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英国首相布莱尔01系列演讲之PM's speech 'Empowering primary care and supporting GPs in the NHS' - 19 March

2006-05-30 16:26

  Today I set out, in the first of a series of speeches, how after 4 years of laying the foundations for change we move powers down to the front line of public services, delivering the necessary structural change to make local empowerment work.

  But first, we publish a report by the NHS Chief Executive on how the NHS and social care have managed winter pressures this year. The report makes encouraging reading.

  More patients treated. But fewer people kept waiting for very long periods in A&E departments. Fewer intensive care transfers. Fewer beds blocked.

  Increased planning and extra investment paid off. More hospital beds for the first time in 40 years. Critical care beds up by nearly a quarter. More home care packages. More people vaccinated against flu. Greater use of the private sector. Better local co-ordination. NHS Direct available nationwide. And 2,500 more doctors and over 6,000 extra nurses than the previous winter.

  Yes, it helped that there was less flu about than last year - in part due to the success of GPs and nurses in doing so well on flu immunisation.

  But there were still considerable pressures on the health service. In 14 out of 17 weeks this winter, hospitals coped with more emergency admissions than last year.

  Extra resources and better preparations helped, but it also required a huge amount of personal effort. Everyone played their part. GPs, social services, nurses, managers, consultants, ambulance personnel, diagnostic staff, professional bodies and many others.

  I want to take this opportunity today to put on record to NHS and social care staff my appreciation - and that of Alan Milburn - for all the hard work over the past few weeks and months. You rightly get praised when you respond so heroically and instinctively to disasters such as the Selby train crash. But you also deserve our thanks for the hard work that goes on day in and day out and so often passes unnoticed.

  Despite this positive performance particular hotspots have at times struggled to cope. Staff shortages are a particular problem in some areas. And if you were one of the patients who did wait too long or had your operation cancelled then you might still feel that the NHS let you down.

  And I know that for primary care whatever the improvements, the pressures on you remain intense. And those pressures increase if patients use the health service irresponsibly. GPs are owed respect from their patients.

  The GP practice has always been the driving force of the health service. Nine out of ten of patients receive all their diagnosis and treatment within primary care.

  The close to home service and continuity of care that British primary care provides is valued by patients and envied around the world. We need to hold on to all that is best about our current arrangements.

  But the world is changing.

  We can now identify and treat diseases which in previous generations proved fatal. We can prescribe medicines in a local practice for conditions, which a few years ago, required a major operation. Technological, medical and genetic advances continue apace.

  Lifestyles are changing too. 70% of working age women are now in employment. The number of people aged over 90 will double over the next 25 years. The consumer society demands instant access.

  How is the average GP or family practice to cope with and manage this cascade of change? Today I will set out points of change.

  First, we need more systems of collaboration. Hence structural change. The emergence of multi-funds and commissioning groups was a recognition that GPs needed the resources and support that came from working with others.

  Our primary care revolution has built on these foundations. It may be a quiet revolution but it is a revolution nonetheless.

  Primary Care Groups and Trusts provide a strong framework for doctors and nurses to support each other. To enable practices to innovate while ensuring that the benefits of innovation deliver high quality services for the whole local population - not just patients in particular practices. PCTs also provide the means to improve partnerships with social services. And to commission the services patients need from other parts of the health system.

  In our vision practices retain their independence but work to shared goals co-ordinated by PCTs. I have enormous faith in PCTs and what they will achieve for patients.

  Second, GPs, supported by practice nurses and pharmacists, will as they have always done provide medical care for routine ailments. But increasingly the practice will become the place where diagnostic tests and minor operations are carried out and where, as GP specialisms develop, one practice can provide a service to the patients of another. Where a referral to hospital is needed, appointments will be booked there and then, on the spot.

  The best way to deal with each major condition will be designed and agreed with hospital doctors so that patients move easily and swiftly round different parts of the health care system. The biggest gains in health care will come from primary and secondary care working together - not from one trying to benefit at the expense of the other.

  Preventive care will also change. People with chronic conditions such as diabetes, asthma and depression will have more regular help. Systematic programmes to identify those at risk from heart disease and cancer will become routine.

  The GP practice team will work with community nurses, physiotherapists, social care and housing staff to help older people stay fit and independent.

  Electronic patient records will enable GPs to maintain continuity of care even though their patients may be contacting the health service through NHS Direct, walk-in centres or e-mail.

  All this will take time to achieve. That is why it sometimes feels as though there is a gap between the vision and the reality on the ground. But we need to hold on to this vision - a vision I believe is shared by most people in primary care - and step by step work towards it.

  Third, we need to recruit more GPs and free them up to spend more time with patients.

  The NHS Plan commits us to 2,000 extra GPs by 2004. I know many feel that this is not enough. But all along we have said this is a minimum not a maximum increase. And the recent measures announced by Alan Milburn make it more likely that we will be able to exceed this target.

  550 extra GP training places. 400 extra GP trainers. ??5,000 for every new GP and for those returning to working after having a career beak. An extra ??5,000 on top of that for those working in deprived or under-doctored areas. And a ??10,000 bond or ISA to reward those who decide to work on to 65.

  Fourth, the primary care workforce review being conducted by John Denham will report later this year. It will no doubt recommend a significant further increase in GP numbers. But this review is also looking at the roles and numbers of other health professionals.

  The last 10 years has seen the number of practice nurses grow by 40%. The work of health care assistants and physiotherapists is growing. We are legislating for pharmacists to take on a bigger role. We shall be recruiting 1,000 graduates specially trained to help GPs deal with common mental health problems.

  So boosting GP numbers is important, but it is not the complete picture or the only objective.

  Fifth, it is also important how we use GPs. I know many feel overwhelmed by the volume of work, the rushed consultations and the unending stream of patients coming through the surgery door. Nearly a year ago I announced a review of how we reduce GPs' workload. Today we are announcing the results of a report on streamlining GP paperwork. It sets out 36 practical changes which will free up millions of appointments for GPs.

  GPs will no longer be expected to sign driving licence, passport or postal vote applications. Other health professionals will be empowered to deal with many requests that only a GP can currently action. Timescales are being co-ordinated. Forms simplified. Advice updated. All with the intention of reducing unnecessary red tape.

  I have asked the Cabinet Office to monitor the implementation of these proposals and to report back to me in a year with a progress report and further proposals for cutting GP bureaucracy.

  Unnecessary red tape and regulation is a scourge not just for GPs but for other employees as well. Where regulations have outlived their usefulness we should get rid of them. New rules should be framed as sparingly as possible. We must balance the need to reduce risk with the need to encourage flair and innovation.

  The war on red tape in primary care does not stop with this report. Before too long we shall be commencing discussions with the General Practitioners Committee of the BMA on changing the GP contract so that it focuses more on quality and outcomes. A key aim will be to simplify the extremely complicated expenses system and reduce the time GPs have to spend on claiming reimbursement.

  I know how hard GPs work. I know we have set you challenging targets. I am not asking you to run ever harder on a treadmill of never ending work to deliver them. You know that is not possible or desirable. We have to look at other ways of responding. GPs up and down the country are finding that doing things differently can revolutionise their working lives.

  The Primary Care Development Team under the leadership of John Oldham is helping GPs to cut waiting times for appointments and implement the standards in the National Service Frameworks. By making greater use of telephone consultations, developing the skills of practice staff and changing the way clinic sessions are organised, all the first wave practices are now offering their patients an appointment within 48 hours. Faster access is a challenge but it can be done. Some of the people who have done it are here today. Teamwork has been an essential ingredient of their success.

  Sixth, if the primary care revolution is to take off it is important that we support practice teams as well as individual GPs.

  By upgrading and modernising GP premises. Since 1997 1,000 practices have been refurbished and by 2004 that number will have grown by another 3,000. NHS LIFT, a ??1 billion public private partnership, will help create 500 modern one-stop health centres. Already we have announced the first areas to benefit.

  By ensuring that all GP practices are equipped to operate in the electronic age. Most GP practice are now online. Half of GPs have their own desktop PC connected to NHSnet. By the end of March 2002 every GP will have this facility. I want to thank the BMA for their role in helping us to deliver this strategy.

  By enabling practice teams to have more protected time away from the hurly burly of seeing patients, so that they can review their work and update their clinical practice. Some PCGs and PCTs now provide out of hours cover for one afternoon a month to enable GPs to do this. More PCTs should follow this example.

  Finally we need to incentivise and reward practice teams for their effort. A further 1,000 Personal Medial Services schemes are going live this April. One of the advantages of PMS is that it provides a very clear focus for GPs: it sets out clearly the health outcomes to be achieved. We want to build on that approach.

  Incentive schemes are nothing new in primary care - whether for improving patterns of prescribing or achieving a broader range of targets. Overall the Department of Health reckons that around ??100 million is being spent on incentive payments in primary care.

  Today I am announcing plans to double that amount. The Chancellor's Budget allocation for the NHS included an extra ??45 million a year for primary care incentives. We shall link this sum to primary care's share of the NHS Performance Fund to bring it up to ??100 million.

  PCGs and PCTs will draw up with practices their own incentive schemes. The schemes should be simple and deliver local service improvements reflecting NHS priorities in areas such cancer, heart disease, faster access and reducing health inequalities.

  I want to stimulate innovation. To foster new ideas and different ways of doing things. To tap the energy and creativity of GPs and spread best practice.

  The money - ??10,000 for an average practice - will go to practices. Half will paid out up front to fund improvements in service such as extra clinic sessions, extended hours or training GP specialists.

  The second ??5,000 will be paid out at the end of the year provided that a practice hits its local incentive targets. Practices that hit their targets and earn this bonus will have complete freedom on how they use it. They can take it as a cash sum for themselves, reward practice staff or put the money back into patient services.

  PCGs and PCTs will be free to roll in other incentive payments into this scheme and boost the incentive pot from the unified budget. We shall look to try and increase this incentive fund in future years.

  We have introduced new arrangements to reward effort and enterprise in schools. Now it is the turn of GPs and the primary care team. Money for results. Financial incentives have a key role to play in delivering better public services.

  I know that teachers, police officers, nurses, doctors and other NHS staff do not come into public service primarily to make money. They are motivated by a sense of vocation. That is something that is beyond price. Both the public and the Government value that commitment. But I also see no reason why staff who do a good job for the public should not be rewarded for what they do.

  Drawing this together, the aim is clear. It is to empower local doctors and nurses to make changes necessary to drive forward progress in the NHS. Putting doctors and nurses in the driving seat was the driving force behind the creation of PCGs and PCTs.

  At present PCTs cover around half of the country. By 2004 we expect them to be nationwide. These are early days but already we can begin to see benefits. A better grip on clinical quality. Support for single-handed practices. New services for patients.

  Now is the time to press the accelerator and give more power to PCTs. We shall devolve more responsibility to the front-line: a steady increase in money, information and support to PCTs.

  As for the money, the PCTs, as commissioners of most services for patients should control the lion's share of health service cash. In 1997 GPs were controlling just 15% of NHS spending. I can confirm today that by 2004 PCTs will have responsibility for at least 75% the NHS budget - a budget which is growing, on average, by 6% in real terms every year. That represents a huge act of devolution and delegation.

  More freedom for all. But not as, as some would have it, a free for all. National priorities will remain important. But trusts will have more freedom on how they are achieved and more freedom to address the local as well as the national agenda. More freedom for the frontline not just for PCTs and hospitals, but for schools and police commanders as well.

  Devolution is not just about controlling the money. Budgetary power has to be turned into reality. Every PCT will get data on the performance of their local hospitals and be able to compare them with others round the country, and so exert pressure for improvements in quality and efficiency.

  PCTs will also receive detailed information on each practice. This will enable PCTs to give practices indicative budgets and, as practices demonstrate their competence, gain increasing responsibilities.

  PCTs are young organisations. They need support if they are to mature and thrive. The NHS Modernisation Agency will shortly be starting an intensive scheme of support for leaders of PCTs. The work of the Primary Care Development Team is being expanded. Management support for PCTs will grow.

  Those who serve as GP executive chairs or lead work on clinical governance should be properly rewarded for their effort. John Denham has made clear that funding payments for this work is a legitimate call on the unified budget.

  Today I want to give details of two other initiatives that will enable PCTs to develop their potential.

  Over the next three years we will spend ??25 million to set up a series of Teaching PCTs. As teaching hospitals have brought excellence and expertise to the acute sector, so teaching PCTs will do the same for primary care. They will be developed in disadvantaged and under-doctored areas and have a very practical bias. They will help develop the skills of GPs, spread best practice and act as centres of learning.

  The first three Teaching PCTs will be established from 1 April this year in Salford, Bradford and Sunderland. And we will invite applications for further centres in the near future.

  The second initiative is aimed at improving cancer services. Although cancer kills over 100,000 people a year, the average GP will only see around nine cases diagnosed as cancer each year.

  From this April this year each PCG and PCT will receive ??5,000 to support the work of the GP or nurse leading their work on cancer.

  The money will help make sure that people with cancer and their families get the treatment and support they need from their GP practice. It will enable GPs to develop their knowledge and improve the links between primary care, hospital and hospice services.

  Half the money has come Macmillan Cancer Relief. I want to pay tribute to all the work they do in partnership with the NHS.

  This then is our agenda for primary care. A big agenda. We must ensure that we move forward together to implement it. So my final announcement today is the appointment for the first time of a National Director for Primary Care Services. As with the directors for cancer, heart, mental health and the elderly it will bring clinical expertise right into the heart of the Department.

  I am delighted that this post will be filled by Dr David Colin-Thome. David will be known to many of you and is himself a practising GP.

  Taken together, the aim of all these initiatives is to move us into a new phase of change in the NHS. In the past 4 years, we have had to exercise a significant degree of central intervention, to stop the seemingly inevitable decline of the standards of service. We had to do it moreover, against the backdrop of real financial difficulty - financial deficits in Trusts, lack of staff, capital investment down; and with a large public sector debt for the nation we had to reduce drastically.

  I know you have faced real pressures - because along with the extra demands, has been huge structural change in the advent of PCGs and then PCTs. But the process of structural change is taking root - PCTs are establishing themselves. There is extra financial investment, not for 1 year but sustainably. The extra staff are or will be recruited. The largest ever capital investment programme in the NHS is under way. With the economy stable and public finances strong, we can invest for the future.

  Now, in the second phase, we can start to empower the local change makers to deliver in a more flexible, less centrally directed way. It is a huge opportunity. Whatever the difficulties, it will be the basis of renewing the NHS. It is what we all want and, in partnership, can achieve.

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