"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Sunday, 29 June 2014

Name and Shame and Patient Choice of GP Practices

Jeremy Hunt's latest announcement is that GPs should be "named and shamed" for poor cancer referral rates. (The article is in the Mail on Sunday, I won't link to it here, but you can find it through an internet search.)
"Under the Government’s planned reforms, surgeries will be ranked as ‘green’ for cancer on the NHS Choices website if they quickly refer patients to hospital when they are showing possible signs of cancer. But if they miss too many cancer cases – or if patients have to return numerous times before being sent for tests – they will be classed as ‘red’."
This plan has been criticised by doctors,
"the Royal College of GPs has criticised the proposed rating system as ‘crude’ and said the Government should be ‘supporting GPs, not criticising them’"
This sentiment was repeated on BBC Broadcasting House on Radio 4 by Dr Sarah Wollaston, Chair of the Health Select Committee and a GP. Dr Wollaston said that the policy could lead to over-referral which would "clog up the system".

There are other reasons to reject this idea. Over-referrals are bad for patients because they cause anxiety to "false positive" patients, cause unnecessary tests and potentially damaging interventions.

The announcement also doesn't recognise that cancer is more effectively beaten with improved public health.

The whole "naming and shaming" idea is flawed. At present GP patient lists are geographically based, and while there is some choice at the boundaries, most patients are registered at the practice in the area where they live. It is well known that this ideologically-driven government want to change this.

What happens when the cancer diagnosis rankings appear on the NHS Choices website and a patient finds that their practice is 'red' rated? Hunt's gut feeling is that the patient will move to another practice with a better rating, and this "market" behaviour will improve incentives and quality. However, under current situation, this will not happen because changing practices is not a simple thing for patients to do. A 'red' rating will cause unnecessary anxiety amongst a community who will have no choice other than the practice badly rated (even though it may well be unwarranted). So why has Hunt come up with this policy?

In the 2010 Health White Paper the government said:
"Give every patient a clear right to choose to register with any GP practice they want with an open list, without being restricted by where they live. People should be able to expect that they can change their GP quickly and straightforwardly if and when it is right for them, but equally that they can stay with their GP if they wish when they move house."
So what has happened to this policy? The results are mixed. The BBC, as ever acting as the mouthpiece for the Department of Health says:
"The lead author, Prof Nicholas Mays, said: "While demand for the pilot was modest, our evaluation found that patients had positive views of the scheme."
However, Pulse Magazine, the trade magazine for primary care, is less enthusiastic:
"The long-awaited report into pilot sites concluded that, despite positive feedback from users, there was little demand from patients or practices and called on the Government to consider alternatives to support increased access."
Pulse reported figures from the study that the BBC chose to ignore: "More than a third of the practices taking part in the Government’s ‘choice of GP practice’ pilots failed to register a single patient from outside their area". This is hardly the "modest demand" that the BBC reported, it is a wholesale rejection of the idea.

There are good reasons why this idea should be rejected. Pulse says of the study:
"It also found that commissioners had big concerns about the potential destabilisation of general practice and impact on the wider health service if it was to be rolled out nationally."
Commissioners are under immense pressure at the moment to meet increasing demands due to an aging population, government diktats about integration and moving care out of hospitals, while at the same time having to meet unachievable targets to reduce A&E attendances. All of this must be done with a budget that is static and inadequate. The last thing they need is one more destabilising policy.

The "choice of GP practice" pilot has shown that few people want to change practice, so it is possible that someone in the Department of Health has said: if there's no demand for this policy, why not create it? If a GP practice has been labeled "poor" at cancer diagnosis then there will be demand from some worried patients to change to a practice that has a good rating. Thus cancer diagnosis rating has a potential to create the demand for patients to practices.

It is not too far fetched to suggest that the whole point of Hunt's cancer rating announcement is to create the demand needed for the failed "choice of GP practice" policy.

UPDATE 23.00

Dr Clare Gerada tweeted the following at 21:36:

This puts another perspective on Hunt's cancer name & shame: cancer is rare and so the diagnosis rate of each GP is small. This means that it will be difficult for NHS Choices to come up with a criteria to use to determine when to give a "green" or a "red" flag. Going on this tweet, it seems that the cancer diagnosis rating flag will be a non-starter.