I used to love Yes Minister. The civil service is full of very clever and erudite people who are hugely creative.
Their brilliance shines through in the guidance just issued to PCTs and clinical commissioning groups on strategies to achieve cost-effective prescribing. As it says in the widely circulated Chief Executive’s Bulletin, “This guidance reflects the decision of the European Court of Justice on the legality of prescribing incentive schemes.” The DH website points the reader to paragraph 7; what does this say?
“Prescribing Incentive Schemes
7. PCTs and clinical commissioning groups operating prescribing incentive schemes to support the implementation of switching strategies should follow some additional principles about the payments made under such a scheme:
i. PCT Boards or Professional Executive Committees should be made aware in advance of any incentive arrangements supporting a switching scheme. Details of the incentive arrangements, including success criteria and underpinning therapeutic evaluations, should be published on the PCT’s website;
ii. All payments under a scheme should go into practice funds and not to individuals. The scheme rules should specify that payments must be used for the benefit of patients, and, for audit purposes, practices should keep written records of expenditure;
iii. Incentives should not conflict with or duplicate other funding rules, e.g. QOF. Payments or any other inducements to good practice must not reward prescribers or their practices simply for blanket prescribing of particular named medicines (i.e. without consideration of the individual circumstances of patients).”
This seems eminently sensible, for the most part. It is the statement that, “All payments should go into practice funds and not to individuals,” that perplexed me. Then I realised how clever the civil servants were being. They are playing on the fact that most people think GPs are salaried – employed by the NHS. The reality is GP partnership draw profits based on the difference between practice expenses and the income generated through a complex stream of capitation, item of service, and quality payments.
So, as a GP, I simply offset the incentive scheme against the cost of my practice nurse or administrative staff who will, undoubtedly, be helping deliver care, to the benefit of patients. The money continues to help the bottom line and has no impact on my profit margin. Ergo, I as an individual am benefiting but it is virtually impossible to prove. Unfortunately, it does mean practices will have to set up a process which “audits” this, but GPs are used to hoops and jumping.
Unless, of course, knowing the impossibility of actually being able to comply with the guidance means that every PCT, fearful of a legal challenge (as the accountable body), will simply have to abandon prescribing incentive schemes and give the money back to the Treasury as a saving – surely that isn’t the intention? Is it?
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.