The vote is out

The GPC announced the result last week of the poll of GP opinions on the two possible contract options from April. The summary is basically that GPs are not happy but have voted for option A as the least worst of a bad bunch. Lots about this in the media although some have portrayed it as an agreement to do extended hours. It is not. This was about what will be taken away from practices. Whether practices offer extended ours will depend on the DES specification. That judgement will be made individually by the 8000 odd practices in England and in similar ways across the rest of the UK and Ireland.

In practical terms for this website it means that the loss calculation is no longer relevant as it only applied to the potential imposition. There is simply not enough data available to calculate the loss for the current proposals. The DES calculator is still running with the best information that is coming out in an official form. You can find a link to this in the left hand menu on the practice summary page for each practice. This applies to England only as there was no comparable patient survey in the other countries, or at least not one that I am aware of.

I am taking the link to the loss calculator off the practice pages to avoid confusion. The direct URL should work for the foreseeable future but if you want or need access to the data then drop me a line.

Six million people can be wrong

There are a lot of statistics bouncing around about extended hours. One that keeps coming up is the demand of six million patients for them. Here we have no less a figure than the Secretary of State for Health answering a question in parliament.

About 6 million people in our patients survey said that they want improved access to their GP in the evenings and on Saturdays, which is why we are seeking to reach a negotiated settlement with the BMA.

The survey he seems to be talking about here is the 2007 GP patient survey. Looking at the results things are not quite as clear as they might seem from the above answer. For a start six million people did not say anything of the sort. There were not even six million in the survey. The survey was only sent to 4.7 million people and less than half of them (2.3 million) sent it back. The people sent surveys were picked largely from those that had been to their GP in the previous six months.

So where does this figure of six million come from? Well out of those who replied 16% said that they were, in some way, dissatisfied with opening hours. Take that figure together with the population of England over 18 (just shy of 40 million) - multiply and you get a figure of around around about six million. Clearly what Mr Johnson intended to say was that if the whole adult population had been asked and they all replied he believed that six million people would say that.

Now that is a pretty rotten bit of statistical conjecture. It assumes that all of those people who did not reply would think the same way as those who did. Of course it may be they did not reply because they had not particular views. Even more ambitiously it assumes that that group that were not polled - people who had not seen their GP recently - had identical views.

Worse still it ignores the fact that only ten per cent were able to say in what way they were unhappy with the opening hours (lunchtimes, evenings etc). Only 208,000 asked for increases outside of the usual 8-6.30 Monday to Friday - about 9% of the total responses. It is difficult to call this a massive pressure. Even with the simplistic extrapolation this would only be 3.6 million. The pie chart graphically shows the responses (click on it to enlarge).

Its not just me saying this. When you pay 11 million pounds for a survey MORI gives you some quite detailed analysis - in this case 111 pages (2.4Mb) of it. So what do the experts have to say?

When interpreting the findings, it is important to remember that the results are based on a sample of patients registered with a GP in England who responded to the survey, and not the entire population of England.

The vast majority of patients (84%) say they are satisfied with the hours their GP practice was open during the last six months, while the remaining 16% say they are dissatisfied with the opening hours.

What do we know for sure then? Simply there is some demand for extended hours, but not a lot. You can read the MORI report for some detailed socioeconomic breakdown of the figures. What is quite clear though is the figure of six million people is definitely wrong.

Changes to Extended Hours DES

In the fast(ish) moving world of GP contract negotiations the finances of the extended hours DES have changed again. In his latest letter to the profession Lawrence Buckman has announce an increase in the rate of payment from £2.80 to £2.95 per patient for extended hours. It has also been clarified that the survey will be in QOF and not part of the extended hours DES

This is in general good news - there is more cash for providing extended hours under the DES although and this is surprisingly substantial for many practices. I have updated the extended hours calculator which can be accessed from left hand menu the practice pages.

I have also corrected a bug which overestimated the hours required for about one in six practices. Sorry about that and thanks to the eagle eyed reader who spotted it.

The contents of the DES are still far from fixed as you can see here and here.

Questions in the House

Perhaps an old fashioned phrase to describe a significant event but there have been questions in Parliament about the QOF. At health questions this week the Alan Johnson defended of putting cash into extended hours rather than clinical areas. He accused the BMA of propaganda in suggesting the reverse. That suggestion seems to have produced a sharp intake of breath from the Honorouable Members. Ultimately though, like most parliamentary answers, there is more heat than light here.

Overextended?

The changes to the QOF detailed on this blog and the detailed calculations of losses under the proposed contract imposition are only a relatively small part of the current issues between GPs and the government. The central issue from Numbers 10's point of view appears to be extended hours. If the governments proposals are accepted then a Directed Enhanced Service will be commissioned for these extended hours. The politics are complex an I would direct the interested reader to Lawrence Buckman's letter to the profession.

The fundamental drive of the DES is that there should be 30 minutes of extra time per one thousand patients on the list to be delivered in 90 blocks in the evening or weekends or 60 minutes in the mornings. We are, however on shifting sands here. A new provision brought in at the end of January is that there should be no time when reception is closed during the core hours. Any reception close would have to be replaced with clinical time. The extended hours would be agreed with the PCT and based on the results of the GP Patient Survey, a national survey of patients about primary care.

The results of the patient survey have been published and so the figures can be used to work out an estimate of the impact of the DES. What I have done on this site is to calculate the amount of time required from each practice and then allocate those hours according to the result of the survey. Thus is 51% wanted weekend access and 49% evenings and there were two sessions to allocate then there would be one to each. If there was only one it would go to the weekend. A fairly simple formula but it does make it easy to automate. The ultimate detail is in the source code.

The results can be seen on the practice pages. The summary is that it is not the couple of hours a week that many imagined. 55% of practices will be required to produce three hours or over on a Saturday. Around 160 practices would also be doing Sundays under this formula. Interestingly only eight practices would be required to provide early morning surgeries.

Some of the problems with the current proposals are also seen. It is widely reported that simultaneous surgeries would not be permitted (i.e. you could not supply three hours of time by two GPs working for 90 minutes simultaneously). One of the effects of this rule is that opening hours for smaller practices will be considerably less than those for larger practices. Under this rule two practices would be open from 8am on Saturday until half past midnight on Sunday morning. Clearly this is absurd.

I will try to keep the model updated with changes, but there remains a lack of detail in these proposals, and much of the detail that does exist may not be that practical. Obviously if anyone from the government side of negotiations knows better then the email address is below!

Who loses what?

As many of you are probably aware the site has had information about the potential loss of cash to practices under the government's proposed imposed changes to the QOF in England. If you have not seen this you can click on the link on the left of each of the practice pages. There is also table of the changes effects at PCT level.

Of course now that we have these statistics we can look at the breakdown a little. As I have said before the threshold changes will mostly affect those who have had most problems in meeting the targets. The practices that have tended to have lower score have tended to be those in more deprived areas. A reasonable hypothesis would be that more deprived practices tend to loose out more.

We can go onto test this. Helpfully the deprivation index for most practices was published as part of last year's GP patient survey. We can put all of this together in a spreadsheet and work out the loss per patient for the threshold changes and overall for whole set of changes. Not difficult as we have practice list size from the QOF data as well.

As it turns out there is a correlation between the deprivation and the cash lost through threshold changes at practice level. For the mathematically minded the correlation is 0.13 - not particularly strong but it is there. In practical terms the thousand least deprived practices are to loose 62 pence per patient whilst the thousand most deprived practice will loose 84 pence per patient - a difference of 12 pence. For a "typical" practice of 5891 patient this works out at £1,287 per year between the most and least deprived practices.

This all looks pretty bleak but there is another factor that works against this effect. The removed points take more from practices that have gained all of these points in the past. Statistically these tended to be practices in the least deprived areas. If we bring in the removed points then the effect almost disappears. The correlation drops to 0.03 which is small enough to be ignored.

So balance is restored - whether by luck or judgement! It does however give some idea of the less obvious effects of changes to QOF.

Less cash for QOF says HMG

It has been a busy few weeks. Just as I was starting to digest a report suggesting the development of the QOF then the negotiations for changes to next year's GMS came crashing to a halt. The report is still worth reading, if only for the summary of research done with QOF data thus far.

There is a pretty good summary of the situation in a letter from Laurence Buckman - chair of the GPC which I would recommend reading. In summary, for the impatient, the government (only in England for now) is imposing changes to the contract to move cash from QOF and Choose & Book and put it towards increased hours of availability. This, we are told, its only priority for primary care this year. Arguably this is a move from quality to quantity

As far as QOF is concerned several indicators are to be removed taking with them a total of sixty points.

• Holistic points (20 of them) - points for consistency - all gone
• Records 3 (1 point) - communication with out of hours service
• Education 4 (3 points) - induction training for new staff
• Management 2 (1 point) - computer back up
• Management 4 (1 point) - instrument sterilisation to national standards
• Management 6 (2 points) - job description for all new posts
• Management 10 (2 points) - employee procedure manual (absence, bulling etc)
• Medicines 4 (3 points) - repeat prescriptions in 72 hours - 48 hour target remains
• Medicines 11 (7 points) - medication review for patients on four or more medications (review for all patients remains)
• CS 5 (2 points) - there is a system for inform women of smear results
• CHD 12 (7 points), Stroke 10 (2 points), DM 18 (3 points) and COPD 8 (six points) - flu jabs in high risk groups

As there are 1000 points in the QOF a rather obvious bit of maths shows a 6% drop already. There is more, however. Initially the scoring area for each of the indicators started at 25%. This was increased two years ago to 40% and this new imposition will increase it to 50%. The top thresholds for payment will also be increased to something around the mean of current achievement. This second part is likely to be more significant for most practices. Pretty much by definition half of practice would be expected not to hit this higher threshold.

The effect of all this remains to be seen. We already know that exception reporting tends to be reactive - i.e. there is more exception reporting when below the threshold than above it. This is largely because practices stop reporting when they get over the threshold. It would not be unreasonable to expect a bit of an explosion in exception reporting with these changes. Of course there will almost certainly some increase in achievement but the extent is uncertain.

We can use the data we already have to try to model the effect of these changes - and apply them to last 2006/7 data although with the caveat above. This should be online in the next day or so.