Nearly half of recently qualified GPs are experiencing rising levels of stress, while over a quarter say they don’t have time to deliver the care patients need.

Of 368 GPs surveyed by the BMA who qualified in 2006 (from a cohort of 435), 40% said their morale had deteriorated in the last 12 months.

The respondents identified the current NHS structural reforms – claimed by the Government to be ‘empowering’ GPs – as a major reason for this decline in the professional experience of primary care.

However, 92% said that interactions with patients improved their morale – showing that patients being more unwell or more demanding was not a major issue.

The 2012 survey found that 44% of respondents said their stress levels had worsened over 2012, 20% reported ‘unacceptable’ levels of stress at work, and 28% said they did not have time to deliver the care that patients needed.

In addition, more than half (54%) identified understaffing as a major problem in their practices, while more than three quarters (79%) said work-related administration duties negatively affected their time outside work.

The BMA said the survey's evidence of declining patient access to NHS primary care of adequate quality was “troubling”.

Health Secretary Jeremy Hunt has pointed the finger of blame at GPs for rising A&E admissions and the added pressure placed on emergency services.

Speaking to MPs, Hunt said that “poor primary care provision” was behind some four million additional people unnecessarily visiting accident and emergency services.

But the General Practitioners Committee called Hunt’s claims “nonsense”.

A Department of Health spokesperson played down Hunt’s accusations insisting the Health Secretary was “clearly not blaming GPs” and that he was referring to procedures set by the former Labour government.

Hunt was responding to figures published by Labour that showed the NHS had missed its national A&E waiting times each week for the past six months.

He claimed this was down to poor alternatives to primary care which was the result of changes introduced by Labour to the GP contract.

“The reason that there is so much pressure on A&E is because of the disastrous GP contract that was negotiated,” he told the House of Commons. “That is what is causing the huge pressure. That is what we are determined to put right.”

The Health Secretary said the solution to the rising number of A&E admissions was to analyse the GP contract, introduce alternatives to secondary care and integrate health and social care services.

More than half of GPs see accusations of conflicting interests as the greatest danger of the new CCG system.

A survey of more than 1,000 GPs and practice managers by medical indemnity provider the Medical Protection Society (MPS) revealed that 59% were afraid of losing patient trust through their role in the new NHS.

The survey indicates that the new regulations enforcing competition in CCG commissioning are unpopular with the majority of GPs, who see a threat to the doctor-patient relationship.

MPS warned that without “clear and robust governance structures and processes” within CCGs to deal “openly” with perceived conflicts of interest, public confidence in the new NHS could be eroded.

Dr Richard Stacey, Editor of the new WPS journal Practice Matters, said: “MPS has always had concerns that CCGs could place GPs in a potentially challenging position of being not just the patient advocate but also the budget holder, and we believe this leaves GPs vulnerable to accusations of conflicting interests. This survey not only confirms MPS’s fears but those of GPs and practice managers.”

Responding to the survey findings, Dr Mark Porter, Chair of the BMA Council, commented: “The BMA believes that any GP who has financial interests in a private sector company that might be awarded contracts in their area should consider seriously whether they should be a member of a (CCG) governing body.”

He added that the economic pressures facing the NHS will threaten patient and public confidence in GPs, as they will come to be seen as rationers rather than providers of services: “Ministers must ensure that CCGs have an appropriate level of resources so that they can meet the needs of their patients.”

The new NHS structure came into force on 1 April, with local commissioning now entrusted to clinical commissioning groups (CCGs) that combine business and clinical expertise.

The CCGs are managed by NHS England (formerly the NHS Commissioning Board) and governed by new laws that enforce a ‘level playing field’ for provider competition.

The 152 Primary Care Trusts are now abolished, and all NHS hospital trusts are required to qualify for Foundation Trust status within the next year.

NICE, renamed the National Institute for Health and Care Excellence, will set standards for both health and social care services, promoting integrated care.

The statutory role of CCGs in facilitating competition between providers of NHS services has polarised opinion, with only a third of GPs in a Pulse survey saying they felt empowered by the new system.

According to private health analysts Laing and Buisson, the NHS in England spent 11% more on services from private providers in 2012 than in 2011 – a clear sign that the provider base is already shifting.

Professor David Haslam, the new Chairman of NICE, commented: “It is a time of huge risk. We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together.”

Mike Farrar (pictured), Chief Executive of the NHS Confederation and a long-time champion of community-based healthcare, warned that trying to improve patient safety while reducing costs would place great pressure on the new NHS.

“We need to recognise the huge challenges facing the health service,” he said. “New structures alone won’t enable us to tackle these challenges, and we should not see them as a silver bullet.”

The days when pharmaceutical representatives arrived with a simple printed paper aid is thankfully long gone. Morten Hjelmsoe explains how the latest technology is helping to develop the customer-client relationship like never before.

This is an important moment for pharmaceutical sales professionals. Right now technologies are being implemented that will shape how the technology sector relates to healthcare professionals for years to come. These technologies matter because, if they are applied correctly, the sector can free itself to communicate in new ways and rebuild the industry’s relationship with healthcare professionals.

It’s a sad fact that medical professionals often see little value in technological communications. Representatives now have only a few minutes or perhaps seconds to communicate and, in some countries, are prevented from seeing medical professionals altogether. Where contact is maintained, this is often driven more by sampling than the exchange of information. If current trends continue, then direct access to medical professionals may fade away altogether.

The problem is that the information that sales representatives are being asked to deliver simply cannot be relevant enough. Every medical professional has a certain level of knowledge on a topic and a particular set of needs and concerns. It’s hard, if not impossible, to respond through traditional ‘campaign’ communication.

For example, a certain doctor might be particularly concerned about the safety of a new brand. So until that is satisfactorily covered there’s little point in discussing its speed of action. Yet this may be precisely what the representative is asked to do as a new campaign kicks in.

The representative knows this but cannot react to the doctor’s needs. And, as we all know, when something isn’t relevant to the audience it won’t receive much attention. So no matter how skilled the sales representative is, the lack of relevance creates a barrier that is hard to overcome. The good news is that technology now makes it possible to eliminate these potential barriers by not establishing them in the first place.

Push to pull

The introduction of new technologies enables us to think differently about communication. While closed loop marketing is the terminology often used, I actually prefer to use the term ‘pull marketing’ or ‘pull communication’. It’s not a big deal but it more clearly demonstrates the difference from traditional ‘push’ forms of customer communication. Put bluntly, the difference is:

• A push communication is what I want you to know

• A pull communication is understanding what you need to know and then providing that

Traditionally, technology has concentrated on push communication. I like to think of this as acting like train drivers. There’s a destination in mind for healthcare professionals and so tracks are built to transport them there. Of course, this means that everyone has to travel together and at the same speed.

Pull communication requires that we act more like taxi drivers. Here the job is to react to people’s individual needs and work out the best route for them. Asking, “Where do you need to go?” is fundamentally different from asking, “Do you want to go here?” It is also more likely to get a positive response.

Paper Thin

Through its sales force the pharmaceutical industry has a unique and precious contact with its customers. In fact, it’s hard to think of another industry that has these advantages. Yet technology has actually prevented pharma from making the most of this.

Pull communication wasn’t possible in a paper world. We simply couldn’t keep track of what each physician needed to know – or where they needed to go. There’s currently thousands of GPs, each needing slightly different pieces of information. It’s impossible! Unfortunately there would be one printed detail aid and that would have to work for everyone. And that’s the way it stayed until information technology advanced enough.

Look at it this way; each day, sales representatives go out loaded full of information. They deliver these messages but they return home empty. Or so it appears. In reality, sales representatives will have learned a great deal but this information couldn’t be transferred. The problem was that the technology in place lacked a way to collect insight and collate this in such a way that it became actionable information. Now everything’s changed.

The future

We already have the technology that allows doctors to choose the information that they are interested in. During a discussion with a company representative for example, medical professionals can actively pull the information they want, which ensures they don’t talk past each other.

Technology can also help sales representatives gather this feedback. Intelligent communication systems, which fit naturally with normal workflows, record each medical professional’s particular interests as they interact with the systems.

Suddenly, sales professionals no longer appear to come home ‘empty’. Now it’s clear that they are active gatherers of information who refuel at each appointment to collect insights that drive future communication. And it continues this way – continually developing a better customer understanding that powers the provision of high value information.

While technology has the potential to reinvigorate relationship with healthcare professionals and key customers on its own it is not enough. New technology calls for a new strategy: pull communication. If we simply add technology, we’ll only get more efficient push communication – the one-way, mass messaging route that has sales reps replicating train drivers. And that will only accelerate problems.

If you recognise there is an underlying problem, in the fact that healthcare professionals feel over-exposed to non-relevant messages and increasingly close themselves off from the industry, then how can increasing the efficiency of communication change the situation? More contacts made more easily? It’s like trying to treat side-effects by increasing the dose. I fail to see how that can work.

So instead of just seeking greater efficiency, I would argue that we should take the opportunity that technology offers to fundamentally change what we’re doing.

Choose freedom

When technology is allied to a pull strategy representatives are freed from acting as a mass communications channel and can become true communicators, providing personal service. If we embrace the opportunities of technology and raise our expectations of what it can provide, we can enter new era of personalised communication and service delivery.

This is what sales teams have been asking for. They know their customers best and can now create, not just local, but individual strategies. This means that they can get measured on their ability to educate and not simply deliver messages. Whether it is through face-to-face meetings, group workshops or online discussions, it’s the ability to meet needs and actually change behaviour that really counts.

This is a huge opportunity for the industry. In the hands of company representatives, pull marketing technology starts to create a virtuous circle: bringing customers real value, with representatives generating better relationships and gaining more meaningful access which allows them to deliver more value, and so on.

This can have a dramatic effect on the relationships between pharmaceutical sales and medical professionals. The more value that is brought to the table, the more valuable pharma reps become. If the technology is applied in the right way pharma can restore the traditional position as a treatment partner. Who knows, perhaps there will come a day when the value of what sales professionals can offer is so great that healthcare professionals actually pay for a visit from a company representative? It’s not impossible. What’s certain is that there are exciting times ahead. It’s time to turn the tables.

Morten Hjelmsoe is founder and CEO of Agnitio A/S – the provider of the leading pull marketing software platform for the pharmaceutical and medical device industries. Agnitio’s system is already implemented in more than 45 countries and 25 languages – and used by major pharmaceutical and medical device companies globally. www.agnitio.com.

The introduction of CCGs has not made doctors feel more involved in commissioning decisions, a new survey has revealed.

Research by Pulse magazine found that out of 303 doctors questioned more than half (55%) said they do not feel any more involved in commissioning services now than they did under PCTs.

Only 36% of GPs surveyed said the introduction of CCGs had made them feel more involved in commissioning decisions.

Dr Chaand Nagpaul said the lack of engagement was a result of the Government pushing the reforms through “at breakneck speed” which did not allow for “adequate involvement and organic development”.

The survey also found that a fifth of GPs had not signed their CCG constitution – only days ahead of commissioning groups taking on their new responsibilities. Doctors who had not signed a constitution, claimed they had either not been asked to or that the documents were still in draft form.

Ineffective drugs are prescribed by 97% of GPs as ‘impure placebos’, according to a study by researchers at two UK universities.

A survey of UK doctors found that nearly all admitted prescribing treatments they knew would have no direct pharmacological effect, including antibiotics for viral infections.

The survey findings present strong practice-level evidence that placebos have a real health impact – which has implications for the debate around whether homeopathic medicines should be used in the NHS.

The study authors emphasised that the ‘placebo effect’ is not medically negligible: a placebo treatment can help to stimulate neurological and endocrine reactions to the disease, reducing the symptoms.

‘Impure placebos’ are real treatments whose efficacy for that particular patient is doubtful. It differs from off-label use, where the drug is not approved for that indication but there is trust in its efficacy.

In addition, 12% of GPs admitted prescribing ‘pure placebos’ (with no active ingredient) to reassure patients whose anxiety was itself a health risk factor.

Researchers at the Universities of Oxford and Southampton analysed the responses of 783 GPs to an online survey. The respondent population was analysed and judged representative of registered GPs in general.

The survey found that doctors used impure placebos to induce psychological treatment effects, to counter patient anxiety or to comply with patient choice.

While 84% of doctors judged the use of impure placebos to be acceptable in some situations (and 66% supported the use of pure placebos), more than 80% said their use should not involve deception.

Professor George Lewith, co-lead author of the University of Southampton study, said the two studies showed that “doctors are generally using placebos in good faith to help patients”.

Previous studies “have clearly shown placebos can help many people and can be effective for a long time after administration,” he added. “The placebo effect works by releasing our body’s own natural painkillers into our nervous system.

“In my opinion the stigma attached to placebo use is irrational, and further investigation is needed to develop ethical, cost-effective placebos.”

The use of placebos is discouraged by the General Medical Council. However, Dr Jeremy Howick, co-lead author of the University of Oxford study, argued: “Current ethical rulings on placebos ought to be revisited in light of the strong evidence suggesting that doctors broadly support their use.”

The Department of Health has agreed to withdraw and revise the current secondary legislation on competition in NHS commissioning.

New regulations, tabled in Parliament a month ago, appeared to give Monitor the power to enforce private sector tendering of virtually all NHS services.

Following protests from the Academy of Medical Royal Colleges (AMRC) and over 1,000 GPs, the DH has claimed any difference between this and the former regulations was purely “inadvertent”.

Allowing CCGs to decide which services would be put out to competitive tender was one of the modifications to NHS reform agreed following the ‘listening exercise’.

However, the new secondary legislation appeared to override the ‘discretionary’ powers of CCGs and enforce competition in all areas of care, potentially driving the contracting out of most NHS services to the private sector.

Monitor would be empowered to enforce competitive tendering except where only one qualified provider existed, which is rarely the case.

Last week, a letter signed by over 1,000 GPs was sent to the Daily Telegraph urging a full Parliamentary debate on the new regulations, which will become law by default unless actively opposed.

This weekend, the AMRC wrote to Health Minister Earl Howe expressing “considerable concern” that the regulations disregard assurances formerly given by the DH and would drive a “dangerous” fragmentation of the NHS.

The situation recalls former Health Secretary Andrew Lansley’s statement that the listening exercise had not significantly altered any aspect of the NHS reform.

However, following the protests, Health Minister Norman Lamb (pictured) said the DH had “inadvertently created confusion and generated significant concerns”, and would revise the secondary legislation to show that it was in line with existing rules.

The revised version will be “fully in line with the assurances given” to the medical professions, he said, and will confirm the power of CCGs to decide which services go out to tender.

Shadow Health Secretary Andy Burnham said the revision of the secondary legislation, less than a month before it comes into force, shows that “Coalition policy on competition in the NHS is in utter chaos.”

The UK medical professions have worked together to develop a strategy to address the national obesity crisis – the worst in Europe.

Two thirds of adults in the UK are now overweight and a quarter are clinically obese, the Academy of Medical Royal Colleges (AoMRC) has warned.

Professional training, weight management services, nutritional education and changes to the built environment are among the measures it recommends.

Obesity is a strong risk factor for diabetes, heart disease, musculoskeletal disorders and mental health problems.

The UK’s national health services should collectively invest £100m in weight management services modelled on the existing smoking cessation services, the AoMRC argues.

These should range from early intervention to bariatric surgery, with QOF incentives for GPs to refer patients to the relevant services.

Healthcare professionals should seek to “make every contact count” in influencing patient behaviour.

While most of the recommendations are related to patient lifestyles and the “obesogenic environment”, many medicines can impact on weight management – and vice versa.

While some measures, such as a ban on the advertising of junk food to children, are unlikely to be adopted by the Government, the prioritising of the obesity crisis within the NHS will influence many aspects of medical care.

Linda Hindle, Chairman of the Dietitians in Obesity Management group, said: “Obesity in the UK is an absolute epidemic, there is no question that the recommendations in this report are essential.”

The NHS Commissioning Board has identified the enforcement of generic prescribing as one of its key priorities for 2013.

A study commissioned by the Board found the NHS could save £200m per year by replacing two branded statins with generic alternatives, and annual savings of up to £1bn could be achieved across all prescribing.

The study recommends that GPs with expensive prescribing habits should be required to explain their decisions to the CCG – thus potentially creating conflicts between CCGs and pharmaceutical companies.

An embargo on branded drugs where generic versions exist could also see deep erosion of the specialised biopharmaceuticals market by biosimilars.

Branded drugs are often more recognisable, easier to swallow and even easier to digest than generic alternatives – but they can cost up to 25 times as much.

Open Health Care UK and data research company Mastodon C analysed the prescribing of two statins across the country. Many GPs were still prescribing branded versions, despite the availability of generics.

The Board’s Medical Director, Sir Bruce Keogh (pictured), said: “Variation in prescribing habits costs the NHS millions of pounds a year. Sharing of information will help clinicians understand whether they are over- or under-prescribing.

“This will focus minds in a way that will not only improve the quality of treatment for patients but also reduce cost and free up money for reinvestment.”

According to experts cited by The Independent, two mechanisms underlie the over-prescribing of brands: GP practices with on-site pharmacies have an incentive to prescribe branded drugs as they generate more profit; and hospitals buy branded drugs in bulk, reducing the cost but creating an ongoing patient expectation.

Open Health Care UK and Mastodon C will develop software to help the new CCGs target local GPs whose prescribing practices are expensive.