Wednesday, 24 August 2016

A Very Brief History of Time

Very early in my blogs I wrote about FFS (Fee for Service) vs Capitation especially comparing Australia as a model of FFS and UK as a wholly capitation based system where provision of GP services are concerned. That post and my blog in general look at this issue from a provision of service perspective- the advantages and disadvantages of one system compared to the other on a day to day level.

I would now, however, like to examine this from a completely different angle. A contractual angle. To examine the nuts and bolts of the contract(s) that underpin either system. This is very topical as Australia is now embarking on a self confessed "biggest shakeup of GP Funding". We are going to be adopting a Medical Home model and this will introduce Aussie GPs to capitation, albeit in what is being described as a 'blended system' comprising of FFS+Capitation.

For those unfamiliar with the NHS GP contract, here is a wikipedia entry on the same. I'm not sure it's entirely accurate on some assumptions it makes, but the timeline of the various changes is accurate. Have a read here.

I left the UK 2 years ago. I was a partner in a Practice. Let's examine this from a contractual perspective based on the timeline above.

I was a partner in a practice with a list size of 4200 patients. I was working Full Time (FT) by doing 9 clinical sessions a week. My partner, a female was doing 6 sessions. Remaining 3 sessions were covered by a salaried GP or long term locums. So a practice with 2 WTE Drs.

Imagine this happened in 1946. No problem for anyone concerned. Coventry would have lost a GP and the remaining GPs would have had more patients to see. As all patients paid a private fee, they would decide whom they would see. Logically many would want to see my partner as she happens to work out of the same building. My partner may have got busier (and richer) or could have carried on as usual and not taken on any new patients. There would of course have been no 'salaried' GP back then.

Between 1948-2004, the patients I was actively seeing before my departure would have been capitated to me. Since the capitation payment came from the Govt and not the patients, the patients and their notes (NB- the notes belong to the Govt, not the Dr) could be traded and bartered - by the govt and the remaining partner in my practice.
The Govt through its various Avatars during this period would have 'sold' this enbloc to another GP. My partner, could have advertised for a new partnership (in the building and as a trading partner) and the Govt would most likely hand the patients to whoever would choose to take the partnership. This encouraged the partnership model of General Practice. If my practice chose not to, or failed to find a new partner, the patients would be sent elsewhere, i.e no partner, no patients.
Remaining partner would have still got her own patients, but would now have higher overheads (building and staff etc).

2004 onwards however, the situation changed drastically. All the patients registered at my practice, were now registered to the practice and not the individual drs!.

This change had a profound and deeply detrimental effect on General Practice in UK. Yet, this was also the turning point for many GPs, especially single handed GPs (solo GPs with no partners). This contract allowed GPs to opt out of Out of Hours services. So, solo GPs who, believe it or not,were technically on call 24/7 throughout their working lives, were now working 8:30- 6:30pm, 5 days a week for very little drop in the capitation payments they received. This massively improved the profile of the job and profession and numbers of applicants skyrocketed. At the same time the Govt introduced something called QOF, a value added optional service, if you like. Extra payments were made to those who signed up. Everyone did, and soon QOF payments were contributing 20-25% of a surgery's gross income. So, why was this a bad thing?

Simply because it killed off partnerships. Practices had no incentive to take on partners- they could keep the patients, regardless of how many partners they had as long as they provided the services they were contractually required to. So, upon my departure in 2004, the remaining partner in the practice would have simply taken on a salaried Dr and her profit share from the surgery would have gone up dramatically. In a small practice, as a 0.7 WTE she might have opted to get a new partner as she would have struggled with the non clinical work. But, in a larger practice it became common to replace retiring partners with salaried Drs or even Nurses. ANPs, physician assistants etc all became ways for a practice to increase their profitability. So, partners got richer and partnerships became rarer.
As long as the profession was desirable and there was a steady supply of Drs and other staff, this wasn't necessarily a problem. But, it opened the gates for corporates to step in (no GP principal required to attract a capitated patient base). The Super Surgery had arrived. Owners weren't necessarily corporates; many GPs were on the hunt too.

The patients, too were starting to get  a raw deal. Imagine my practice. I leave. Remaining partner chooses to replace me with a mix of a Nurse and a salaried GP. Patients have poorer access to a Dr but the remaining partner is now earning more than she ever did. Or there is a succession of locums covering for my absence.

But, this goose did not lay golden eggs for long. Govt got it horribly wrong with QOF. They ended up paying a lot more than they anticipated. So, they froze the 'global sum'. Then, they made the QOF payments harder and harder to achieve. Since, practices owned the patients rather than individual Drs the Govt introduced more and more complicated contractual levers to monitor the practice.  Mystery shoppers, patient panels, compliance to various regulatory standards and bodies (each accompanied by a hefty fee) became the norm. Partnerships became less attractive and partners even if they earned more, were an increasingly harried lot.

Then came Andrew Lansley's White paper in 2010. This laid bare the fallacy of accepting the new contract in 2004. Since Drs no longer owned the patients, the market could be opened to "any willing provider". Clinical commissioning was the latest craze - Darzi Centres, Virgin Helath etc etc all got into the game. Recruitment and retrenchment became real issues in many parts of UK.

Compared to 2004, where my departure could have a blessing in disguise to the remaining partner, imagine I left after 2010 like I did.

Now, the remaining partner, even though she is only a 0.7 WTE Dr has to ensure adequate services are provided to all patients registered at the practice. So, a 0.7 WTE Dr shoulders responsibility for a patient list intended for 2 WTE Drs.
If she can't recruit a new partner to share the increasingly onerous contractual, non-clinical work, tough luck. If she can't find a salaried GP or even locums, tough! She is now legally, morally and more importantly contractually bound to provide these services. Even closing your list requires approval from the powers that be. Locums want and get higher rates. The partner is haemorrhaging money and tied up in keeping the practice running. Seeing patients is almost a distraction. Many partners emigrate or take early retirement. Some hand in their contracts. General Practice in UK is imploding. Is anyone surprised?

So, where on the timeline described above, do you think General Practice in Australia is now?
Is is gonna be boom or bust? Or is it going to a 'blend' of the two?

Think long and hard my friends

Gaurav




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