It might not seem like that long since the GP Forward View (GPFV) was published, but at the end of the March we come to the end of the 5 year GPFV period.  Just as a reminder, the headline of the GPFV was an investment of £2.4bn over those 5 years to demonstrate that the challenges in general practice had been heard and understood, and to provide real financial and practical support to the service.  What did the GPFV achieve, and where has it left general practice now?

There are a number of reflections to make about the GPFV:

5 years is too long a time frame.  In 2019, 3 years into the GPFV, the GPFV was effectively superseded by the new 5 year GP contract and the introduction of Primary Care Networks (PCNs).  When announcing funding uplifts a longer timescale works better because the money sounds more, but the reality is things change too much over that time period for it to remain a firm plan.  No one has really spoken about the GPFV for the last 2 years since the new contract was introduced.

It was really about access. While not immediately obvious, what became clear from the GPFV over time was that the real intention of the document was to deliver the government’s agenda of improved access to primary care.  The only significant recurrent additional funding in the GPFV, on top of the contract awards, was the £500m funding, or £6 per head of population, for additional access.  What then happened was the introduction of access stretched the already-thin workforce even further, diverted portfolio and part-time GPs away from core practice, as well as moved funding thought to be for core general practice into alternative providers – the £6 per head never went direct to practices.

In the new contract the primary policy objective is the introduction of primary care networks.  As with access in the GPFV, the real new money follows the policy objective, not the demands of the service.

There was never £2.4bn additional funding.  The GPFV struggled right from the outset with transparency over the funding.  It was very difficult to track and find the money.  Some of us persisted in trying to track it down, and it turned out the extra £2.4bn never really was £2.4bn.  It was less than £1bn.  Headline announcements of large sums of money over 5 year periods are largely an accumulation of inflationary rises to the global sum.  And in the case of the GPFV these were backdated to before the document was even published.

Money in the GPFV came via NHS England to CCGs, sometimes to federations, and eventually to practices.  Multiple pots all had their own application processes.  The money proved difficult to access and was beset by bureaucracy.

In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years. £1.8bn of the £2.8bn comes via the new networks, the rest is primarily in the uplifts to the global sum.  This year the uplift was 2.1%, less than the figures around 3% we were seeing during the GPFV.  But at least this time there is more transparency and the money is embedded in the contract.

5,000 extra GPs was always a myth.  One of the government’s promises when it published the GPFV was to provide an extra 5,000 GPs.  This became a particular source of embarrassment for the government, as not only did it fail to provide the extra GPs but the total number of GPs actually fell.  In 2019 there were 6.2% fewer full time equivalent GPs than in 2015[1].  At that point the old trick of changing the way the numbers are counted was introduced (see here[2]) to try and prevent further embarrassing comparisons.

With the 2019 contract the move was to additional roles to support GPs via the Additional Role Reimbursement Scheme.  How successful this is in supporting practices with the core workload remains to be seen.

It started the journey of delivering care in new ways.  The GPFV promised to support practices to introduce new ways of delivering care, and the Releasing Time for Care programme and the work of people like Robert Varnum on the 10 high impact actions were amongst the most helpful parts of the document.  However, there is no getting away from the fact that it was Covid-19 not the GPFV that has ultimately led to a step change in the way that care is delivered.

But for all its faults, the GPFV did represent a clear change in government policy towards general practice.  Previously, ever since the introduction of the revised GP contract in 2004 which the government felt it had paid too much for, there had been disinvestment in the service over many years.  This had left general practice in a parlous state, and it was only the introduction of the GPFV that really marked the end of this period of austerity.

However, for many this came too late, and the GPFV struggled to stop the exodus of GPs either into retirement or reducing their hours.  As a result the plan was never able to address the core workload and recruitment issues the service faced.

Five years on general practice is starting to feel different, but that is primarily down to the new contract and Covid-19.  The next few years are critical for general practice, particularly in terms of whether it can access the PCN funding to support the delivery of core services and build a sustainable staffing model, and whether it can embed the more helpful changes made during the pandemic. At least with a clear contract now in place the service has a more secure platform than the GPFV ever was to build on.

[1] https://www.bmj.com/content/bmj/369/bmj.m1437.full.pdf

[2] https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services