The brave new GMS world

pharmafile | April 26, 2004 | Feature | |   

The new General Medical Services contract (nGMS) started officially on 1st April, though its far-reaching effects may be far from apparent at first. It will present the pharmaceutical industry with a very different world, hopefully with new opportunities, though its very unfamiliarity may pose a threat to traditional practices.

Although thought of simplistically as just another revision of 'pay and rations' for GPs, it is really a revolutionary change in how services are provided throughout the NHS. GPs may do more or less, hospitals may do more or less, and there will be golden opportunities for new people to provide services. Increasingly the PCO should be seen as the critical management unit for what will happen. Individual practices will be very much pawns in a bigger game.

The services traditionally provided by primary care will be split. Out of hours care will be provided by organisations commissioned or directly managed by PCOs. There will be a circumscribed definition of 'core GMS' with much current activity outside that definition being re-defined as 'enhanced services' provided by whatever method the PCO determines, including retained in primary care, though perhaps only in selected practices, transferred to secondary care or commissioned from other bodies including commercial organisations.

A critical exercise is defining 'core GMS', those jobs all GPs currently do or would be expected to do in future.

These services will be funded by something called a global sum, based on a weighted capitation calculation. Out of this sum practices must also fund all their expenses – the days of staff budgets or other 'badged' money are gone. Given that staff and doctors are the main source of expense for practices the message is 'ean and mean'. Fewer staff, and less well paid at that, and fewer doctors will also mean greater profits and hence doctor income.

The new, lean practice team

Looking critically at the work involved in nGMS will lead to some shrewd conclusions, especially around skill mix. Many of the activities that will generate income under nGMS do not require senior health professional input – such as doctor, nurse or pharmacist – except in a supervisory capacity.

Much of this work can be defined in terms of patient interviewing with specific 'closed' questions and answers, specific technical processes such as blood pressure measurement and cholesterol monitoring, then accurate recording of this data on computer. Not only will this work not require graduate health professionals but, if they try to do it, it will probably drive them spare.

There is already talk of healthcare assistants, people who will be trained in-house or with perhaps a couple of months outside training. They could become major players in the nGMS world.

The new out of hours arrangements are likely to depend heavily on less doctor input. Partly this may mean nurse practitioners, as pioneered in NHS walk-in centres, but also paramedics. The great virtue of paramedics is they can be trained quickly to plug staff shortages, whereas nurses and GPs take several years to reach career grade. I mention these groups because my prediction is large numbers of these folk will get 'poached' by GP practices to provide day-time services.

Within a few years, healthcare assistants, nurse practitioners and paramedics could be controlling most disease management in primary care, and with that the major prescribing decisions in this high-volume area.

Quality and outcomes

Somewhat tagged on to 'core services' is the quality and outcomes framework. While all GPs will be expected to do core services, and enhanced services will be at PCO discretion, quality and outcomes sits as a truly optional extra. Practices who do it will gain some extra income though some might say not that much for the effort. If the practice meets the criteria for payment the payment is guaranteed: there is no local discretion.

Quality and outcomes is built around chronic disease management, and being based on scores for 'quality'is inevitably over simplistic. Us thinking doctors do despair at how 'Noddy' activities, like logging how many patients have epilepsy gets points, and points win prizes, but early diagnosis of rare endocrine diseases – I have had three such in the past year – counts for nothing.

This is a real dumbing down where those things traditionally equated with professional excellence are discounted against tedious and repetitive care processes.

Most interesting for the pharmaceutical industry will be the numerical targets. These apply principally to cardiovascular disease and diabetes. Cynical clinicians have always doubted the value of 'treating to target'.

Take blood pressure as an example. We know there is a law of diminishing returns on blood pressure lowering, with more health gain from the initial reduction than further incremental falls with additional treatment. In the real world, miles away from the environment of RCTs where evidence-based medicine (EBM) is synthesised, things are very different. Treatment failure is usually due to poor compliance and adding more drugs just aggravates the problem.

Additionally, patients in the real world usually have co-morbidities which complicate care, and may (Heaven forbid!) have their own ideas on how and to what extent they wish to have their condition treated.

None of this fits well with nGMS. The targets are inflexible and there are no concessions to ideas such as patient autonomy or an informed choice. As everyone struggles to get their patients to target there will be a remarkable alliance between a nGMS system based on Stalinist economic principles and a liberal, capitalist pharmaceutical industry all too ready to cash in on the consequences.

Detailing in a new world

Detailing by the industry may take on a somewhat schizoid nature. Much day-to-day management of patients will be delegated, whilst more senior practice staff may take a more detached, strategic view of clinical practice and prescribing policies.

With delegation and changing skill-mix, many prescribing decisions will be made by less qualified practice staff, who, unlike doctors have far less experience dealing with representatives. GPs have been exposed to extensive critical coverage of pharma activity in the journals and from NHS agencies which has promoted widespread scepticism if not cynicism about drug marketing. In contrast these new healthcare workers may be more receptive and less suspicious of simple marketing messages.

This effect was seen in the 1990s with the promotion of asthma management via practice nurses, where these newly influential people were much more receptive to industry messages than most of their GP employers.

With healthcare assistants and paramedics the effect may be similar. They may feel a little insecure in their new roles, or may have had, or feel they have had, little preparation for what they are doing. They may welcome a friendly face and simple well-presented information. Unlike many doctors, for them the palate for a free lunch will not be jaded.

In contrast, there may be more centralised planning of medicines management. Already there is talk of two-tier professional staffing in primary care with a small number of senior doctors and nurses consultants in primary care calling the shots, whilst employing other graduate health professionals as 'associates' or whatever. In such a structure, securing the attention of the 'consultants' may be vital to promote changes in prescribing behaviour, though these are likely to be hard people to see and harder people to persuade.

The extent to which prescribing decisions will be under PCT or other NHS management control is unclear. The pooled budget approach, where saving prescribing costs promised benefits in other health funding including sometimes cash directly to the practice might be coming to an end. On the other hand lack of funding for enhanced services, a problem shared by PCTs and their GP practices, might be a spur to new efforts at cost control with major financial benefits for doctors should the savings be possible.

In fact looking at the potential practice income from quality and outcomes which will cause prescribing costs to spiral compared to that from enhanced services, it would probably pay many practices to ditch the former to gain funding for the latter, although I suspect NHS management would stop them doing this.

Working with primary care

The traditional collaborative working with primary care has been largely centred around providing staff for jobs such as audit and medication review plus some items such as software support.

The constraints on practice finance, imposed by the global sum, may make input from pharma sponsored staff and support services far more attractive than before. This is especially true of those GPs who have traditionally tried to keep pharma at arm length.

A major change for the future is the relationship between pharma and practices may no longer be so one-sided – where pharma had the money and GPs didn't. All that could be about to change. Enhanced services do carry substantial cash rewards, provided that practices can secure the contract.

But this will often involve being able to demonstrate a better service than provided by secondary care, at lower cost and the ability to make real disinvestments from the hospital sector to fund the service. This will require innovative thinking and new resources. It is likely individual practices will have difficulty coping with this.

The opportunities will lie around business planning and developing shared resources to make local service provision possible. An obvious player in such developments would be the industry: providing a tailored package which supports primary care by 'filling the gaps' current practice teams could not deliver. In return there will not only be some brand loyalty but real money, with the pharma company and practice sharing the resultant income stream.

Depression might be a good example. A company active in the therapeutic area could apply the lessons of US-style managed care to develop a depression service with planned care pathways. Typical content might be patient self-administered psychological profiling and therapeutic programmes, besides computer-supported programmes, which could be administered by a generic practice nurse or healthcare assistant.

The company would employ a team of more specialist therapists, again with the emphasis on skill-mix and economies of scale. This would include counsellors, specialist nurses, psychologists and perhaps psychiatrists.

Working with PCOs

The rigid rules about pharma working with NHS management bodies are being rapidly undermined.

Many items of service currently provided by primary care will benefit from economies of scale which primary care teams are too small to provide. The PCOs can deal with this by  concentrating services in a proportion of practices who will provide the service not only for their own patients but other people in their locality. Minor injury services might be a good example. Imagine a medium sized, compact, urban community with six general practices, some large, some small, some with spacious premises, some less so.

The PCO would likely give the contract for all minor injuries for the area to one practice, probably the largest, best organised, best staffed and also the most persuasive. Crucial to such decisions will be economies of scale, as one large practice will be able to deliver the service far more efficiently than several smaller ones. It all comes down to money and, yet again, skill-mix.

But a further option for PCOs is to commission services from another agency, either another NHS body such as an acute trust, or a private provider such as a pharma company. This will be especially attractive for services provided in very inefficient ways by current providers.

A good example might be warfarin therapy and monitoring for the house-fast. Typically this currently involves a district nurse doing the phlebotomy, transport to get the sample to the lab, performing the INR by technicians, conveying the result to a clinician – usually a haematologist or GP – who will do the dosing. The instructions for continued treatment will then be conveyed to the patient, usually by telephone. Each step of this pathway is strewn with potential dangers.

Suppose a private company offered a one-stop mobile service? The 'worker' would be a healthcare assistant with dedicated training circumscribed to their specific functions – probably a three months training programme, if that. They would drive to the patient house, take the sample, use near patient testing to get the result immediately, then use a software support package on their laptop to do the dosing and review date. This would be at a fraction of the cost of current practice and PCOs would indeed have difficulty, given the legal framework in which they operate, in declining to use such a service were it available.

There are obvious, golden opportunities here for people of an entrepreneurial bent, such as the many readers of Pharmafocus, as well as some of the featured companies.

It is probably too soon to say how nGMS will really work out, or know with certainty how the NHS will look in a couple of years. What we can say is the world will never be the same again and for those who are winners, including those from pharma, the winnings could be very great indeed.