Keogh review puts GPs at heart of urgent care reform

GPs should work with other NHS services to deliver fast, consistent advice and urgent care outside hospitals around the clock, an NHS England review has said.

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Sir Bruce Keogh: urgent care reform plan

The bureaucratic burden on GP practices must be cut to boost access to primary care and reduce pressure on A&E, the review by NHS England medical director Sir Bruce Keogh argues.

RCGP chairwoman Professor Clare Gerada welcomed the report for highlighting GPs' vital role in urgent care without blaming the profession for existing problems.

Transforming urgent and emergency care services in England calls for a dramatic rise in the proportion of urgent care delivered closer to home.

But it warns that ‘many people are struggling to navigate and access a confusing and inconsistent array of urgent care services provided outside of hospital, so they default to A&E’.

Sir Bruce says A&E is a ‘trusted brand’, with an average wait of just 50 minutes for treatment and most patients treated within four hours.

But in a letter to health secretary Jeremy Hunt and NHS England chairman Sir Malcolm Grant, he warns: ‘The opportunities for bringing about a shift from hospital to home are enormous.

‘We know that 40% of patients attending A&E are discharged requiring no treatment at all; there were over 1m avoidable hospital admissions last year; and up to 50% of 999 calls requiring an ambulance to be dispatched could be managed at the scene.’

Sir Bruce argues that ‘starting from scratch, nobody would design the current array of alternatives and their configuration’, warning that the complicated NHS system itself is driving up demand by ‘sending people around various services, confused about who to call and where to go’.

The review calls for a series of changes to improve urgent and emergency care including:

• A ‘significantly enhanced’ NHS 111 with access to patient records, offering advice from a range of clinicians, appointment booking or call back by GPs and others, or a transfer to 999 services if necessary.
• Faster and consistent same day, every day access to primary care and community services for people with urgent care needs.
• Improved 999 services to handle more cases ‘at scene’, with support from GP advice.
• Two levels of hospital-based emergency centre, with standard centres and a tier of ‘major emergency centres’ with consistent levels of senior clinical staffing and more specialist capability.
• The ‘array’ of confusing terms for services should be reduced by co-locating community-based urgent care services in facilities uniformly referred to as ‘urgent care centres’.

Professor Gerada said: 'We are pleased that this report recognises the vital role of general practice and other community primary care services in providing care to patients with urgent needs. It is encouraging to see a report that sets out landmark changes in the way NHS emergency and urgent care will look in the future but that doesn't blame GPs.

'It explicitly recognises the sustained pressure and multiple demands on general practice in recent years, and the need to "create headroom" to transform the way we work so that we can continue to provide safe care for our patients. For the recommendations in this report to become a reality, that "headroom" has to include greater government funding and resources, including more GPs.'

GPC deputy chairman Dr Richard Vautrey said: ‘We would agree that the current system is too complicated and fragmented.'

Proposals to overhaul NHS 111 show the GPC is 'being listened to’, he added. ‘There is a need for more clinicians involved in dealing with calls so that patients are not only directed to the right service, but are given appropriate advice and if possible treatment through that one contact,’ he said. ‘The NHS 111 call service needs to be integrated with the see and treat elements of the urgent care service.’

Dr Vautrey said GPs already provide 24/7 services through daytime work and out-of-hours care. But he warned: ‘Both services are running hot in terms of coping with high demand and workload pressures.

‘We need a commitment from NHS England to reverse the fall in the proportion of funding spent on general practice so that both practices and out-of-hours organisations can start to take on additional staff to meet these growing demands. Expecting the current number of GPs to work harder and longer will simply lead to more GP burnout.’

http://www.gponline.com/News/article/1220721/Keogh-review-puts-GPs-heart-urgent-care-reform/

Private healthcare fraud - a growing risk

MARK BUTTON 21 June 2013

A brand new report from the Centre for Health & the Public Interest highlights how the increased use of private healthcare providers in the NHS opens up considerable opportunities for fraud. The government must act to protect us, the authors suggest.

Last week, new independent think tank the Centre for Health and the Public Interest (CHPI) released a report showing that the reforms to the NHS in England introduced by the current government will lead to significant implications for the level of fraud, which have not been adequately mitigated against by the government. The introduction of markets, with large companies preoccupied with profits, combined with greater complexity will make fraud (and error) a much greater risk.

One can look to the experience of the USA to illustrate this risk. In the USA large for-profit health companies delivering healthcare through contracts with state and private insurers is the mode of delivery. There is much evidence of private companies delivering these contracts of ‘upcoding’ or invoicing for higher levels of treatment and for services not delivered. In 2009 it was estimated there were $98 billion of improper payments (fraud and error) of which $54 came from Medicare and Medicaid.

Closer to home, the recent Public Accounts Committee inquiry into the provision of out of hours care by the private company Serco found that it had wilfully falsified data on 252 occasions to misrepresent its performance under the contract that it had with Cornwall Primary Care Trust. The Committee found that the company had “fiddled the figures”to present a “false, much rosier picture of its performance” particularly in relation to emergency care. Unlike the US, where there is an effective set of sanctions for deceiving or defrauding the state in this way, no action has been taken against Serco for its behaviour. This is perhaps because politicians have yet to wake up to the increased potential for fraudulent behaviour as a result of the new NHS market.

The main body countering NHS fraud is NHS Protect, which has a counter fraud service within it. This capacity has reduced from 200 to 165 staff in recent years and traditionally most of the investigative work has focussed upon fraud by individuals, typically nurses working for agencies while supposed to be off sick, midwives submitting false overtime claims, dentists exaggerating treatments administered and consultants abusing their entitlements for private work.

The NHS Counter Fraud Service (CFS) has had some success in the past taking on major corporate entities engaged in fraud as ‘Operation Holbein’ illustrated. In 2008 the criminal case brought by the SFO against the pharmaceutical companies involved collapsed after an 8 year investigation. The case centred around an alleged £120 million of fraud by pharmaceutical companies fixing prices. The CFS, however, did receive some success through civil actions and out of court settlements with cases brought in parallel between 2002 and 2007 with around £46 million paid by five pharmaceutical companies in compensation. This case was pursued at the height of the CFS’s resources and influence and since 2007 there has been a substantial decline in the capacity of this body.

The lessons from this investigation illustrate a number of issues. First and foremost there needs to be an appropriately dedicated unit within NHS Protect dedicated to this type of fraud. Such a unit should also be equipped to utilise the civil route and other sanctions too. The reality is that criminal prosecutions in complex cases involving large sums of money against opponents with resources for high quality lawyer are very expensive and high risk for failure on legal technicalities or bewildered juries.

It is for this reason that other tools utilised in the USA should also be considered. The passage of the Crime and Courts Act 2013 provides the legislation for the implementation of Deferred Prosecution Agreements in England and Wales. Deferred Prosecution Agreements (DPA) and Non-Prosecution Agreements (NPA) have been commonly used in the USA to deal with major corporate wrongdoing. In return for non-prosecution the corporate body agrees to co-operate with the authorities, undergo additional compliance scrutiny and pay penalties/compensation. These have been frequently used in healthcare in the USA. For example in 2011 the pharmaceutical giant Merck and Co (and related subsidiaries) in relation to the inappropriate marketing of a painkiller called Vioxx in 2004 entered into a corporate integrity agreement with the US Department of Health and Human Services, paid a fine of $321m, settled a civil case for $628 million and pleaded guilty to a misdemeanour criminal charge. This ended an investigation which had been ongoing for many years. These will be initially tools for the SFO and CPS but should also be extended to NHS Protect.

In the USA another tool is the False Claims Act. This essentially gives whistleblowers a financial incentive to report fraud and wrongdoing (15 to 30% of funds recovered). Cases of merit are usually joined by federal and/or state prosecutors who also have a financial incentive to become involved. It therefore puts corporate organisations at greater risk of exposure of wrongdoing.

The new landscape of the NHS with the greater risk of fraud therefore requires the following action to meet this challenge:

(1) An appropriately resourced unit dedicated to corporate fraud should be created within NHS Protect, with appropriate staff capable of pursuing all possible sanctions and with experience of successfully doing so.

(2) Deferred Prosecution Agreements, which are to be introduced in the UK, should also become a major tool for dealing with the likely problems, based on a recognition that criminal prosecution – although desirable – is not always the most viable option.

(3) Consideration should also be given to passing a UK equivalent of the False Claims Act to encourage the exposure of fraud and malpractice by private corporate bodies in receipt of public funds, and to legislation to ban the award of a contract by any NHS body to any company, or subsidiary of a company, which has been convicted of, or settled, a criminal charge.

(4) Consideration should also be given to preventing companies or subsidiaries of companies found guilty of healthcare fraud in the UK from providing NHS services in the future, and to providing for the imposition of punitive fines on the scale necessary to provide a deterrent to multi-billion pound enterprises.

Interestingly the government has just introduced a provision within the Care Bill to make it a criminal offence for providers of NHS funded care – including private providers – to deliberately supply false information to regulators or commissioners of services. Whilst the intention behind this is to prevent providers from concealing ‘poor quality care’ – a key recommendation of the Francis Report Inquiry – the impact assessment makes no mention of the fraud issue at all, but does acknowledge that “there are incentives for providers to supply false or misleading information”. The debate on these provisions, therefore, perhaps provides an opportunity for Parliament to take seriously the risk of healthcare fraud.

Read CHPI’s new report, ‘Healthcare Fraud in the new NHS market – a threat to patient care‘ by Professor Mark Button and Colin Leys.

This article is cross-posted from the British Politics and Policy at the LSEblog

GP PATIENTS RATE EXPERIENCE 'GOOD'

Released 17/06/2013

The results of the latest NHS GP Survey show that patients are generally happy with the overall service they receive but identify areas for improvement

The majority of patients in England (87%) rate the experience with their practice as ‘good,' with almost half (45%) describing it as ‘very good,' according to the latest national GP Survey.

Those with long-term conditions were the most satisfied with just under 89% giving a ‘good' rating.

The survey covers the period from July 2012 to March 2013 and gained a response rate of 35%, equivalent to 971,232 completed questionnaires out of a total of 2.75m distributed.
The survey also indicated a shift in patient requirements.

Despite 80% of patients booking appointments over the phone, nearly a third (31%) said they would prefer to book online, and 225 said they experienced problems getting through on the phone.

Just over a third of patients (36%) were able to actually see or speak to someone on the day they initially contacted the surgery, but 15% waited a week or more to see or speak to someone.

Most who were able to get an appointment said that this had been convenient (92%), with just under half saying that this had been ‘very convenient.'

Once in the surgery, 26% of patients had to wait over 15 minutes, and while more than half (59%) are happy with their waiting time, one-in-four (25%) believe they wait ‘a bit too long'. Worryingly, 10% felt they have to wait ‘far too long'.

Over half the respondents (58%) said they knew how to contact an out-of-hours GP service. But only one in eight (13%) had tried to access the service in the past six months. Of those who did so, most found it easy to do so (79%), with 38% describing it as ‘very' easy.

However, 31% said it ‘took too long' to get the care they needed. Although (81%) said that they had trust and confidence in the out-of-hours clinician, 12% said they did not.
Overall, 70% said their general experience of out-of-hours GP services was good, with a third (31%) saying it was ‘very' good.

Dr David Geddes, head of primary care commissioning at NHS England said:" "Nine out of ten contacts the public have with the NHS are with their GP practice. The GP patient survey highlights where patients are satisfied with the service they receive, but also helps us identify areas where we could do better and where NHS England along with CCG leaders need to focus.

"The GP survey gives us insight into patient feedback on GP services in and out of hours and this will form an important part of our work to modernise and develop the contribution that general practice can make to the NHS going forward."