Last week NHS England published, “Our Plan for Improving Access for Patients and Supporting General Practice”.  It is a document that lacks coherence, and is clearly a performance management document that has then been added to to try and make it ‘acceptable’ to the profession (e.g. add “and supporting general practice” to the title).  This hasn’t worked, and, understandably, it has created an angry reaction across the general practice.

In the NHS direct performance management like this has been common for a number of years.  Statutory NHS bodies such as Acute trusts, Community Trusts, CCGs (etc) receive edicts like this that demand certain actions and delivery on a reasonable regular basis.  These are then reinforced by senior leaders not achieving the targets being summoned to local then regional then even national performance meetings.  There was a time in the not too distant past when acute trust chief executives not meeting the 4 hour A&E target were being summoned to meetings with the then Secretary of State Jeremy Hunt.

This style of performance management is a particularly unpleasant side of the NHS.  It comes because those in the highest positions of the NHS have to demonstrate they have levers they can pull to make things happen on the ground, when they themselves are under pressure.  We have a new Secretary of State and a new NHS Chief Executive, and the bigger worry is that this is just the first taste of what life is going to be like under this new regime.

But if nothing else, the document is a timely reminder of the benefit of the independent contractor status that general practice enjoys.  The reality is that the Secretary of State cannot directly tell GPs what to do, or instruct how they should behave, in the same way that he can with NHS Chief Executives and senior leaders.

Whilst the document might feel like direct performance management (it is designed to), it is in fact an instruction for how NHS staff that are under the direct control of NHS England are to manage the contract they have with general practice.  They are the ones who are to submit returns by the 28^th October, not practices themselves.  For general practice, its responsibility lies in making sure it delivers against the contract it has signed up to, nothing more.

For those who have not read the document (and it is not a read I would recommend), it essentially outlines a series of measures that it will introduce to try and increase the number of face to face appointments GPs hold with their patients.  They will use the data practices are now submitting to publish waiting times at practice level, and send a ‘hit squad’ into the practices with the longest waits.  The NHS is asked to compile a list of practices where the number of appointments is lower than pre-pandemic levels, of the 20% of local practices with lowest level of face to face appointments and with the most significant level of 111 calls in hours and A&E attendances compared to expected, and of where concerns have been raised with CQC and others.

The NHS is then to use this data to create an overall list (by 28^th Oct) of local practices where “it will be taking immediate further steps to support improved access” (43).  These actions are to include “partnering with other practices, federations or PCNs”, and “contract sanctions and enforcement” (45).

Pretty grim stuff.  It is effectively an instruction for commissioners to use any contractual lever they can to make practices see more patients face to face.  They themselves will be directly performance managed on this, as they are “required to produce a fortnightly updated report for their region” (48).

For GP practices the best thing to do is simply ignore it.  As long as you are happy with the balance of remote to face to face appointments in your own practice and are confident you are meeting your contractual requirements, then don’t do anything.  The worst thing that could happen would be for this approach to be effective, because it would encourage the new national NHS leadership regime to do more of the same in future.  Practices have enough on their plate to content with right now, so let commissioners manage the flak that comes from above.  The good ones do this regularly and they do it well.

If general practice was part of the NHS (as opposed to an independent contractor) it would be having to manage this itself.   Independent contractor status is hugely valuable, and one general practice would do well to hold on to as long as it can.