Official Yearbook & Annual Review 1998
| FOREWORD | PREFACE |
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National Association of Fundholding Practices
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Web Site: http://www.primarycare.co.uk/
EDITOR Dr David Tod
PUBLISHER David Selwyn
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Dr. Kenneth Scott
The Government's commitment to end Fundholding in England on the 31st March, 1999 inevitably means that this will be the last issue of the NAFP Yearbook and I regard it a privilege to be invited to write the Foreword for this edition. On behalf of NAFP it gives me the opportunity to recognise the invaluable contribution fundholding practices have made to improve the quality and delivery of health care in the United Kingdom.
NAFPs first Yearbook was published in 1993 and the foreword was written by the then Secretary of State for Health who acknowledged that "... Fundholders have been at the forefront in improving the quality of care and developing new and exciting ways of delivering better services".
The present Government has recognised that given the opportunity, with the introduction of the NHS Reforms in 1991, GPs and their managers have had a major impact on the delivery of health care. This is evidenced by their White Paper "The New NHS" which expects primary care professionals and managers to fashion the future health services through Primary Care Groups and Primary Care Trusts.
During the past 5 years the production of the Yearbook has kept pace with the continuing improvements in health services both in its delivery and management by the ever growing number and variety of innovations that have been introduced by Fundholders and Multifund practices most of which have been practice based. Perhaps the greatest achievement has been the success of the Total Purchasing pilots which were originated by a pioneer groups of Fundholding GPs in 1994 and which form the model for level 2 PCGS. Many of these developments have been recorded in editions of the Yearbook.
We must also admire the Primary Care Act Pilots which include both fundholders and nonfundholding practices and individuals who are navigating unchartered waters of budgets for primary care (PMS) which will be a key feature in the unified budgets of Primary Care Groups.
All members of Fundholding and Multifund practices can be justly proud of their achievements in improving the delivery of health services both in the primary, secondary care and community services.
In our tax funded health service the Government directs the level of provision and allocates the resources to meet its objectives. The present administration is committed to build upon success, consequently in putting GPs, practice and community nurses in the forefront of delivering "The New NHS" it recognises the achievements of primary care professionals and managers and seeks their support in achieving a "Modern and Dependable NHS".
The Government has offered us a challenge which we cannot ignore because fundamental to the success of the White Paper is the development of a sound infrastructure in primary care which will be in the hands of PCG Boards. This development is essential to support the ever developing complex health services that can only be provided in the secondary and tertiary sectors.
It is the primary care professionals who understand the needs of their community that are crucial to managing a unified budget effectively. The responsibilities of PCGs are considerable and the journey through to Primary Care Trusts will be exacting and their success can best be achieved by a pragmatic partnership with Health Authorities, Social Services and Trusts together with the appropriate level of support for practices.
The Government's plan to raise clinical standards, improve quality and equality in the NHS is applauded by NAFP who recognises that success can best be achieved by closer working with all professionals involved in the delivery of health care. It is for this reason that NAFP and the Association of Independent Multifunds have formed a new organisation "The National Association of Primary Care" (NAPC). A principle objective of the new organisation is to represent the interests of all health professionals and managers involved in delivering health services all of whom are welcome to become members.
On behalf of the Council of NAFP I hasten to wish the new Organisation every success, and thank the editorial team for another excellent edition of the Yearbook.
Dr. Kenneth Scott OBE FRCGP, President NAFP
Dr David Tod
1998 sees the publication of the fifth NAFP Official Yearbook. It is appearing at a crucial time; 1998 saw the 50th anniversary of the creation of the NHS, during this time enormous changes have taken place in the way healtheare is delivered and in the way the NHS has developed.
Towards the end of that period Fundholding was created and along with it the NAFP, of which I had the honour to be the first Chairman, and later President.
Although fundholding achieved a position of influence and growth, so that it represented 60% of general practitioners, it failed to seize the imagination of a large minority of general practitioners and it became obvious that the voluntary aspect would need to be addressed if a genuine primary care-led NHS was to be created.
The new government's thinking has led to a natural development of fundholding into the creation of primary care groups, based on a population of about 100,000 - a population roughly the size of many centres of population and a number which health economists agree is the minimum necessary for proper 'risk management'.
1998 has seen the NAFP exerting considerable influence, which has continued to grow, on the NHS Executive, Civil Servants, and Ministers in the way primary care can develop; taking into account the lessons learnt from fundholding, total purchasing projects and the community action pilots.
Whilst the reply to the GMSC by the Minister of Health to their seven points raised over the primary care groups is most reassuring, those with a background of fundholding wait to see how the problems of practicebased budgets will be tackled and the legal framework addressed.
1998 has seen also the development of a new relationship between the NAFP and AIM (the Association of Independent Multifunds). It is sad that this new relationship, which has led to the creation of the National Association for Primary Care, did not include the organisation representing commissioning, but hopefully in time the new organisation will become the priunciple organisation representing all PCG'S, just as the NAFP was the only repesentative GP body involved in active participation within the NHS, so I believe the new NAPC will eventually become it's successor.
I have no doubt the NAPC, which had its successful launch earlier this year, will operate with the same degree of success as the NAFP.
This edition includes several contributions concerning the white paper and the future of primary care, for which I make no apology, as they represent the personal views of those with influence and at a time of change it is important to listen to those with experience.
As usual contributions from many distinguished experts are included concerning many different aspects of practice and I extend my thanks to all those who have contributed to this (the last NAFP Yearbook) and previous editions.
Dr E.D.M.Tod OBE FRCGP, Editor, NAFP Yearbook,
and Immediate Past President and former Chairman, NAFP
Mr Clive Parr
At the time of writing, Primary Care Groups are being formed, and yet another batch of guidance is being distributed to GPs about how the system will work. The Association has been heavily involved in influencing the guidance, and will continue to be so involved. The question that everyone is asking is, of course, "will the new system of PCGs be as successful in bringing about change and development as fundholding and multifundholding has been"? I suppose the answer to that question will not be known for a year or two. The guidance on making the new system work is voluminous. There is lots of detail, and the danger is that the new system could turn into a bureaucracy. Indeed this is recognised in the guidance itself, and the Ministerial statements, where pleas are made that PCGs should not become "talking shops" but rather management systems, for empowering and developing primary care teams, to provide and commission high quality services for patients. And, we would all wish to say "Hear! Hear!" to that.
The difficulty is that the omens, in many senses, are not good. There is an old adage that is very difficult for anything big to get done. This is certainly my experience, as a Health Service Manager, going back over the years. Most management theorists regard PCGS, even with a hundred thousand population, as being too large. We now know that some PCGs will be well over two hundred thousand in size - far too large - and some will be around fifty thousand. The chances for success in the smaller areas seem to me to be very much greater. Professor Donald Berwick, from the Institute of Health Improvement in Boston USA, and a leading observer of health care management systems, has also recently suggested that control over health care must be kept as local as possible, with small groups of health care professionals being entrusted with the care of as few as ten to twenty thousand patients. Speaking at the Fiftieth Anniversary Conference of the NHS, organised by the NHS Confederation, in June 1998, he suggested that the success of fundholding should have been built upon, rather than submerged into much larger primary care groupings, with all the bureaucratic controls that such a system will inevitably bring.
Much, as always, will depend on local management - the key relationship between PCGs and Health Authorities, where these are good, then there is a chance of success. The problem is, there are currently too many "ifs and buts" to be certain.
The National Association of Primary Care
Once it became clear that fundholding would be replaced by a system of primary care groups, the Association reviewed its current role. By joining with the Association of Independent Multifunds, we have, over the last few months, been able to create a new organisation that we expect to become the leading primary care organisation in the UK. The new Association will represent not only Primary Care Groups, but also practices and members of primary care teams. We have also been pleased with the interest expressed in the new Association by Health Authorities, and professional organisations and companies working in the setting of health care. There is no doubt that a new Association, representing the wider interests of primary care, is much needed, not only to represent the interests of primary care, (and in particular Primary Care Groups), with the Government, but also to facilitate change and development locally through seminars and conferences, and to provide a help-line service and other support for members across the country. We have received strong encouragement from Health Minister, Alan Milburn, in our endeavours to establish a new Association, and he kindly attended the launch of the new Association in July.
It will be seen that we have had an extremely busy and eventful year. We have endeavoured to keep in very close touch with our members, as always, and have conducted a number of surveys to gauge opinion. In addition, I have spoken at several meetings across the country, and am always pleased to accept invitations from local members, not only so that I can convey the picture from the national level; bur also hear from the grassroots. We have organised a number of seminars and conferences during the year, and it is particularly pleasing to report the success of our Annual Conference in Harrogate, back in November 1997, and an extremely well-attended one day conference at the QE II Centre here in London in February.
Next year will see major changes for fundholders and the Association. We have laid the groundwork for the new Association and we believe it will have a crucial role in the inevitably difficult period of change that is now confronting the NHS.
Clive W. Parr, is the General Manager, NAFP
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