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Securing our future health: Taking a long term view-The Wanless report

• Links between medicine and social care
• Lack of regard for preventive care
• The disease/NSF-based approach

1. There does not seem to be any real recognition of the inter-dependence of health and social care, although the links are acknowledged. There is little recognition of the need to examine funding of these two aspects of care together, nor of the momentum being built up for so doing.
2. In keeping with the lack of emphasis on primary care, there is only passing reference to prevention and the debate about funding this as opposed to curative medicine. It is realistic not to hark back to an excessively Utopian view of the potential for prevention to eliminate the need for investment in curative medicine and indeed this is clearly flawed. Equally however, it seems to be wrong not to put more emphasis in the area of prevention considering the potential return from it. This is especially the case in conditions where there is a strong evidence base for preventative care, e.g. Coronary Heart Disease.
3. This lack of emphasis on prevention is another aspect of the apparent lack of regard for primary care. While the NSFs do emphasise the need for preventative care, only those parts which relate to secondary care seem to have been highlighted as major cost pressures. While we would not suggest for one moment that secondary and tertiary care issues do not provide cost pressures, they need to be seen alongside those of primary care. The disease/NSF-based approach risks a reductionist view of health and health care. Although this is an important perspective, it should only provide one stream of evidence for the long term view. It is also wise to take a more holistic view of patients rather than chopping them up into different diseases, this holistic approach is one that has been taken by GPs for many, many years.
4. We comment further on this approach later in our response to Chapter 8.
5. Except for one brief mention on page 142, the Report does not adequately deal with the challenge of co-morbidity. It is highly likely that co-morbidity will constitute an increasingly important aspect of health services challenges in the next two decades, and it needs more discussion in the report, both in the context of risk factors for ill health as well as for co-ordination of services across types of providers. It is also probable that more technologies will lead to more co-morbidity and therefore onto polypharmacy. The whole area of polypharmacy also needs more discussion in the report.
6. Most of the data is based on the white population. Caring for an ageing ethnic population is likely to present a huge challenge and add to costs. More data on specifically the south Asian population needs to be included and analysed. For example, diabetes and heart disease is up to four times as common in ethnic populations than in the white population.
7. We regret that the whole of England is considered as a single unit. We would suggest that, within this country there would be areas of greater disparity than there are between UK countries. London, in particular, has areas of great affluence and great poverty, and it is an error to consider it to be homogeneous. England also has ten times as large a population as Scotland, which introduces peculiar problems of communication and diversity.
8. The Review does not consider two of the three elements of the cost of delivering a high quality service: the cost of changing processes e.g. training, altering buildings or equipment, and motivating change; and the cost of monitoring the change e.g. audits. The Review instead focuses on the third element: the cost of the process itself e.g. the cost of the drugs or the workforce. The other two elements need consideration.
9. We are also concerned that the Review does not mention pharmacists and their future role in health care. We would suggest that, in particular their role in self-care should be investigated. We discuss the concept of self-care further in our response to Chapter 11.
   Comments on specific chapters
10. We are pleased to see that the Review acknowledges the high level of patient satisfaction with their General Practitioner. We also note that access to general practice is not cited as a major problem but rather access to consultants and A&E. This leads us to question, as we have since it was announced, the target of access to a General Practitioner within forty-eight hours as announced in the NHS Plan. We believe that only patients with urgent problems require such fast access, for others a slightly longer wait is acceptable. Forty-eight hour access has placed an unnecessary burden on an already over-worked profession whilst not significantly benefiting patient care.
11. In our view there is a mismatch between expectations of the general public and expectations of patients; these two are often interchanged indiscriminately, but they are not the same thing. In general, the public wants fast access and a free service. Patients want the best quality care when they need it - without having to fight for it, pay for it, or wait for it.
12. Changes to the way that services are delivered are inevitable. Advances in medicine will mean that patients can have minor operations or other procedures carried out in GP surgeries. Funding for these services should follow the patient to ensure adequate resources are directed to areas where treatment is being delivered.

 

Q7.1

1. There may be a move towards a general acceptance that some services will require to be paid for in future. Many patients already pay for treatments like Chiropody and Dentistry privately. If this becomes the case then patients will expect a better service than that currently delivered by the NHS.
   Q7.2
2. The public will demand better and more services as a result of the increasing information on health issues supplied by national and international providers. It is understandable that their expectations will be high as long as patients themselves, or their relatives or friends, receive care which is less than satisfactory. As long as where it is evident from experience in other countries that it is possible to receive better care, patients will remain dissatisfied.
   Q7.3  
3. Universal and fair needs to be included in the list.
   Q7.4
4. This is the most poignant question asked in this section and the answer is a resounding yes, of course.
5. This chapter is devoted primarily to the diseases featured in the report. If these diseases are to be the focus of quality efforts, Chapter 5 should make some effort to provide evidence that the UK performs poorer in these disease areas than the other comparison countries. We understand the reasoning why these conditions were chosen, but the underlying rationale of the report is that the UK lags in performance in international comparisons and yet no evidence is provided that these five conditions account for the poorer performance.
   Q8.1
   The extent to which the five bullets are aligned with the health needs of the UK is unclear. Is there any evidence to suggest that they will improve the position of the UK relative to other countries, or are they to be defended on their own merits? The answer to this query depends on the answer to these questions.
6. NSFs:The report looks at costs of introducing the treatments/therapies required by the NSFs. It examines the costs of extending the treatments to those who are not receiving them at the moment, but seems to assume that these patients are not currently receiving any treatment. There may be some savings to be made by cutting out inappropriate treatment and these estimated savings should be subtracted from the estimated costs of introducing NSFs.
7. The economic benefits and/or health gain of preventative care are discussed in the overview to the Report , but they do not seem to be taken into the calculations of the impact of NSFs except in the case of the mental health NSF.
8. There is no reference to the costs of managing the implementation of the NSFs, and of continually updating clinical practice as the NSFs are updated. These may include costs of professional development and also the management costs of reviewing and changing the patterns of service delivery to enable the new treatments/therapies to be delivered. There is an assumption that the same patterns of service delivery will be appropriate for the new clinical practices.
9. The costs of the structures for developing and updating NSFs, guidelines and audit tools are not mentioned – i.e. the costs of NICE at a national level and the costs of local adaptation and implementation of guidelines. The ambitious programme of guideline development and technology appraisal which will need regular updating, is not referred to.
10. Clinical governance:although there is a brief mention that all staff will need protected time for clinical governance, there is no analysis of the numbers of new management posts associated with clinical governance. The need for protected time for staff who are not directly employed within the NHS e.g. practice nurses, must be taken into account.
11. We note that the Report assumes that General Practitioners, and some other health professionals, currently spend 5% of their time on clinical governance activities. We would like to point out that this is not protected time. We also believe that the timescale of 2010 for all health professionals to have 10% of their time protected for clinical governance activities is too long.
12. Despite this lack of protected time, we would like to point out the enthusiasm with which General Practitioners have taken up the College quality awards. Uptake of Quality Team Development and the Quality Practice Award, both launched within the last few years, has been high. This coupled with the steadily increasing uptake of our more challenging quality markers; Fellowship by Assessment and Membership by Assessment proves that General Practitioners are committed to quality practice. More information on these quality awards is attached at Appendix 3.
13. It may be beyond the remit of the Report to consider the appropriateness of the models of quality which are beginning to dominate the health service. However, investing in ensuring compliance with targets and performance indicators is not inevitably beneficial to health. Some aspects of clinical governance may introduce inefficiencies and a concern with paperwork rather than real quality improvement.
14. NHS Estates:renewal of the estate is certainly important, but a higher level of investment in cleaning and maintenance is probably needed across much of the estate - new as well as old. It is not clear if the different financial arrangements for estate in primary care have been included in the calculations. Increased activity in primary care will increase the need for buildings as well as for staff.
15. ICT.Throughout the document much comment is made about the poor level of investment in ICT. The emphasis in the report is on how better ICT will help people take more responsibility for their own care. We would not wish to quarrel with that but there needs to be rather more emphasis on how better ICT would help NHS staff, including health professionals to deliver a better service.
    Q8.2
    The chapter seems at times to confuse choice with quality - they are not necessarily the same thing. The priority must be to provide accessible services which are fit for purpose to the whole population. If there is acceptable quality available to all, the issue of choice becomes less important. Where choice is directly related to improved health outcomes, e.g. through greater compliance, then it is appropriate to invest in choice. Equally where it leads to greater efficiencies, e.g. by reducing wasteful non-attendance. However, some types of choice may be more to do with political ideology than health care. It may be more important to make it clear that some limitations on choice are necessary in order to use resources to provide a universal fit-for-purpose service.
16. The report does not consider that there may be a tension between increasing patient choice and implementing guidance such as NSFs.
17. Issues relating to the elderly seem to lack depth and breadth. The emphasis on patient expectations and the removal of age discrimination is welcome. However we believe that this report really does not address the issues faced by the elderly or by the NHS in dealing with them. It may be that this is beyond a report on funding, but it does have very serious implications for funding.
18. Many patients would seem to want to make choices for their care which relate as much to their comfort and convenience as to technical quality and longevity. Increasingly we feel that a distinction must be drawn between making decisions purely based on grounds of age and making decisions based on a holistic approach to patients problems including the existence of multi-system disease and general frailty. These are clearly very significant ethical issues, but will have important consequences.
19. We question the assumption that fitness into old age implies that health problems up until that time will be of a minor nature. It seems perfectly possible that the problems that occur on the route to old age may still be major and therefore expensive even though they become increasingly survivable.
20. We would also question the assumption that there will be "a greater affluence of the next generation of older people" (para 2.54). We are not convinced that this is pre-determined, especially as the State pension system appears to be being dismantled. We are more likely to have an underjustify">We were concerned at the Government’s refusal to accept the recommendation that elderly people should receive free personal care made by the Royal Commission on Care of the Elderly. We support the Commission’s recommendation which is based on considerations of both equity and efficiency. Whereas the state through the NHS pays for all the care needs of sufferers from, for example, cancer and heart disease, people who suffer from Alzheimer’s disease may get little or no help with the cost of comparable care needs. We would, therefore, strongly advocate that this is considered in the final Review.

9.1

1. Most of the data is based on the white population. Caring for an ageing ethnic population is likely to present a huge challenge and add to costs. More data on specifically the south Asian population needs to be included and analysed. For example, diabetes and heart disease is up to four times as common in ethnic populations than in the white population.
2. There needs to be explicit consideration of co-morbidity as a changing demand on the organisation of health services.

9.2

1. In ethnic populations age related illness occur earlier i.e. late sixties rather than seventies.
2. Consumerism and demand are likely to continue to increase.
3. If the trend to family disintegration continues, as the numbers of older people increase so will the need for more sheltered housing and care home places. Hospitals bed numbers are likely to continue to decrease as more treatments and surgery are done on an out patient basis. It is likely therefore that social care costs will significantly increase.

9.4

1. Morbidity in the elderly is unlikely to decrease as patients live longer but are vulnerable to more age related diseases.

9.5

1. There need to be interventions in obesity reduction and increasing exercise. These could have an impact on CHD and diabetes morbidity and mortality. Inequalities are often based on factors of socio-economic deprivation. Disease prevention initiatives usually do not work in the presence of poverty.
2. We are concerned that the Review does not consider what the situation will be if the Government does not meet its targets on inequalities. Indeed, an analysis of the existing Government targets are valid and credible would have added weight to this comprehensive analysis.

9.6

1. Demands will clearly increase. Current elderly by and large are not excessively demanding, but future elderly will demand in line with increasing consumerism.
2. Good health will become the expectation of all. People will expect to be able to have major interventions such as coronary bypass surgery if this is indicated, regardless of age.

9.7

1. People who seek always continue to seek help throughout their lives. Accepting telephone advice and telephone consultations are a step forward.

10.1

1. It is very difficult to predict the correct answer to this question. On balance, we believe that it is correct to assume that the aggregate effect of new technologies and medical advances will increase expenditure. History shows us that new technologies do tend to cost more than old ones (but perhaps with better outcomes) and tend to allow intervention in situations where none was previously available. In addition to this, we believe that a key factor is that much future innovation is likely to come from outside the NHS/academic research and may be driven by the need to make a profit.
2. Pharmaceutical and biotechnology companies are investing large sums of money in genomics and will require a return on this investment if they are to remain viable businesses. NHS and academia therefore need to invest in health services research (HSR) to act as a counter balance to ensure that any new technologies are fully evaluated prior to introduction into clinical practice. This is of course true for all new technologies but is particularly important for genetics as there is a tendency to view it as a "special case". Because of the vast investment in the human genome project and in genomics by biotechnology/pharmaceutical industries, there is the assumption that genetics will inevitably improve practice and offer more cost-effective options than the status quo. This is not necessarily the case and proper HSR is required.

10.2

1. Information technology is certainly going to be a major driver for two reasons. Firstly, in facilitating the public’s access to medical information (now the commonest reason for use of the internet) and secondly in facilitating the medical profession’s use of other technologies as outlined above.
2. Education of both the public and the professions will be important, in order to ensure appropriate and informed use of new technologies. This is one of a number of barriers that prevents evidence-based medicine from becoming routine practice.
3. Perhaps one of the major drivers, and a surprising omission from the report, is the pharmaceutical and biotechnology industry. This industry has already invested millions in genomics and requires a return from the investment. Therefore new technologies will have to result from the investment if companies are to remain viable concerns. If the NHS does not adopt the new technologies, then the companies are likely to seek other avenues into the health market place.
4. Having the facilities and staff to provide the service is also, we agree, key. Current practice is already limited by lack of both resources. Genetic technologies currently available are under-utilised, partly due to lack of public and professional awareness, but also through lack of resources to cope with the demand should awareness be increased. There is a lack of clinical and laboratory staff; for example the Joint Committee on Medical Genetics recently discussed the lack of funding for training of clinical scientists to work in laboratories.

10.3

1. The top-down approach is probably the most pragmatic way of estimating the historical impact of technology growth. However, for new technologies in general and especially for genetics, as the Review points out, the estimates do not provide any information on whether past spending on technology has been adequate. We believe it has not been adequate and therefore, if we aspire to providing an adequate genetics service, past behaviour of the health economy is not a good guide to future health spending required.

10.4

1. This is a very difficult question to answer. As the Review points out, there is much uncertainty over what the next 10-20 years will bring. In terms of genetics, costs are likely to increase in the next 10 years - not for any revolutionary reason but simply as the UK catches up with technology that already exists.
2. As risk reduction evidence becomes available for conditions where the genetics has been defined (e.g. BRCA1 or BRCA2 forms of breast cancer) then services will be required. There are three large scale trials of breast cancer risk reduction currently running, one in the USA, one in the UK and one in Italy. We are quite likely to have some evidence to put into practice within the next 10 years. There are 47,000 women per million at moderate risk of breast cancer as a result of their genetic makeup. This could be a significant cost.
   10.5
3. We agree with the Review that pharmacogenetics has great potential benefit. If it proves to cost-effectively reduce the use of ineffective drugs, to identify the best product for a patient faster, and to reduce adverse drug reactions (ADRs), then it could revolutionise the way doctors prescribe and patients take drugs. It needs, however, to be assessed by health services researchers to ensure that it achieves these aims.
4. As well as assessing new technologies as they appear from industry, the academic community requires funding to develop and research its own innovations. This is likely to be key in the area of pharmacogenetics, as the agendas for use of pharmacogenetics in medical academia as opposed to the pharmaceutical industry have some differences. Lack of funding for empirical pharmacogenetics research outwith industry may lead to an imbalance in overall costs of using the new technologies.
5. The report indicates the UK’s slow uptake of new technologies including new drugs. We believe there is a balance to be struck. Just as slow uptake can withhold effective treatment from a population, so rapid uptake can lead to use of a technology before the long term effects of that intervention are apparent.
6. Overall the chapter contains substantial inconsistencies, mostly caused by a failure to take a whole systems approach. The vision of how health care will be delivered is predicated on two areas that are the report’s major weaknesses.
7. On the one hand the gatekeeper role of GPs is praised and the objective of making sure specialist services are used appropriately is emphasised. At the same time it is suggested that many GPs should be replaced by nurses and those that remain will become increasingly specialised. Specialists will, at the same time, become more generalist. In the introduction to our response we have argued further against this assumption.
8. The report suggests that patients will become increasingly able to care for themselves although it gives no evidence for this and the statement appears contrary to current experience in both the primary care and A&E environments. It also suggests that nurses will be able to deal with much of the minor illness. It has missed the point that NHS Direct, Walk-in centres and 48 hour access for all will make patients more dependant and not less so. The consumption of over the counter (OTC) medicines in not entirely self managed: health professionals, particularly General Practitioners, provide a safety net for patients who take OTC medicines.
9. We suggest that the Review analyses the impact on workforce of General Practitioners involvement in teaching and research.
10. Between 10-20% of the undergraduate medical curriculum is now being taught outside hospitals, in general practice. This huge change has taken place over the last 10 years, and represents a welcome addition to the working patterns of general practitioners but also has implications for workforce planning and for the consideration of job descriptions. The reasons for this shift in teaching are complex, but include much shorter hospital stays, so that fewer patients are available for teaching purposes in university hospitals, and a general transfer of the care of chronic illness from the hospital sector to general practice and primary care.
11. Research and development in primary care also need to be considered as part of the job descriptions of many general practitioners and these, like teaching, also have workforce implications job description implications. In a primary care led NHS, the importance of primary care-based research to provide robust evidence for clinical effectiveness in primary care, is essential, and has been recognised as such by both the NHS and the Medical Research Council. The involvement of many general practitioners in research practices and research networks should not be forgotten, because of the resource implications mentioned above.
12. We are attaching a recent document that we produced outlining the workforce problems that we in general practice currently face. This document is also on our website.
13. Although 11.3 makes the point about graduates it fails to comment on the effect of graduate nursing as a career and its possible effect on medical recruitment as both professions will increasingly be looking for recruits in the same and diminishing pool. The same paragraph refers to the high number of women in the NHS without making any comment about participation rates. Indeed the whole document appears to deal with headcount although this is not made explicit.
14. In para 11.5 the figures for both training time and cost appear to be inaccurate as no definitions are given. The time to train a consultant from scratch is nearer 15 years and the cost excludes undergraduate training.
15. In 11.7 the increase of numbers of medical staff is headcount and disguises the position in primary care.
16. 11.8 is accurate in its statement of the major changes in primary care. However it fails to say how this change can continue to be supported with fewer doctors and with increasing specialisation. The figures in 11.9 are headcounts, the whole time equivalent (WTE) in 1995 was around 10,000.
17. Discussions on pay in 11.15 could have made more of the fact that doctors in London and the South East are proportionally disadvantaged by a national pay structure.
18. The conclusion in para 11.20 is wrong when related to GPs. The majority of the additional GP numbers by 2004 will be achieved by counting non-principals. It is unlikely that there will be real increase in numbers of this scale. Even if it were so, it would be totally inadequate. Again headcount is a particularly poor proxy for participation in the highly feminised GP workforce. Apparent increase in GP registrar numbers is largely spurious and caused by double counting since the change in funding arrangements has allowed innovative posts to be created. This may improve recruitment and conversion in the longer term but currently the figures are disappointing. Further increases in training places will, in the short term, lead to an increase in vacancies.
19. The extra doctors in 11.21 are speculative and will be almost completely used up meeting the Working Time Directive in employed settings and the reducing participation rates across all sectors. Much of the NHS Plan increases, even if achieved, would only go towards reducing current vacancies in medical and nursing staff. Even if all this were not true, chart 11.6 shows clearly that by 2024 the UK will not even have reached the EU 1997 figures.
20. Although the proposed increase in qualified (as opposed to in training) doctors is welcome (11.23) working practices in secondary care will need to radically change if this is to be cost effective. Recent increases in consultant numbers have increased the demand on doctors in training rather than reducing it.
21. 11.29 underlines the short term and short sighted nature of the current drive to recruit doctors from abroad. Although colleagues from over-producing countries are welcome, and the cost to the NHS of recruitment is relatively small (around £15k per head in the case of the current GP recruits from Spain) the effort expended to ensure quality and to support these doctors is huge. The fact that overproduction is largely in secondary care is emphasised.
22. 11.34 raises the opportunity costs of administration and record keeping. This burden is increasing exponentially and is a huge cause of dissatisfaction in front line health care staff. The paradox of patients taking more responsibility for their own care and yet wanting more time with their carers needs further exploration.
23. Of course, if tasks are taken in isolation and assessed, they can be delegated (11.39) but the effect on the care of the patient has not been assessed in this approach. A similar argument for replacing 10,000 GPs with nurse practitioners appears in 11.42. HCAs will inevitably come but as with many substitution arguments they will actually be doing tasks that nurses are no longer doing and that are often not done rather than further freeing up nurses to undertake medical tasks.
24. Although there is clearly a place for some of the new workers in 11.40, increasing fragmentation of care will bring its own problems. We already see continuity of care decreasing with consequent reduction in patient satisfaction and increase in risk. Increasing specialisation also brings its own bottle necks into the system. One of the current blocks to increasing the amount of CABGs for example is the number of trained technicians available to work in cardio-thoracic theatres.
25. Skill mix has been increasing in primary care over the recent past and nurse practitioners have taken on many tasks previously done by GPs, this has freed GPs to care for those patients who need more skilled care. We would, however, question the assumption that between 20 and 32 per cent of GPs could be replaced by nurse practitioners. It must be noted that this study was carried out in Canada in 1985 and therefore cannot be assumed to relate directly to the UK or be relevant today. Appendix 2 sets out our concerns about the evidence for skill-mix in primary care.
26. As mentioned above, there is no evidence for bullet 1 in 11.50. This is a major weakness of the report as it predicates much of its vision on increasing self-care by patients without supporting evidence. The final bullet states that specialists will have a strong general background. This is probably desirable but would require a major change in both attitude and training.
    Q11.1
27. Earlier in our response, we have set out our views about a number of these points, but would like to add the following points.
28. There is clearly scope for a significant expansion in the services provided by nurses, but the further development of triage and the substitution arguments set out in the report give a simplistic view that results in greatest "efficiency" but ignores the complexity of care in the real world. Firstly it may make care more "expensive" for users and the NHS – a person might be assessed several times before seeing a GP who can effectively manage their condition – a consultation that the GP might have recognised that a patient when the patient first presented. With an increasing consumerist society and patients who know more about their health, patient demands are likely to continue to increase. They will, therefore, be less likely to tolerate obstacles to accessing a GP if that is what they deem necessary and/or desirable.
29. Second, many problems have aspects that require nurse, GP or hospital care. Problems are often not simple ones with single simple solutions. Linear care, rather than team care, will often be disruptive. Also, there is no mention of co-morbidity (we have discussed this issue in more detail earlier in our response) which, in a task-oriented workforce, increases the need for co-ordination. Currently, with GPs taking a holistic approach to patients, co-morbidity is managed effectively.
30. We do recognise that there is scope for more nurse led services. There is particular need for this in secondary care to release PRHOs and SHOs to concentrate on training.
31. The use of Health Care Assistants (HCAs) seems to be increasing and is likely to increase rapidly. This increase is desirable to free up skilled nursing time and for the individual personal development of people who could undertake this role. HCAs already do phlebotomy, take blood pressures and carry out registration health checks in many practices. This trend should be encouraged and the range of work done by health care assistants is likely to increase to include other investigations such as audiometry, pulmonary function tests and electro-cardiography etc and simple dressings. It should also be noted that current pay and conditions are unlikely to attract an appropriate quality of recruit. Also, it is important that their use does not block the access for patients to the most skilled personnel for diagnosis and discussion of management.
32. The partnership with other professionals is important and has not been sufficiently exploited. However, this is largely due to the absence of organisational support and the poor resourcing of other professions as well as those in the NHS. Social work is clearly the most important area and we have already argued that the liaison with social work receives insufficient attention in this report. The aspiration should be to reduce the overlap between the work of different agencies, reduce the need for hospital and perhaps other institutional admissions and empower patients and their families. However, this will need an up front investment and there can be no guarantee that domiciallary care will be a cheaper option than institutional care.
    Q11.2
33. The current training places will not give the UK the number of health care professionals it needs. The College and the JCPTGP have argued that the current provision is woefully inadequate and that even with the numbers promised (and we see no immediate chance of achieving these) it will not be possible to address the government’s agendas which include an increased reliance on primary care, higher quality of provision and a less stressed but more skilled workforce. Work has already been done by the College to try to quantify the shortfall and the Joint Committee would wish to argue for investment in training to ensure that general practitioners are fit for purpose and are equipped for lifelong service, thereby increasing the chances of retention.
34. Work by the College estimates that 10,000 GPs are needed to match current exceptions, retirements etc. A conservative estimate is that 150 GPs currently need to be trained for 100 that currently retire.
35. There has been poor investment in practice nurse training and primary care trusts need to be enabled to develop proper training and support programmes for practice nurses. Many PCTs are experiencing difficulties in practice nurse recruitment, training and retention. Likewise, training opportunities for health care assistants and training as a whole needs to be seen as an integral part of provision and not as an add on.
36. The immediate and medium term looks concerning. The numbers of nurses planned is grossly insufficient. Not only do we need nurses to fulfil the roles above, but we need a return to nurses who care for patients who are ill – physical hands-on caring. Future GP demands will significantly increase as GPs take on more complex care, management roles, national service frameworks, and various quality improvements. Intermediate care will add further to GP’s workload and so add to pressure to increase GP numbers.
37. Q11.3
38. There are two extremes, both flawed and a pragmatic middle road. The "free market" approach of open numbers for medical schools (as in Italy or Spain) results in reduced standards of training and medical unemployment on a significant scale. This represents poor value for the investment (state or private) in education and training for medicine. At the other extreme the state determines future demand and fine tunes medical school places in anticipation of needs in ten or more years time. This has resulted in a chronic shortage and Britain being a net importer of doctors (often from poorer countries who can ill afford to lose such expensive human resources).
39. This mismatch between demand and supply needs to be addressed on several levels. The supply needs to be increased, particularly for GP’s and practice nurses. However, in the long run primary care and secondary care are interdependent and one should not be developed at the expense of the other. Selection processes need to ensure the best possible fit between those selected for training and the jobs as they evolve and training needs to be made relevant. Retention has received insufficient attention both for doctors, especially in the later parts of their career, and for nursing staff. The provision of effective CPD and of time to benefit from it is important. The mismatch can to some extent be corrected by opportunities for re-training and by enhanced flexibility within the workforce. While we have reservations about skill mix as a panacea, the ability to deploy staff as flexibly as possible will be seen as an important part of the management of this mismatch.
40. Q11.4
41. The concept of productivity is difficult, particularly in general practice and in a service which should be increasingly driven by quality. Patient expectations, job satisfaction, retention of the workforce and risk management all seem to point towards an imperative to allow more time for patients.
42. The face-to-face time of NHS GPs is substantially less than that of doctors working in a fee-for-consultation service in, for example, Australia. If GPs involvement in paperwork was reduced (a move that has occurred in many practices already) then their time can be further freed for more clinical contact or more involvement in health strategy and management.
43. If General Practitioners only saw more complex cases (and then mostly as part of team care) or those that specifically requested access to them, then the reduction in workload might be balanced by longer consultations and movement of work from other settings (especially secondary care). Again, it seems inevitable, that productivity gains are more likely to improve quality and outcomes rather than to reduce costs and improve efficiency.
    11.5
44. Once again the question about the appropriateness of productivity as a concept arises. However, if this is defined predominantly in terms of the improvement of quality and outcomes, it is possible to comment with more or less precision. The principal barrier is probably time, but not as seems to be implied in this report. Contact time here seems to be regarded as patient throughput. Of equal importance from the quality point of view is the amount of time available to spend with each individual patient. However, this in turn is related to all the other factors mentioned. Thus better use of skill mix and clarity about roles may enable higher quality care to be provided on the basis of longer contact with smaller numbers of patients. Again, if part of the role of the general practitioner is in the management of the care of individual patients, time spent on related paper and office work may contribute directly to productivity. For example, if GPs were more clearly responsible for the ongoing care of patients, including preventive aspects, they might well need to spend more time reviewing patients’ records on a regular basis and planning their care. This may require a major reduction in list size or in better exploitation of skill mix and other devices. In addition, the application of information and computer technology will be an important factor. Easy access to information on a regular basis and practice systems that facilitate the pursuit of quality in the care of individuals in practice populations will be an important factor.
45. The next question also addresses the involvement of patients and this too should help drive productivity again and overcome potential barriers. For primary care, improvements in secondary care are also a potentially significant factor. Some of the difficulties in primary care and the disaffection of GPs relate to the need to deal with the consequences of long waiting lists and difficulties in dealing with hospitals. Improvement in the secondary care sector would therefore drive "productivity gains" while the perpetuation of the status quo would be a significant potential barrier.
    
    Q11.6
46. There is good evidence that involving patients in their own care improves outcomes in a number of situations, particularly those involving the management of chronic illness and behaviour change. Having said that however, as we have said previously, the assumption in the report that patients will be better educated and better informed in the new climate, with the implication that patient involvement will follow naturally is not well argued; no strong evidence is given.
47. It is also clear that for many situations and for some patients a more traditional justify">Over time the involvement of patients should result in improvements in quality and outcomes, but this coupled with availability of treatments is likely to increase demand. Patient awareness does not necessarily drive cost down; increasing consumerism may well push costs higher. The cost of new pharmaceutical agents especially for lifejustify">Much of the information currently available to patients, for example on the internet, is of dubious quality and the education of patients in the discriminating use of information is a long term project. This requires greater time in face to face consultations and also greater time in practice and information management.
48. If the future health service is truly to become patient centred then it will inevitably become more locally focused and differences across the UK will follow. As there are different central systems managing the health service in their part of the UK, the worry is that there will be a series of health migrations; of health care workers to where pay and terms of service are better and of affluent patients to where 'better' service can be bought. This will lead to an impoverished underjustify">An important but unmentioned question is the extent to which the differences within the UK are associated with differences in the mix of types of personnel as well as differences in information as well as other technology.
49. Turning to expenditure in Para.12.17, which compares England with Scotland. At present, expenditure per head in Scotland is £1,000, rising to £1,400. In England it is £800 per head rising to £1,180 - still a vast deficiency, which is not being redressed.
50. Para.12.23 cites areas of remoteness as a cause for special consideration. There is more evidence that congestion and high levels of housing density is an indication for more resources.
    
    Q12.1
51. There are a number of differences between the four countries which will affect the provision of health care in the future. The Review will need to take account of these – highlighting different health needs and, so, priorities.
52. The population of Scotland is predicted to fall over the next twenty years at a time when the UK population is set to increase. This will presumably have an effect on current funding patterns – heralding change in the Barnett formula, for example.
53. In Scotland there is a higher proportion of the population living in remote and rural communities – and the proportion of "old" elderly is increasing in such settings. This will have a profound effect on the way in which services are delivered (not least by primary care).
54. The high levels of immigration, particularly asylum seekers, is mainly concentrated in England, especially the Home Counties and London. The peculiar health trends and needs of these people should be considered.
    
    Q12.2
55. Absolute social deprivation, especially real poverty and social isolation, is a major source of ill health. However, relative deprivation is also associated with worse health and outcomes. There is a gradient across social justify">If any of the countries in the UK either reduce their absolute poverty or change their relative poverty we would expect these changes to be reflected in health needs, status and outcomes.
    
    Q12.3
56. CHD and cancer are particularly important issues for Scotland. The nature of these conditions means that they consume considerable resources – and that will make funding considerations more complex. Within general practice we need to consider more thoughtfully our current and future role in tackling these issues.
    Q12.4
57. The complexity and very size of the health management structure in England precludes efficiency when compared to the simple unitary structures of the other countries. Given the differing needs and priorities, it does make sense for each of the four countries to develop different systems when necessary. However, there does need to be equity across the UK with regard to the principles underpinning the NHS. Such issues as access to different levels of care, standards of care, etc should be broadly the same.
    
    Q12.5
58. The diverging population trends are less important than other factors and do not need to be approached differently.
    
    Q12.6
59. Devolved responsibility may facilitate technology diffusion if resources are also devolved. This is less conclusive in workforce development and may lead to competition between adjacent health economies in the search for scarce human resources.
    
    Q12.7
60. We regret that the whole of England is considered as a single unit and would suggest that, within this country there would be areas of greater disparity than there are between UK countries. London, in particular, has areas of great affluence and great poverty, and it is an error to consider it to be homogeneous.
61. England also has ten times as large a population as Scotland, which introduces peculiar problems of communication and diversity.
62. There are well-established differences in health needs between English regions at present and the distribution of health resources does not reflect those needs – the inverse care law applies. We do not know how those differences will change with time, but in relative deprivation is to be addressed, then future investment must go to areas of highest health need.

1. Shum C, Humphreys A, Wheeler D, Cochrane M, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000;320:1038-43.
2. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, Stainthorpe A, Fraser A, Butler C, Rogers C. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting ‘same day’ consultations in primary care. BMJ 200;320:1043-1048.
3. Venning P, Durie A, Roland M, Robets C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000;320:1048-53.
4. Baker R. Development of a questionnaire to assess patients' satisfaction with consultations in general practice. Br J Gen Pract 1990;40:487-90.
5. Baker R, Whitfield M. Measuring patient satisfaction: a test of construct validity. Quality in Health Care 1992;1:104-9.
6. Hjortdahl P, Laerum E. Continuity of care in general practice: effect on patient satisfaction. BMJ 1992;304;1287-1290.
7. Linn LS, Brook RH, Clark VA et al. Physician and patient satisfaction as factors related to the organization of internal medicine group practices. Med Care 1985;23:1171-8.
8. Smith CH, Armstrong D. Comparison of criteria derived by government and patients for evaluating general practitioner services. BMJ 1989;299:494-6.
9. Baker R, Streatfield J. What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction. Br J Gen Pract 1995;45:200-206.
10. Ettlinger PRA, Freeman GK. General practice compliance study: is it worth being a personal doctor? BMJ 1981;282:1192-4
11. Hjortdahl P, Borchgrevink CF. Continuity of care: influence on general practitioners’ knowledge about their patients on use of resources in consultations. BMJ 1991;303:1181-4.
12. Weyrauch KF, Rhodes L, Psaty BM, Grubb D. The role of physicians’ knowledge of the patient in clinical practice. J Fam Pract 1995;40:249-56.
13. Mainous AG III, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Family Medicine. 2001;33:22-27
14. Sweeney KG, Gray DP. Patients who do not receive continuity of care from their general practitioner – are they a vulnerable group? Br J Gen Pract 1995;45:133-136.
15. Mainous AG III, Gill JM. The importance of continuity of care in the likelihood of future hospitalisation: is site of care equivalent to a primary clinician? Am J Public Health 1998;88:1539-41.
16. Gill JM, Mainous AG III. The role of provider continuity in preventing hospitalisations. Arch Fam Med 1998;7:352-7.
17. O,Connor PJ, Desai J, Rush WA, Cherney LM, Solberg LI, Bishop DB. Is having a regular provider of diabetes care related to intensity of care and glycemic control? J Fam Pract 1998;47:290-7.

1. Executive summary

1. Structural changes within the NHS
   

1. The evidence

6.9.1Measuring workload and financial considerations.It has been traditionally perceived that on an hour for hour basis it is cheaper to have 24 hour cover from GPs, who have included out of hours provision within their existing contracts, than from nurse working strict shifts. As GPs shed their 24 hour responsibility or organise it in different ways (notably through co-operatives) new costs - both start-up and ongoing - are introduced.

6.9.2 Within the practice setting, most of the comparison trials have been with trained nurses dealing with specific clinical problems at 20 minute intervals (14,15) - which, at over twice the length of the average GP consultation, makes them a more expensive option than GPs doing the same task. When dealing with minor illnesses, the clinical care and health service costs of nurse practitioners were similar (9). It is oversimplistic to state that "If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners." (9)

6.9.3 Likewise, while studies suggest that there are methods which should provide an accurate, reliable and valid picture of GP activity (16,17) the financial implications of increasing the range of work carried out by Primary Health Care Team (PHCT) members has not been fully assessed. This would need to include research on the number of hours worked by GPs, the length of GP and nurse consultations and the range of services offered by comparable PHCTs with and without a wide range of skill mix.

6.9.4Interpractice variation and its consequences. It is well recognised that practices vary enormously in the services they provide, and Jenkins-Clarke et al conclude that "There is no straightforward association between structural characteristics of the practices and either the pattern of activities or the process of delegation referral between members of the PHCT". They also conclude that "…Whilst a broad-brush or macro-examination might, for example, show that 20% of a doctor’s time could be substituted by a mix of other fractions of the manager and the practice nurse (and perhaps other members of the PHCT), the practicalities of weaving together such a collection of part-time workers into a coherent team may be insurmountable." (17). 6.9.5 Depending on the workload generated per patient by standard models of skill mix, it is not known whether it will be financially feasible for smaller practices to employ the same models of delegation and skill mix as larger ones.

6.9.6Quality of care and safety.Several trials confirm that nurses have no higher incidence than GPs of misdiagnosis and adverse outcomes (5,8, 14) - but again, there are no trials comparing the safety of nurses or nurse practitioners working at the same rate as GPs.

6.9.7 There is evidence, however, of significant unmet need, especially with respect to aspects of health promotion (18), and there needs to be research to confirm that delegation of GP tasks to other PHCT members does not reduce the provision of "soft" areas of care such as health promotion still further.

6.9.8Patient satisfaction.While there is, once again, evidence that patient satisfaction with nurse/nurse practitioner consultations is just as high as it is with GPs (5,7, 9, 14), there have been suggestions that patient satisfaction is directly related to length of consultation, and no comparisons have been made of patient satisfaction in nurse consultations of different rates.

6.9.9 Similarly, there is a paucity of evidence about variation of patient satisfaction with length of GP consultation. In addition, the research that has looked at patient satisfaction has concentrated on individual encounters and not on long term satisfaction. The traditional model of continuing personal care by the GP, who has an intimate knowledge of the patient and their personal as well as medical history, is often cited as a main cornerstone of the primary care system.

6.9.10 While there is anecdotal evidence that patients’ priorities have changed, and that for some, at least, having access to immediate care is as important as having continuity of care, large scale studies do not support this point of view. Most research suggests that a patients’ enablement and satisfaction with a consultation is strongly associated with visiting the same doctor (19). It seems certain that as the number of alternative models of primary care increase, patients will become more accustomed to seeking medical care from a variety of sources. This may affect their view of the relative importance of continuity of care. There needs to be more formal evaluation of long term patient satisfaction, comparing traditional models with those incorporating skill mix.

6.9.11 In countries such as the USA, which have no equivalent of the United Kingdom GP, care tends to focus on the acute rather than the chronic, and long term, co-ordinated health care for patients is lacking. There is a risk that the trend towards cash-limited, unified budgets controlled by PCGs or PCTs, in combination with reduced co-ordination as a result of increased skill-mix, could threaten the GPs role as independent patient advocate. In the USA, this has led to both public displeasure and professional disillusion (20).

6.9.12Start-up costs (financial and human resource). While the number of protocols (both national and local) is increasing, there is a suggestion that clinical staff are likely to be happier with, and more likely to adhere to, protocols into which they have had an input. Until the practice of delegating tasks to nurses and nurse practitioners becomes more widespread, there will continue to be a tendency for individual practices to "reinvent the wheel" (or at least the protocol).

6.9.13Duplication of workload.Every time both a nurse and a GP see a patient for the same condition, there is duplication of workload which undermines potential savings. In 1994-6, the University of York carried out an extensive study of workload in general practice and the opportunities for spreading it more effectively among members of the PHCT (16, 17).

6.9. 14 While they concluded that there is "some scope for safely and acceptably transferring some work away from (expensive) GPs towards (less expensive) nurses and other clinical workers", they found that in a high percentage of cases, only part of the GP consultation was delegatable. They also highlighted the fact that the triage function of GP has to be carried out by someone, and the difficulty of organising flexible pathways through care.

6.9.15Knock-on effects for recruitment.Setting aside financial issues, an increase in the skill mix of the PHCT will require a supply of nurses, who appear to be an increasingly scarce commodity(4). Studies suggest further potential for practice nurses to delegate some of their workload to less qualified, or even unqualified, staff(21).

6.9.16 While at its best, careful consideration of skill mix has the potential to align local services much more closely to patient need, there are enormous dangers in setting up widescale models of skill mix without ensuring the prior provision of human resources at all levels.

6.9.17 Similar considerations apply when considering skill mix in other areas - for instance, the substitution of health care assistants for nurses, and the substitution of other health care professionals to carry out administrative and patient advocacy roles traditionally taken on by GPs. For these, the evidence seems even more scarce.

1. Medical Practices Committee Recruitment Survey 1999
2. NHS Act 1990
3. Royal College of Nursing. Skill mix and reprofiling: a guide for RCN members. London: RCN, 1992
4. McKenna H. The "professional cleansing" of nurses. BMJ 1998; 317: 1403-4
5. Lattimer V, George S, Thompson F et al. Safety and effectiveness of nurse telephone consultation in out-of-hours primary care: randomised controlled trial. BMJ 1998; 317: 1054-9
6. Thompson F, George S, Lattimer V et al. Overnight calls in primary care: randomised controlled trial of management using nurse telephone consultation. BMJ 1999; 319: 1408
7. Shum C, Humphreys A, Wheeler D et al. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000; 320: 1038-43
8. Kinnersley P, Anderson A, Parry K et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. BMJ 2000; 320: 1043-8
9. Venning P, Durie A, Roland M et al. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000; 320: 1048-53
10. Stuart A, Rogers S and Modell M. Evaluation of a direct doctor-patient telephone advice line in general practice. BJGP 2000; 50: 305-306
11. Munro J, Nicholl J, O’cthain A et al. Impact of NHS Direct on demand for immediate care: observational study. BMJ 2000; 321:150-3
12. National Health Service (Primary Care) Act 1997. Ch 46. London: Stationery Office, 1997
13. Shapiro J. Personal medical services: a barometer for the NHS? BMJ 2000; 321: 1359-60
14. Spitzer WO, Sackett DL, Sibley JC et al. The Burlington randomized trial of the nurse practitioner. N Eng J Med 1974; 290: 251-6
15. Stillwell B. Defining a role for nurse practitioners in British general practice. In: Wilson-Barnett J, Robinson S, eds. Directions in nursing research. Scutari Press, 1991
16. Jenkin-Clarke s, Carr-Hill R, Dixon P, Pringle M. Skill Mix In Primary Care: A study of the Interface between the General Practitioner and other members of the Primary Health Care Team. University of York Centre for Health Economics July 1997
17. Jenkins-Clarke S, Carr-Hill R. Measuring Skill Mix in Primary Care: Dilemmas of Delegation and Diversification. University of York Centre for Economic Studies January 1996
18. Charlton BG, Calvert N, White M et al. Health promotion priorities for general practice: constructing and using "indicative prevalences". BMJ 1994; 308: 1019-22
19. Guthrie B, Wyke S. Does continuity in general practice really matter? BMJ 2000; 321: 734-6
20. Koperski M. The state of primary care in the United States of America and lessons for primary care groups in the United Kingdom. BJGP 2000; 50: 319-322
21. Fallon CW, Bhopal JS, Gilmour WH, Bhopal RS. The work of the family practice nurses: an audit in an inner city practice. Health Bulletin 1988; 46(3): 176-81
    

• Membership by Assessment of Performance (MAP)MAP is a route to membership of the College which enables experienced GPs who can show evidence of good quality practice to become members through an assessment of their performance rather than through sitting the MRCGP exam. MAP is equivalent to membership by exam; the principal difference is that the exam is designed to be taken in the registrar year, whereas MAP is particularly appropriate for doctors who have been practising for several years.

Those GPs who wish to undertake the assessment are required to produce evidence that they can meet a set of criteria that include both clinical and organisational standards and require evidence of CPD. Candidates have to produce a portfolio of evidence which describes their practice, demonstrates audit, and includes surveys of, for example, accessibility and continuity of care. Candidates are assessed on their consultation skills and are visited in their practice by two trained assessors. They will also be asked to produce evidence of their competence in child health surveillance and CPR.

There are 36 essential MAP criteria and several optional ones under the headings: Accessibility and Continuity; Patient Records; Health Promotion; Management of Acute Illness; CPD; Practice Organisation and Team Working; Management of Chronic Illness; Ethical Standards; Prescribing and Referral; Consultation.

 

• Fellowship by Assessment (FBA)

FBA is a route to Fellowship of the College for members of not less than 5 years’ standing and who have been in practice for at least 5 years. FBA is based entirely on the candidates’ work as doctors with their patients in their own practices and it is based entirely on the quality of care provided to patients. The assessment process is based on a set of criteria which are under constant review and development. When an application for FBA is submitted it is assessed by 3 assessors, who are all Fellows and who act as peers on behalf of the College. The assessors visit the applicants’ workplace to check that the material submitted is an accurate reflection of the candidate and their practice and to assess those criteria that can only be assessed in discussion with the candidate. The assessors then make a recommendation to the Fellowship Committee, which considers all the relevant evidence. It then makes a recommendation to Council, who then announce the election of the applicant at the AGM. Failure of the candidate to meet any one of the essential criteria will fail the candidate. The areas assessed in FBA include health promotion activities, consultation skills and out of hours emergency care arrangements.

 

• Quality Team Development (QTD)

QTD is an initiative which aims to help PCGs/Ts asses the performance of primary care teams. At present, the scheme is only available in England. The standards and criteria within QTD are aspirational, with the emphasis on the primary care teams developing over a number of years. It is not expected that the teams will meet all of their criteria at their first assessment visit but that they will use the criteria to assess themselves and highlight their development priorities. The local assessment team provide external validation of the teams’ self assessment. QTD is awarded for three years and is reviewed annually. The criteria for QTD have been produced by a national steering group representing the professions in primary care. Assessment methods based on the criteria are: practice self assessment questionnaire; practice profile; patient questionnaires; documentation review; and, a practice visit by a team of colleagues (usually a GP, nurse, and practice manager) who undertake direct observation, interviews and clinical record review. Feedback is provided on the team’s strengths and weaknesses and help to create a practice development plan provided. QTD is particularly useful as a tool for clinical governance as it is carried out through a PCG/T and there is scope to adapt the way it is implemented to meet local clinical governance strategies. The criteria can be prioritised and used to develop a picture of strengths and weaknesses within a PCG/T.

 

• Quality Practice Award (QPA)

QPA is a quality assurance process undertaken by practices which recognises a high standard of quality patient care delivered by every member of the Primary Care Team. Each practice is required to submit a portfolio of written evidence set against 19 sets of criteria, which include: communication; health promotion; medical records; information technology; staff development. When a practice’s written evidence is complete, a full day assessment visit is conducted by a panel of four, usually two GPs, a Practice Nurse and Practice Manager. The assessors interview the team and inspect the practice premises, systems and medical records. At the end of the visit, the assessors give feedback to the team on their achievement and make recommendations for continuing improvement. Practices will normally take between one and two years to complete their submission. The criteria manual contains a step-by-step User Guide and a Local Adviser is appointed to provide advice and guidance through the process. Practices vary in the amount of support they require.

 

• Practice Accreditation (Scotland only) (PracA)

Practice Accreditation is designed to help practices meet the demands of the developing quality and clinical governance agendas. It is set at a fundamental level to allow the primary care team to demonstrate that they have in place the essential elements to provide good general practice. In June 2000, Practice Accreditation was endorsed by the Clinical Standards Board as its recommended method of accrediting standards in general practice in Scotland. The Scheme is delivered locally by Primary Care Trusts and Islands Health Boards and there is no cost to practices. Practice Accreditation covers a wide range of clinical and service criteria applicable to both patients and the primary care team. The criteria are set in three categories - Essential, Good, and Quality, and there 127 in total. Practices must meet all 46 Essential criteria and must demonstrate that they can also meet a maximum of 20 Good and Quality criteria. Practices complete a self-assessment checklist indicating which criteria they have met. This is then assessed by a multidisciplinary team of two, one of which is a GP, who will conduct a half-day visit to meet members of the practice team and verify the information provided on the checklist. On successful assessment, practices receive a Certificate which is valid for three years. Work is currently underway to develop Version 2 of the criteria, which will be endorsed by the Clinical Standards Board for Scotland, Scottish General Practitioners Committee, Royal College of Nursing and Royal College of Midwives.

• Primary Care Research Team Assessment (PCRTA)

PCRTA is an assessment scheme for primary care research teams, which focuses on individual practices and their teams as the unit of assessment. The scheme provides both primary care teams and stakeholders with a mechanism for acknowledging the quality of research infrastructure within a practice and provides a way of assessing and recognising the quality of research infrastructure against professionally developed and tested standards. Two levels of assessment are available: PCRTA Collaborator Research Practice or PCRTA Investigator Led Research Practice. PCRTA seeks to encourage individual practices to develop their research experience and to foster a wider culture of research while providing a reliable and professionally recognised kite-mark of quality. Standards for the assessment are grouped into 7 areas of activity: practice organisation; strategic planning; practice as a learning organisation; research resources and infrastructure; project funding and management; involvement of patients; dissemination of research. Candidates are required to complete an application form to help with the preparation and submission of written evidence. Additionally, practices have to compile a folder of documentary evidence relating to their application that is reviewed by assessors when they visit the practice. After the practice has been visited, the assessors prepare a feedback report, which announces whether the practice has been successful or not.

 

• Accredited Professional Development (APD)

APD offers ongoing support for GPs’ continuing professional development as part of their everyday practice. The process will help GPs to collect all the information and evidence that is required for their annual appraisals and revalidation, over a five year period. That is, to plan their learning, demonstrate the quality of their practice and celebrate their achievements in looking after patients. Documentation for appraisal and revalidation is provided within the programme wherever possible. The APD programme is all about learning in a way that is relevant to participants’ everyday practice and individual needs. The programme incorporates 6 modules over 5 years: keeping up to date and improving care (an ongoing module); communication skills; record keeping; access and team-working; referrals and prescribing; complaints and removals. At least once a year the participating GP will undergo a peer review with their APD facilitator of participation in all stages of the APD programme and their own standards matched against those set out for all aspects of practice in Good Medical Practice for General Practitioners. Record sheets to demonstrate learning and progress are provided which comprise the core APD evidence but GPs will also attach other evidence in their APD portfolios such as the work they prepare for their full annual appraisals, clinical audits or significant event audit sheets, certificates of awards, tangible demonstrations of improvements in practice etc. First candidates for the APD programme are hoped to be registered in spring 2002.