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The Nightmare Before Christmas

Still practising

Chris Preece

Tuesday, 07 January 2020

AdobeStock_295993572_NBC_blog.jpgNHS England has been trying to get into the Santa business. On the 23rd December they climbed down the metaphorical chimney of each and every GP practice in the country, and delivered a beautiful new draft of the Service Specifications for the GP Contract. Sadly, whilst the majority of us simply failed to notice the arrival of this gift at all, those of us that did unwrap it, found themselves in a Nightmare Before Christmas scenario. 

I would try and summarise the specifications for you, but having just done that for my own PCN, I discovered that I had successfully reduced an unwieldy 42-page document to, well, an unwieldy 8-page document. So instead I’ll summarise it thus: It’s a car crash.

It’s a series of specifications so spectacularly ill-considered that I found myself wondering how, precisely, they had come to be. In the end I produced a number of potential theories…

The “We Don’t Know Maybe They Do” Scenario

Picture it. You’ve just agreed a brand spanking new GP Contract with a whole bunch of vague headings for Stuff That Will Get Done, but you haven’t really worked out what any of those specifications actually mean yet. It’s fine, you tell yourself, there’s loads of time, and you wouldn’t have come up with those headings unless there was a really solid evidence base for it – “we can knock something together in a couple of weeks”.

A couple of months later and the panic’s starting to set in. You’ve said it will start in April, and you’ve still not got any real idea what any of it means. You know it has to sound like A Lot or the guys in head office will wonder what they’re paying for, but the evidence around half of it is at best contradictory, and there’s no real agreement on how anything should be done. Suddenly it’s December, and people are screaming at you to have it done before January, so in the end you just go “Sod it, I’ll just write down everything I’ve ever heard anyone say they would like to see happen, and they can figure out exactly how it will work. I mean, they must know, right?” So you write a specification full of buzzwords like “integration” and “care planning” – and even though very few people have managed to meaningfully pull any of it off, not least without any actual funding, you stick a pin randomly in a calendar and declare it will all happen by the end of June. Job done, off to the pub. 

Speaking of which…

The “We wrote it in the pub” Scenario

Self-explanatory really. Maybe it was the NHS England Christmas Party. I like to imagine they started with the Structured Medication Reviews. There are a few bits in there to give away their early inebriation – the idea that these extra long appointments that have little or no impact on GP attendance will somehow reduce workload for instance – but it’s mostly coherent with metrics that fit the stated aims, and clear benefits to patients at least.

They obviously tackled the Supporting Early Cancer Diagnosis specification next. The specification is mostly sensible, but becomes progressively less focussed and vague, leaving you wondering how the suggested actions will result in the desired outcomes. It’s like talking to a pleasantly inebriated friend, who isn’t entirely making sense, but clearly means well. At this stage there was presumably still hope that it would all make sense by the morning.

By the time they had got to Enhanced Health in Care Homes however, I suspect some of the writing team were staggering about on table tops singing along with The Proclaimers. By this point they no longer knew what specification they were writing, with bits of Anticipatory Care popping up in Personalised Care, whilst both blended into the Care Home spec like a particularly ill-conceived cocktail.

Really it’s a miracle the whole thing doesn’t end with “Item 5.8:  I love you I do. I do. I bloody love you…”

Except, maybe they don’t love us at all…

The “Let’s Destroy Everything” Scenario

There were moments reading the specifications where I genuinely wondered whether the whole thing was an attempt to make everyone just hand in the towel. Again, picture the scene. They’re all sitting round the table, maybe one of them has had a run in with some mouthy GP on Social Media, and they just decide they’ve had enough of the lot of us. So they try to cook up the most effective way they can of making everyone quit…

“Right, how about this? Five different service specifications, right? So every PCN needs to appoint a clinical lead for each and every one of them.”

“I don’t know. That’s a hassle sure, and they’ll never find people to do it, but still… I was thinking, how about ward rounds in every care home, with a full MDT and GP at least fortnightly? And they can be made responsible for supporting the professional development of the care home staff… And vaccinating them all! Oh, and the requirement’s the same whether they have zero care homes or a hundred!”

“Hmm, add some care plans to that, and we might be onto something. We’ll do the clinical lead thing as well though, yeah? Here’s the clincher though, we’ll fund none of it. Tell them they don’t need it ‘cos the additional roles stuff will ‘provide more than sufficient capacity’, that’ll get the resignations flowing…”

To be fair, I’m sure they don’t hate us that much. But maybe they do know how badly some of this will go down?

The “Opening Gambit” Scenario

As I say, this is a draft specification. Interested parties are invited to feedback to NHSE via the communications hub, here, by the 15th January. As such this is presumably an ongoing negotiation. Given that, you can’t help but wonder whether this is a deliberately outrageous bit of brinksmanship, made in the knowledge that we’ll be grateful for almost anything so long as it isn’t this.

Or maybe those writing have simply lost any sense of what it’s like out here in the real world?

In any case I’d encourage readers to let them know your views (though the survey doesn’t particularly invite any critical comments). Perhaps, with enough feedback, there’s still hope that this will be changed for the better. Whilst this was an unwelcome Christmas surprise, the specification isn’t due to start until April, so perhaps it can be reborn in a more appealing form in time for Easter.

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Chris Preece

Chris has worked as a GP Partner in North Yorkshire since 2004, and still relishes the peculiar challenge of never quite knowing what the next person through the door is going to present with. He was the chair of his local Practice Based Commissioning Group, and when this evolved into a CCG he joined the Governing Body, ultimately leaving in April 2015. He continues to work with the CCG in an advisory capacity. When not being consumed by all things medical, Chris occupies himself by writing, gaming, and indulging the whims of his children. He has previously written and performed in a number of pantomimes and occupied the fourth plinth in Trafalgar Square. Tragically, his patients no longer tell him he looks too young to be a doctor.
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