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Speech by Lord Warner, Minister of State for Reform (Lords), 15 June 2006: Primary care and patient benefit - Speech to the Local Medical Committee Conference of the BMA
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Last modified date:8 February 2007
1. I want to begin by thanking you for inviting me to speak at your conference as I read in one of the journals yesterday. I understand that this is the first time a Minister - and I'm assuming this is true - has been invited to do this so I feel very privileged. I have chosen as my theme some current areas where primary care can produce patient benefits by operating differently. However, before doing so let me begin by putting on the record our commitment as a Government to primary care as a cornerstone of the NHS.
2. Family doctors have a high level of public trust and they have a high level of trust among Ministers. I hope you'll notice we did not join in the latest media frenzy over GP pay. I thought we maintained a statesman-like silence! The White Paper we published in January reaffirmed our commitment to primary care. That document could not have developed its theme of care closer to home without considerable confidence in primary care clinicians - GPs, nurses and other health professionals.
3. Delivering the White Paper is a five- 10-year programme and I acknowledge that challenge. However, we must not lose sight of the vision - providing better care, improving patients' experiences and achieving better value for money is the business we are all in, particularly as our population ages, medical science produces more opportunities and public expectations continue to change. Today I would like to say something about each of five key issues for primary care where I believe there are clear patient benefits from new approaches. They are all issues where there are differences of view. But I believe we have to work through any differences together in the interests of patients. I believe we are able to do that.
4. The five issues are:
Improving access to primary care;
Choice;
Practice based commissioning;
Accreditation; and
Electronic patient records and transfer of patient information.
5. As users of services, we have all become more informed and more demanding. Our expectations of all services are higher. At the moment access to core primary care services still varies unacceptably I would say across the country. This is not a criticism of the individuals providing services or managers. But it is a reality. Although I recognise independent patient surveys tell us that the number of patients able to see their GP within 48hrs has risen from under half to nearly 90%. That's undoubtedly a success story and you and your staff deserve a great deal of credit for putting this in place.
6. Patients tell us that being able to get through to their practice by telephone is important -6% of complaints about GPs are about the difficulty of getting through. We want to work with you to end the 8am phone scramble. Part of this is about reassuring patients that appointments are available, and that they will be able to see someone - but we also need to ensure that phone systems are modern and reliable. And we're not thinking only about traditional telephones - what about email and text messaging? I know many of you are already using telephone consultations but why is it that it is not being used in a wider range of practices?
7. I have no problem with the change in arrangements for out of hours services and have supported them. But it is clear that some patients want practices to be open at more convenient times in the evenings and at weekends. That is because we live in a society in which working patterns have changed and they must change for all of us. We've seen this happen already in Waltham Forest, where a practice offered extended opening and was supported by its PCT through a period of sustained growth. I know many GPs are and want to move in this direction and I believe there is more scope for innovation here without re-opening the whole issue of out-of-hours.
8. Patients also support walk-in centres - and we want to see further development here. The 75 Walk-in Centres have proved to be a successful way for patients to access primary care - particularly where they lead 2-centred lives in terms of work and residence. I think we'll see more of these centres. I think we'll be able to ensure people can access primary care services in ways convenient to them and that benefits the community. This need not be at the expense of list-based practice care to which we are totally committed.
9. It's clear that no matter how much we think we've improved the system, patients sometimes are the last to feel real benefit to them. That's why this year for the first time practice payments will depend to some extent on what patients think about the service they receive. I'm sure GPs will respond and show the flexibility to adapt to changing patient needs - and already large numbers of doctors go out of their way to find out what patients think.
10. For some parts of the country better access is about having a range of primary care at all. That is why we are working with the 30 most under doctored PCTs in England to develop a nationally led but locally defined procurement to help them commission additional services that reflect the needs and expectations of their local populations and improve patient access. In deprived areas where it is difficult to recruit from existing providers in deprived areas we will work with new providers to compete for contracts to provide services in underserved areas. Social enterprises, voluntary sector and independent sector organisations (including entrepreneurial GPs) will be able to tender for provision of services in these areas). But I am committed to a level playing field, and I repeat it here -as many GPs have asked me to ensure as I go round the country talking to them. They are not afraid of competition - they just want it to be fair.
Choice
11. GPs have given choices to their patients over many years. GPs have been strong supporters of choice. Initial surveys show that not only do 60-80% of patients want more choice but the great majority of GPs support that. I have to say as a professional group you have been on the right side of the argument on choice. That is why we felt confident over making the change from January 1st 2006 to give patients the right to four or more choices, where clinically appropriate, when referred by their GP for planned elective care. And since the beginning of May eligible patients can now choose not only from the four or more providers commissioned by their local PCT, but also from NHS Foundation Trusts across the country.
12. Within the coming weeks, they will also be able to choose from NHS Treatment Centres centrally procured from the Independent Sector. Later this year, patients will also be able to choose from other centrally accredited Independent Sector providers. And by 2008, people needing planned hospital care will be able to choose from any provider which meets NHS standards at NHS cost.
13. And all this is being facilitated by the Choose and Book system. Now I recognise that all this has had its teething problems. But daily bookings are now running at around 7 - 8,000 per day and we are on a fast rising trajectory. Our aim is 90% of booking through this system by March 2007. That's what I have said and I intend to repeat it. I intend to work with the profession to implement this sensibly and speed up progress in this area.
14. Choice also means making it easier for patients to move practices to obtain the services they want. That means that some practices will grow as they respond to patients' needs, although I recognise that this needs to happen in a managed way and not in any ways detract from the list system of patient care.
Practice-based commissioning
15. I want now to turn to practice based commissioning, In exercising choice the great majority of patients are going to consult their GPs because they trust them. That very trust is why we want you to take forward practice-based commissioning. You and your fellow primary care clinicians are close to your patients and you can identify their needs.
16. Practice based commissioning empowers the primary care professionals. Engagement in it is your chance to influence significantly the way local services are delivered and to provide services that best meet the needs of your patients. It is also a chance for you to act as leaders in your local health economies.
17. A few sceptics have suggested that practice-based commissioning is just a cunning Government plot to ration healthcare. It is not but it is a way of producing a more patient-centred NHS. I will certainly own up to that. Under PBC practices can provide services that are more responsive to patients, provide support to patients to enable them to take control of their own care and to provide services that are more convenient for patients. In an age where such a huge proportion of the average GPs caseload is people with long-term conditions, practice based commissioning can make their lives - and your's - more satisfying. That is why I sought to incentivise its take-up by enabling you to keep at least 70% of any surpluses to reinvest in new services for your patients. We trust you to make a success of this.
18. Sir John Oldham told me of good progress recently. In East Devon, practices are in their third year of PBC. Practices worked with the PCT to take a staged approach to adopting PBC, focusing firstly on information and then on budget setting. They are now looking at service redesign including a locally based fracture clinic and shifting some cardiology services into the community. And practices in Sheffield PCT have employed GPwSIs and nurse specialists as part of a service redesign exercise for routine outpatient appointments which has led to a 37 per cent reduction in waiting times. These are just some examples of practices using commissioning powers.
19. Views differ on how fast take-up is going. We are aware of the problems with practices still not having indicative budgets. DH evidence is that by the end of 2006 all PCTs will have put in place the arrangements to support PBC. And I have also looked at other evidence. A recent NHS Alliance survey of 102 practices found that 42% of those practices were already involved in PBC either by setting up or commissioning through local schemes. I think talking to them and Sir John Oldham we are certainly past the tipping point of 30% and I shall be making clear to the new PCT Chairs and Chief Executives (as well as existing ones) that PBC is something that they need to support and is not negotiable for PCTs. And there are some who claim they can not afford it and I give the same answer to them. The answer to those PCTs who claim they cannot afford it is that they cannot afford not to do it.
20. To help GPs we have established a comprehensive support programme to support practices to undertake PBC. I am in regular touch with Sir John Oldham on progress. He tells me of some very encouraging projects and I would encourage you and your colleagues to get in touch with him. He and Michael Dixon, I know you'll agree, can not be regarded as anything other than credible.
Accreditation
21. Primary care benefits patients when it is quality care. We need to be able to demonstrate quality if primary care is to retain the public confidence to take on wider roles. It isn't good enough to simply say that most primary care is of a good standard in England. All patients have a right to expect, at the very least, certain baseline standards; and they have a right to know which practices offer additional services or higher standards of care. Without some recognised system of accreditation it isn't fair on practices that are providing excellent care - excellence should be recognised and celebrated. And if new providers are to enter the field we need a baseline for entry, to ensure a level playing field.
22. QOF is a great success at the leading edge internationally in supporting the quality of care in an ordered and systematised way that will produce hugely better patient outcomes, as well as helping to develop higher quality public health. The profession deserves credit for moving in that direction. We want to build on this success. That is why the White Paper committed us to consider the wider need for assessment of the quality of primary care practices and other primary care providers. And we will do that, in full consultation with you as professionals. Professional ownership will be vital and I want us to work on this together, as we have with all the policies in the White Paper.
23. I freely acknowledge having had meetings with the Royal College of GPs about their accreditation scheme. We believe that this must be clinically driven and should not be bureaucratic and cumbersome for practices. But we also believe that such schemes will have real merit. This is why we will work with the profession to deliver something of real value for patients and practices. I think it is a good scheme that many practices are already using. But it will be up to the profession to say whether they agree or they think there are equally good alternatives. I was sorry to see the silly stories in the press about this scheme being an embryonic star rating system. It is not. However we do need to move forward in this area and we want to resume discussions with the profession on this issue. It must not become a taboo subject we can not discuss together and extend take up, our thinking and ideas in this area. I would hope the profession can be proud of the work their own professional body and engage in dialogue on how we can draw on lessons from the scheme in the future.
Connecting for Health
25. Finally let me turn to the importance of faster progress on implementing the electronic patient record as part of the National Programme for IT being delivered by NHS Connecting for Health. There are 3 key strands to this 10 year programme that will provide particular benefits to patients and clinicians - the electronic patient record - known as the care record service - electronic transmission of prescriptions and picture archiving.
26. Good progress has been made on the latter two. There are now 32 trusts using the PACS system ending the scrabbling around in hospital basements for X-rays. In total the new system now have 34 million images on it and the bulk of the roll out will have been done by the end of 2007. In the south of England over 50% of trusts have had a new PACS system installed and are using them.
27. Over 1.63 million electronic prescriptions have been transmitted and pharmacies are increasingly hooked up to the system. We are aiming to complete implementation by end of 2007 - bringing significant reduction in medication errors that can kill and damage patients and it will cut prescription fraud.
28. Sadly the progress on the electronic patient record has been slower than we had hoped. And I think the BMA itself recognises, a key issue remains - the lack of consensus about the best way to take forward the electronic patient record. For the sake of patients we need to resolve these differences quickly and make progress. The Financial Times editorial on 2 June challenged - and I commend it to you - the profession on this and I hope the profession will respond.
29. I intend as the responsible Minister to take a number of initiatives in this area to speed up progress. The first of these is to set a firm date early in 2007 to begin pilots for the uploading of patient information onto the summary care record. There should be no technical barriers to this and after a short period of consultation I will publish a date soon. This will enable us to transfer patient records when people change GP's.
30. Secondly and more significantly I shall establish a new taskforce to develop a detailed implementation plan for speeding up the implementation of the electronic medical record. The taskforce will be chaired by a knowledgeable lay-person and involve a cross-section of clinical representatives. I will expect then to come up with a detailed action plan by the end of 2006. In doing this I shall be asking the taskforce to draw on the work in this area done by the Veterans' Association in the United States which has had for some time a fully operational electronic patient record that benefits patients, doctors and medical education and is fully supported by the people in the medical profession who are involved in it. For those who don't know the Veterans' Association is a tax funded health care system with many similarities to the NHS. I shall be consulting the profession speedily on this and I have asked our new Deputy Chief Medical Officer, Professor Martin Marshall - who is himself a GP - to help me in this process. Martin will be taking a fuller role in assisting clinical engagement on introducing an electronic patient record. I expect to make a further and fuller announcement about the taskforce around the end of this month.
31. I have also asked the NHS Chief Executive to set out for the NHS what must be delivered on information governance and the involvement of the public to underpin the creation of the care record Service.
32. And thirdly we are developing a public information campaign to explain the patient benefits and implications of moving down the path of electronic patient records building on the work done with the profession and other on the NHS Care Record guarantee. A further announcement also will be made on this.
33. Let me be clear that I understand fully the concerns and reservations some doctors have about electronic patient records but we cannot carry on with the cumbersome, outdated and I would say - and it's not just me who say this - sometimes dangerous paper based - system. We have to make the transition and the sooner the better for patients and doctors alike. Of course we will consult fully with all professional interests and patients on the nature of the summary record and the confidentiality safeguards. But I would suggest to you that now is the time for leadership in this area and by that I mean clinical leadership as well. The prize is great in terms of patient benefits and NHS Efficiency. We have together to speed up progress in this area.
Conclusion
34. I have tried to set out very briefly an agenda in which we have common interests. I want to work closely with the profession in taking forward this agenda because I think it is an agenda for the benefit of patients and so that primary care in this country can continue to build on its high public reputation and embrace the changes we need to make in these areas. Thank you for listening.
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