The Good Practice

Brighton and Hove’s family doctors have bucked the trend as fewer patients are complaining. Frank le Duc reports

The number of complaints about family doctors has risen steadily over the past few years. Many trace the rise to the new GP contract – a national agreement reached in 2004. The new contract for GPs (general practitioners) changed the way that care is provided out of hours – at nights and weekends. It has coincided with a growing pressure on hospital accident and emergency (A&E) departments.

The most recent figures show that Brighton and Hove has bucked the trend in the latest year for which figures are available. Almost 55,000 people made a written complaint about their family doctor or dentist nationally in 2011-12, up from just under 51,000. Locally the number was 466, down 15 per cent from 551 in 2010-11, after a ten per cent rise the year before. Of those local complaints, 212 were upheld (45 per cent). The numbers were published by the NHS Information Centre in the past fortnight.

The main areas of complaint were about clinical matters – delays, misdiagnoses or not referring a patient to a specialist – or communications or attitude. These accounted for more than half the number of complaints received. Others related to practice management and even issues connected with GP premises.

When it comes to premises, a spending programme has been under way in Brighton and Hove over the past few years to help those doctors currently working in the worst premises to upgrade or move. With the new Royal Alexandra Children’s Hospital – five years old next month – and the proposed £420 million revamp of the Royal Sussex, we should soon have some of the most modern medical facilities in the country.

ACCOUNTABLE AND DEMOCRATIC
All this comes at a time when the public finances are being reined in and budgets are coming under greater pressure. And the coalition Government’s reforms are encouraging greater scrutiny of health and wellbeing. When the NHS was founded, the idea was to provide free universal healthcare for all at the point of need and regardless of the means to pay. The service was also supposed to be publicly funded, publicly provided and publicly accountable with local democratic control.

One retired GP said, “The latest reforms have been much criticised for making it easier for private providers to undermine the NHS – or compete with it, if you prefer. But they have taken at least a modest step in the direction of local accountability and democratic control by giving elected councillors more of a say.

“Some of us seasoned professionals won’t always welcome politicians poking their noses into our business. And each practice is a private business, contracted to the NHS. We might well ask what politicians know about clinical decision-making. Nevertheless, we spend public money and a great deal of trust is reposed in us. And policy-makers have always set priorities, one way or another.

“We have our own interests and we haven’t always been terribly responsive to the voice of the patient. There is a power imbalance in the doctor-patient relationship. It’s not unreasonable, however, to listen to those who have been elected and to open a dialogue with them. In addition, I understand that an increasing number of practices are establishing patient groups.

“In Brighton and Hove, for instance, politicians might ask practices to make a better fist of persuading parents to immunise their children. And practices, in turn, might highlight areas where we believe more resources would influence health outcomes for the better. We have, as a profession, been a little shy of public debate, of explaining why we do what we do and of practising accountably.”

A FINITE POT
Local politicians will be turning their attention to the performance of family doctors today on Tuesday 11 September at a meeting of the council’s Health and Wellbeing Overview and Scrutiny Committee at Hove Town Hall. A report to the committee noted, “The newly reformed NHS requires GPs to play a key role as commissioners as well as care providers.” They are doing this through the Brighton and Hove Clinical Commissioning Group. This will assume many of the responsibilities – and staff – of the soon to be abolished primary care trust.

Some family doctors have expressed concerns that patients may question whether decisions to refer them to a specialist or prescribe certain medicines are being influenced by their budgets. There is, of course, a finite pot of cash to fund treatments and doctors have long been reminded of budget pressures through audits and guidance.

Locally, an organisation called Brighton and Hove Integrated Care Service (BICS) is part of this process. It is staffed by a number of local doctors, carries out benchmarking and provides feedback to practices. In one survey it found that the surgery with the highest rate of referrals sent more than five times as many patients to see a specialist compared with the lowest referrer.

If the highest and lowest were excluded, several surgeries referred between 50 and 100 per cent more patients than a number of others. Introducing the survey, Dr Peter Devlin said, “There are wide levels of variation between individual practices and individual practitioners.” And not all of the 47 surgeries in Brighton and Hove took part in that particular survey. Feedback encourages practices and individual doctors to question whether they might do things differently.

Another doctor who used to practise in the area was clear that clinical need trumped questions about cost. He said, “Every doctor is mindful of good practice. Any doctor who breaches professional ethics puts not only their patients at risk but their career. Given that only ten minutes are allotted for a standard consultation, it is perhaps surprising that there aren’t more complaints.”

SCORECARDS
The report to councillors echoes Dr Devlin’s phrase, noting that there is a “wide variation in effectiveness and delivery of primary care at an individual practice level”. In February and March 114 practice staff attended nine workshops held to explore a system of scorecards that is being used to assess local practices. Profiles of each practice, scorecards for each practice and patient survey results were provided before the workshops. And those attending were encouraged to share examples of good practice while looking at areas where improvements could be made.

An analysis of the scorecards found that there was no particular pattern in terms of locality although practices in West Hove and Portslade tended to be higher scoring. There was no particular pattern in terms of deprivation either although the two lowest scoring practices served parts of Brighton with the highest levels of deprivation. The five lowest scoring practices were all small – as were three of the highest scoring practices.

The biggest challenge, according to those attending the workshops, was access – ensuring that patients were able to see a doctor or nurse when they wanted. One GP said that this had been affected here and elsewhere by a growing reluctance to use locums, partly for financial reasons.

Other challenges included improving the rate of childhood immunisations, tackling the rise in chlamydia and dealing with growing numbers of patients with mental health problems. Care plans, flu jabs, hypertension and prescribing issues, including the prescribing of benzodiazepines, were also discussed, as was the A&E attendance rate. Action plans were produced where significant challenges were faced.

The meeting will barely scratch the surface in terms of the scrutiny of GP performance. But it is likely to pave the way for those who have been elected to work out how best to monitor family doctors across Brighton and Hove. Those elected councillors know that their job is not to second-guess the experts. But they will want clear sight of what’s going well, what the problems are and, where there are problems, to be able to read the prescription.