Doctors and nurses - Reform

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Doctors and nurses
More doctors, more nurses
Most of the available statistics of productivity in the NHS relate to acute care. In contrast, there is only
limited data on the productivity and quality in community and mental health services, as well as primary
care. However, there is considerable evidence to suggest poor value for money in these services. The Audit
Commission has shown considerable variation in bed use for mental health services, while analysis by
Beacon UK has shown that 50 per cent of patients admitted to hospital could have been treated in a
community setting. 134 Beacon’s analysis also found that one in four patients were not seen by a consultant
psychiatrist in the first week of admission. There is also evidence to suggest that crisis resolution and home
treatment (CRHT) teams are not operating at their full potential. 135 In community services there is wide
variation in the number of visits made by district nurses and health visitors. 136
A cottage industry
Spending on primary care services in England was £8.3 billion in 2010-11, with 80 per cent of spending
going on workforce costs. 137 While there has been greater shift towards group practices, primary care
remains a cottage industry dominated by small independent organisations. 138 There is considerable
evidence to suggest that the quality and efficiency of services is highly variable, while primary care services
are poorly measured and consequently poorly managed. There is also considerable opportunity to improve
productivity in primary care. McKinsey & Company has shown that low-performing GPs can spend less
than 30 per cent of their contracted hours actually seeing patients. 139 The quality of care in primary care is
also highly variable. As a King’s Fund commission found, wide variation in the rates of referral and
prescribing by GPs. 140 Despite recent reforms to GP contracts and the introduction of the Alternative
Provider Medical Services contract, the majority of partner GPs are contracted under the national GMS
contract and there remain very few non-NHS or even non-GP providers which are delivering primary care
services. 141 Consequently, GPs’ monopoly of primary care services largely remains intact and it is very hard
to exit poor quality GP practices. While improving the quality of care out of hospital also demands more
flexible and responsive primary care services, several studies have highlighted GP contracts as a major
barrier to integration. 142
Pay not performance
Over the last decade the rise in pay in the NHS was greater than the private sector and across the public
sector. While pay rises were meant to deliver productivity, the rise in pay in the NHS was far in excess of
productivity improvement. The last Government introduced three major pay reforms for NHS staff: the
2003 Consultant Contract, the 2004 GP contract and Agenda for Change for all non-medical staff.
Successive National Audit Office reports have demonstrated that pay deals did not represent value for
money. 143
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134 NHS Confederation (2011), Efficiency in mental health services: supporting improvements in the acute care path.
135 Audit Commission (2010), Maximising resources in adult mental health; Beacon UK (2012), Are mental health patients getting the right
treatment.
136 Crump, H. (2009), “Variation shows NHS community services ripe for efficiencies”, Health Service Journal, 13 August.
137 Taylor, K., George, R. and Hammett, S. (2012), Primary care: Today and tomorrow: Improving general practice by working differently,
Deloitte Centre for Health Solutions.
138 Ibid.
139 McKinsey & Company (2009), Achieving World Class Productivity in the NHS 2009/10 – 2013/14: Detailing the size of the opportunity,
Department of Health.
140 Goodwin N., Dixon A., Poole T., Raleigh V. (2011), Improving the quality of care in general practice, The King’s Fund.
141 Ellins, J. et al. (2009), “Opening up the primary medical care market”, British Medical Journal, Vol. 338.
142 Dixon, A. (2011), “Is the GP contract a barrier to integrated care?”, The King’s Fund blog, 4 November.
143 National Audit Office (2009), NHS Pay Modernisation in England: Agenda for Change.