CCGs, the devolved contractees of NHSE. The partnership covers the liability of contract provision backed by the wordly assets of the partners. Each of the partners is seen as a Schedule D tax payer by HMRC, a self employed trader(1) within a partnership. This self-employed status having a different taxation treatment, and employment status, to an employed person. IR35(2) on the other hand is the notion of disguised employment masquerading as self-employment. The collision between Schedule D and IR35 illuminates the root cause of provider alienation responsible for the terms of reference for this inquiry.

 

2.In 2004 a new GMS contract(3) was agreed between GPs and HMG. At the heart of this new contract lay a central definition;

 

'..obliged to see and offer management services to a patient who believes himself or herself to be ill..'

This opacity has over the years been manipulated by the Monopsony(4) to the detriment of nGMS contract holders. Initially PCGs then PCTs then CCGs [and in April 2022 the new alphabet soup of ICS], acted as the devolved translational agents of the NHS. The nGMS contract being for the first time a formal contract in law for primary care provision. Commissioners subcontracting service provision to willing accredited providers. An important point needs to be made plain, commissioners own the accountability to commission for the citizens they are responsible for. Providers own the accountability in contract to provide to the registered population that which they agreed to provide. Anything outwith a commissioned contract remains the responsibility of the commissioner not the provider. Patients remain citizens within health or disease. Such a nebulous central contractual definition allows commissioners potentially to ride rough-shod over providers. Yet the provider trades to generate sufficient profits to justify holding the contractual liability they have entered into. A market made manifest.

3.Businesses carry operating expenses that are satisfied from their generic turnover, any surplus becomes profit. Any significant and specific reimbursement of operating expenses over and above generic profits could be considered as satisfying disguised employment. Rent, rates, professional civil indemnity, CQC inspection fees are significant and specific reimbursement fields which GP practices can lay claim for to CCG/NHS. Sickness and Maternity locum cover are other fields to which claim can be made. Private businesses access Pension provision for staff on the open market, yet GP partners are eligible to access the NHS superannuation scheme as well as their staff. GP partners pay both employer and employee contributions for their pension, their staff only the employee amount. Yearly uplifts for pension contributions are factored into NHS practice payments. GP partners gain the tax advantage of  Schedule D status for their NHS superannuation contributions. From an operating expenses perspective NHS General Practice enjoys something a Private Dentist does not.

4.A NHS General Practice is not allowed to offer private medical services to any of its NHS registered population other than for a very few defined circumstances. The inability to offer services not commissioned by the NHS curtailing trade.

5.A NHS General Practice generates NHS income from its service provision, paid to it in characteristic lumpy sums, which need dissection at practice level to ensure the claim for payment has been satisfied in full. The request for payment being made on IT hardware and software owned by the NHS. Such lumpiness rather than itemisation at a granular level suggests a perception of payment to an employee.

6.NHS General Practice provides a free at point of delivery experience, yet nothing in life is free. Citizens taxes pay for this transaction-less experience. This is held as a point of admiration yet is one of the fundamental problems for NHS General Practice. Everything ultimately has to have a value. In the case of the NHS this is done remotely to the citizen experience in time, place and person. This displaced valuation has the ability to devalue what is provided. Reimbursements close to cost generate scant profitability.  In the case of NHS General Practice the aforementioned subsidy of operating expenses provides a counterpoise to the generic value and thus business turnover to that provided. A ceiling if you will.  In years past an abstract entitled the Intended Average Net Renumeration(5) was used as a means of controlling GP income, no matter how many widgets they provided. Its perception persists, indeed an ingredient for provider alienation.

7.In 2004 at the inception of the new contract the edifice of Quality outcome Framework QoF was created. An abstract that concentrated attention upon metrics and outcomes, and provided financial reward for achieving said metrics . Yet assumed with each annual re-iteration of its metrics, the previous iteration would continue but at zero cost. A case of obligated Philanthropy?

8.Pursuant to provision is its oversight. Enter the Care Quality Commission. One might assume that a commissioner within what it commissions, applies metrics and KPIs for it to oversee what it has commissioned? I naively consider this to fall within the realm of ownership, ie accountability for that commissioned. Commissioners not having to oversee what they commission cultivates the mischief position of not keeping ones eye on the ball. The contract commissioned becoming a pale imitation of a non NHS entity. Providers being a monopoly, are instructed by the monopsony that this is the only game in town. The financial numeracy for provider profitability and survival becoming disguised. Get away with what you can get away with. The oversight of provision being divested to a body other than the commissioner facilitates poor commissioning in my opinion. Providers then are inspected on their provision by an inquisitor detached from the granularity of what is contractually possible. The inquisitor inverting contractual accountability upon a provider divorced  from the reality of what is possible within the parameters of the contract. And let us not forget NHS General Practice claims from the NHS the fee to pay their inquisitor. Private dentistry pays its own CQC fee, but then it has nothing to do with NHS commissioners.

9.A generational flux needs to be acknowledged, baby boomers reaching retirement age had no education fees to pay at university, and contributed to their pension at favourable rates. Today graduates emerge from study with student debt and pension contribution rates higher than their forebears on poorer terms. A schism visible to anyone able to see

10.Continuity of care was the jewel in the crown of primary care around which all other aspects of healthcare revolved. This was an engine fuelled 24/7, 365 by partners prior to 2004. The costing of Out of Hours work in 2004 and the new GP contract together with the standards set of OOH by the Carson criteria, detached GP partnerships from providing OOH care. QoF concentrated activities to measurable metrics. The unmeasurable continuity of care which existed prior to 2004 was broken in a temporal sense, and from that date has increasingly fractured. Einstein commented upon what is not measurable being more valuable than what is measured. The complexity of therapeutics borne within QoF, ongoing oversight of conditions requires experience and time, evaporating commodities. GP numbers wither, whatever the individual reasons, politicians set targets for 5000 more GPs, full time equivalent or part time? Or is this just a vanity headcount to satisfy propaganda? The slack being taken up by sessional GPs rather than GP principals. Sessional GPs otherwise known as either salaried or Locum GPs. The choice of sessional working being the preferred means for a significant number of doctors in current climes. One ought not decry them their freedom to live their lives and practice  in a manner they feel best for them and their portrayal of medicine. Yet the Rt Hon J Hunt MP devalues them as '..they're much more expensive, they're much less good in terms of patient care..'(6). Todays GP workforce is female preponderant; biology and lifestyle direct engagement with work contrary to that of Dr Finlay.

11.The English speaking world requires doctors, other countries systems and  treatment of their medical graduates facilitating a more professional place to work. It is no surprise to find new graduates emigrating, older graduates emigrating or retiring, some even metamorphose to sessional working, they are only human.

12.Over the last decade I have borne witness to vain attempts to imbue more and more efficiencies into primary care. A wise consultant physician once told me '..when you've cut through the bone there isn't much left to hold you up..'. Place based working and Primary Care Networks [PCN] being the latest iteration of academics attempting to force a false dawn upon a business through misinterpretation of academic works and a fundamental misunderstanding of the healthcare business. Polycentric Governance the laureate paper submitted by Elinor Ostrom in 2010 to the Nobel committee is admitted to be a central plank of PCNs yet the identities of the harvester and the harvested are misconstrued. Upon this misconstruction a whole edifice has been built, based upon quicksand. The examples of harvest being trees, fish and water, common pool resources. In the particular of primary care I would argue the common pool resource is that upon which society interacts, a deliverer of healthcare, the GP Principal. The Principal, as a tree supports the community around it, roots if you will, as water quenches distress and as fish nourishes the body against disease. This identity providing, as well as anchoring the liability of the business of primary care. Who is the harvester...  society, politics, the media? The whole point of Ostrom's work was to avoid big government, to allow bottom-up solutions, to mediate and facilitate organic behaviours by harvesters in order to protect the common pool resource, and thereby the harvesters enduring livelihood.

Polycentricity, a governance system in which multiple governing bodies interact to make and enforce rules within a specific policy arena or location, is considered to be one of the best ways to achieve collective action in the face of disturbance change.

Common pool resources through polycentric governance are protected from excessive harvesting by harvesters, lest the lesson of Easter Island be forgotten. What is the disturbance change Polycentric Governance is addressing? Is it not the vehicle whereby consuming bodies achieve collective action? It is not for the turkey to pluck and stuff itself for the Christmas table. The idea of turkeys stapling themselves together in the vain hope of an eagle emerging is fanciful [see the modus of PCNs]. Yet misconstruing identities has lead to the delusion of PCNs and the blending of CCGs into ICS.

13.Succession in a profitable business is usually a given. Those wishing to succeed the business buying into the operating costs of the business, this capital investment securing profits through turnover. If you are the owner, and the major service provider, the terms and tenor of engagement with your contractee and customer will determine your satisfaction with the relationship. Since 1948 NHS General Practice is forbidden from trading upon goodwill. As we have described above the ingredients of liability, capital investment and the misconstrued notion of PCN has led to problems with GP recruitment, GP partner recruitment more so. The difficulty of retaining GP partners let alone recruit cultivating the nightmare of last man standing, a situation whereby the last partner standing assumes the liability for the whole business.

14.To summarise; provider alienation through a rigged market, passive commissioning, devaluation of product, dysfunctional oversight, half cocked academic intrusion together with hostile political and media propaganda. Cut one of us and we all bleed.

15.What remedies do you offer sir? First of all LISTEN with open ears, unsullied by pre-conceived notions, you have been warned of the current perfect storm for many years.

16.You already have the GP Partnership Review(7) from Jan 2019, a review commissioned by the DHSC in Feb 2018. It provides a pre-covid 19 template to help direct government.

17.Halt the ill construed PCN agenda and look to understand the existent business models at a granular level. Curb the ingress of Academia into describing service provision.

18.Reflect upon the granular mechanics of translating Government policy into reality.

19.Authenticity on the part of Government is a rare commodity, it needs to be made manifest. Political contrition thus far is an invisible construct.

20.CQC ought be disbanded, and commissioners made accountable for their own work.

21.Trust of and Respect for the Medical Profession becomes the new Authentic Governmental message.

22.Spin and media manipulation ends.

23.Revalue the primary care product; cynicism and sentimentality have to recalibrate.

24.Reflect on the current omni-shambles of the NHS superannuation scheme and its consequences.

25.The remit of the professional regulator, the GMC, needs to be reviewed. An exposition of its personnel(8)(9) their appointment and their independent regulatory utility urgently addressed.

26.The debacle of the Junior Doctors contract imposition(10) in 2016 acknowledged. The juniors of 2016 are six years older and the very cohort you are appealing to.

27.Reflection upon the purpose, utility and remit of Appraisal, together with its translational agents and who is best placed to employ them urgently addressed.

28.Clarify the status of the partnership model in NHS General Practice by HMRC.

29.Publicize and energize enlightened practice such as Citizen Assemblies(11) to address vexatious health and social issues. They are the torch bearer for Patient Participation Groups [PPGs].

30.Citizens Assemblies can be tasked with the thorny issues of clarifying the needs vs wants conundrum in NHS delivered healthcare. They can also be unleashed upon the rights vs responsibilities duality, together with the current question of co-payments. Observation informs us that politicians are good at kicking cans.

31.Acknowledge resourcing of transferred work.

32.No reform without full stakeholder engagement (call this skin in the game), and a reasoned debate.

33.Beholden of any representative democracy is transparency and integrity of its representative agents. This authenticity of character is axiomatic to trust in the process and its opined analysis and delivered actions.

34.Bon chance.

   

(1) https://www.gov.uk/employment-status/selfemployed-contractor

(2) https://www.gov.uk/guidance/understanding-off-payroll-working-ir35

(3) https://www.legislation.gov.uk/uksi/2004/291/pdfs/uksi_20040291_en.pdf

(4) https://en.wikipedia.org/wiki/Monopsony

(5) http://news.bbc.co.uk/1/hi/health/1072662.stm

(6) https://www.channel4.com/news/programmes/2021/11/23/1900

(7)https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf

(8) https://www.youtube.com/watch?v=LnH-Pc6MicM

(9) https://www.parliament.uk/globalassets/documents/commons-committees/public-accounts/Correspondence/2015-20-Parliament/Letter-Prime-Minister-re-NHS-Budget.pdf

(10) https://metro.co.uk/2016/07/16/doctors-embroiled-in-another-dispute-over-one-of-jeremy-hunts-aides-6010582/

(11) https://citizensassembly.co.uk/

 

Dec 2021