The Hewitt Review and the National GP Contract

The Hewitt Review was published on the 4th April, and the key takeaway for general practice from the review is that the national GP contract is now very much under threat.

There is an important distinction between the independent contractor model, i.e. GP practices working under a contract with the NHS, and the single national contract, which means that the majority of the work of GP practices is negotiated and agreed via one nationally negotiated contract.

The Hewitt Review, and I would suggest at present the majority of the NHS in general, does not like either of these things.  The independent contractor model prevents the NHS being able to dictate to practices what they have to do (the way it operates with all other NHS organisations).  Instead terms have to be put into a contract in order for a change to take place.

But the review does not go as far as both Wes Streeting and Sajid Javid (when he was Secretary of State) have previously gone in calling for the independent contractor model to be abolished.  Instead it turns it sights more squarely on the single national contract.

This move against the national contract featured heavily in the Fuller Report, which called for more general practice resources to come under the control of local Integrated Care Boards (ICBs).  The Hewitt Review picks up this mantle,

“The contract held by GP contractors for ‘general medical services’, which is negotiated nationally between government and the BMA, provides far too little flexibility for ICSs to work with primary care to achieve consistent quality and the best possible outcomes for local people.” 4.11 p66.

What is it about the national contract that local leaders dislike so much?  The example given in the document is illuminating.  It reports that pharmacists choosing to work in general practice in some areas is now exacerbating shortages in local pharmacies and acute hospitals.  So, one assumes, the argument is that left to local discretion the ARRS role that the majority of practices find is adding the most value would not be permitted in certain areas.

The question, then, is whether shifting from a single national contract to locally negotiated contracts would make things better for general practice, or would it simply prevent any shift of resources into general practice ever taking place?

The reality is that the national contract ringfences resources for general practice.  If a local system is under financial pressure it cannot remove resources that have been agreed within the national contract.  It can (and some areas have) stop any locally agreed resources, such as local enhanced services, but at present that is the limit of what it can do.  Many local system leaders think general practice is unfairly protected from taking its share of system ‘pain’ when local cuts need to be made.

Most local system leaders do not understand general practice, and how it operates.  The majority would have no clue what an enhanced service or an APMS contract is.  There is no understanding that while NHS trusts can simply post a deficit (that is underwritten by the NHS) and continue on pretty much as normal, GP practices have to remain as going concerns to be able to keep the lights on.

Given this environment in the majority of local areas, I do not believe that promises of local flexibility from locally agreed contracts would be worth the risk that giving up the protection that the national contract affords to general practice resources would entail.

The main recommendation of the Hewitt review when it comes to general practice is “that work should be undertaken to design a new framework for General Practice (GP) primary care contracts” (p8).  The national contract, and all the protection it affords, is very much now under threat. NHS leaders want the un-ringfencing of general practice resources, and the ability to be able to dictate directly to practices what they do and don’t have to do (particularly when it comes to access).  The national GP contract is the best protection the service has against this, and I would suggest the profession would be wise to strive hard to protect it.

What to Make of the PCN DES?

The revised PCN DES was published on 30th March, 2 days before it was due to go live.  What are we make of the changes that have been made?

The first thing to say is that the PCN DES cannot be understood in isolation from a number of other documents.  The first, and probably most important, is the updated GP contract.  This still has not been published (as of the 3rd April), but what we do know about it is that it has been imposed (i.e. not agreed by the BMA) and the funding contained within it has been increased at the rate agreed in 2019, i.e. below 3% while the cost of living remains at over 10%.

Bear in mind then that the additional funding coming into general practice is only coming via the PCN DES, hence its importance, particularly its financial importance, is greater than ever.

NHS England published a letter outlining the main changes to the GP contract.  The letter also points to a ‘Plan for Recovering Access to Primary Care’.  It states, ‘The Chancellor in his Autumn Statement set out a commitment to publish a recovery plan for General Practice access in early 2023. The Delivery Plan for Recovering Access to Primary Care will be published shortly and sets out how practices and PCNs can be supported to improve access during 2023/24’.

This letter was published on the 6th March, and yet here we are 4 weeks later with nothing out yet.  But it is safe to say that improving perceived access to general practice remains the number one political, and hence NHS England, goal.

This then frames the ‘big news’ in the PCN DES, which is the reduction in the size of the IIF to just five indicators worth £59 million, with the remaining IIF-committed funding of £246m for 2023/24 now becoming a Capacity and Access Payment.

However, the detail within this means it is not as bad as it might sound on the surface.

PCNs will basically receive 70% of this capacity and access payment just for participating (very roughly £140k per PCN for the year):

‘National Capacity and Access Support Payment: 70% of funding (£172.2m) will be unconditionally paid to PCNs, proportionally to their Adjusted Population, in 12 equal payments over the 2023/24 financial year’  

All PCNs seem to have to do for this is develop an access improvement plan that is agreed with the ICB by 12 May.

The other 30% will be paid based on improvements made in three areas: patient experience of contact; ease of access and demand management (use of cloud based telephony and online consultations); and accuracy of recording in appointment books:

‘Local Capacity and Access Improvement Payment: part or all of 30% of the funding (£73.8m) will be paid to PCNs based on commissioner assessment of a PCN’s improvement in three areas over the course of 2023/24.’

What is really interesting about all of this is that none of these payments are based on how long patients actually have to wait for an appointment.  Now, the IIF contains a single indicator (of the 5 that remain) that actually does measure waiting times (ACC-08: Percentage of appointments where time from booking to appointment was two weeks or less).

But this IIF indicator (the only one with actual measure of waiting time) is worth 71 out of the 262 points available, and worth £14,058 for the year to an average PCN (out of £51,876 for the IIF as a whole).

So, just to break the finances down, PCNs will receive c£140k for participating in the capacity and access scheme, and could receive up to c£60k for improvements in the three areas above, with no measure of actual reduced waiting time.  But they can only earn £14k for achieving the IIF target of patients seen within 2 weeks (the only actual waiting time measure).  And of course the IIF targets are voluntary.

This is why the GP contract itself is more important here than the PCN DES.  PCNs can earn virtually all of the money available without changing how long it takes for a patient to get an appointment.  We just need to make sure there are no horrors hidden away in the main contract when it is published.

There is a hint of what may be to come with the local capacity and access improvement payment being based on “commissioner assessment” of improvements made.  We saw from the Fuller report the desire to put more of GP funding within the control of the Integrated Care Boards, and this does seem to signal a step (albeit small) in that direction.  For example, it means the chances of a consistent approach to what constitutes local ‘improvement’ across the country is zero.

The changes outlined here also does set general practice up for potential waiting time targets in the future, but I am not sure that is avoidable.  What we do have here is a relatively straightforward way for PCNs to earn the IIF funds, and one that is probably going to be easier than if there had been an extensive range of IIF targets instead.

Overall the PCN DES for this year is fine.  The PCN DES is where the extra money and resources are for general practice.  What is not fine is the GP contract for this year and the refusal of the government to fund the cost of living rise for practices and their staff.  What is important for general practice is not to confuse the issues, and end up losing the resources in the PCN DES because the core contract has not been properly funded.

Holding Practices in a PCN to Account

A problem that PCN leaders will often raise is how they can hold their member practices to account.  With all the delivery requirements that are now placed on PCNs there is an inevitable trickle down to delivery requirements on practices within the PCN (e.g. IIF requirements), but what can a PCN leader do if a practice simply is not pulling their weight?

It is a difficult issue.  IIF targets are such that it can easily be that if one practice does not get anywhere close to the target then the whole PCN can miss the target, despite the hard work to achieve it of all of the other practices.  No funding will be forthcoming despite potentially the majority of practices doing the required work.

It is an issue that sits at the heart of why PCNs are so unpopular in some quarters.  The NHS does not want to do business with 7000+ individual practices and instead wants to transact with 1200+ PCNs, but this in turn means it is the PCNs who have manage across their member practices.  This causes internal disputes and division across the profession, by setting it against itself.

There are a number of responses to the issue that have been taken that I wouldn’t recommend.

Some PCNs have tried to explore the idea of financial penalties for practices.  The idea is that if one practice ends up costing the other practices money because their poor performance has resulted in funds not being received, then they have to reimburse the other practices out of their own pocket.  The idea here is that rather than the practice simply not receiving any money for doing no work they actually incur a financial penalty (justified because the other practices have done the work for no reward), which in turn will act as an extra incentive for them to perform.

It is not hard to predict how such a system would be both hard to implement and lead to a serious breakdown in trust across the PCN.  And more fundamentally general practice should not be allowing the introduction of PCNs to set the practices against each other.

Other PCNs have taken even more drastic action.  Some practices have identified that they cannot rely on the other practices in the PCN to perform and so have petitioned to be able to set up their own separate PCN.  We have seen a number of PCN reconfigurations across the country where this issue is at least close to the centre of what is going on (although it is never that explicit).

But PCN reconfigurations themselves are always painful.  They generally end up being even more acrimonious than when financial penalties are introduced!  It is hard to believe this is the best action for practices in a PCN.

What action, then, can PCNs take?

The starting point has to be first and foremost the mindset that the main support general practice has in this new environment of Integrated Care Systems and a not-negotiating NHS England is general practice itself.  A primary role of PCNs must be to support its member practices, not penalise them.  There is precious little support available for practices outside of general practice itself.

What really helps here is a PCN vision, i.e. where the practices in the PCN have come together and agreed exactly what they are trying to do through the PCN, including the role it is to play in supporting practice sustainability.  Having this agreement is very helpful as a reference point in discussions about individual practice performance.

The starting mindset should be how do we help all of the practices in our PCN to deliver.  If one practice has identified ways of effective delivery how are we facilitating them being able to share this with other practices, and supporting those practices when they are struggling.  We are bad in general practice at learning from and supporting each other, and PCNs actually present an opportunity to put this right.

It may be that a practice cannot deliver one of the PCN requirements.  Then the PCN can agree whether a different practice might deliver this for them (and potentially receive any associated funding as well) or agree an alternative solution.  The key here is developing the trust required across the practices to be able to first of all share that a particular aspect of delivery is a challenge, and then to be able to have a sensible conversation as to how to tackle this together.

The job of PCNs is not to hold practices to account.  Rather it is for the group of practices that make up the PCN to ensure that they work together to maximise the benefit that the PCN brings to each of the member practices and their patients.  It is this mindset that can enable PCNs to work for practices not against them.

More Changes to the NHS Pension!

In the podcast published on 13th March I spoke to NHS pensions expert Paul Gordon.  He explained all the changes that are coming as a result of the recent consultation.  You can listen to everything he had to say here.  But then the Chancellor of the Exchequer announced further changes in his March budget!  I caught up again with Paul with more questions about what it all means, and he gives his answers below.

Were you expecting all the recent changes to the NHS Pension?

What an amazing few weeks for those with NHS Pensions, two consultations and a Budget which left many, including me, staggered.  Normally the pace of change when it comes to the NHS pensions is, at best, glacial, so it is incredible for so much change to have been packed into such a short space of time!

What changes are being made to the Annual Allowance?

The Annual Allowance is the amount you are able to grow your pension by each year without incurring any tax charge.  This amount has been increased from £40,000 to £60,000 per annum.  At first glance, this is excellent news but please note, there could still be tax charges and so the review of your existing benefits is paramount.  Those with higher incomes will still see the standard allowance reduced as a result of the Tapered Annual Allowance which is to remain.

What about changes to the Lifetime Allowance?

The Lifetime Allowance is the value your total pension pot is allowed to reach before it incurs any tax charges.  Once this value is breached tax charges then start to apply.  However, the Chancellor has just announced that the Lifetime Allowance is to be abolished.  This could lead to the saving of thousands of pounds throughout retirement with the maximum tax-free lump sum remaining at £268,275, although those with Lifetime Allowance Protection already in place may be able to access a higher level.

Is it true that the need for 24-hour retirement has been abolished?

We now have the feedback regarding the December 2022 consultation which removes the need for 24-hour retirement.  This is called the Partial Retirement option, and will be implemented from October 2023.  This will allow access to the NHS Pension for GPs, partners and all NHS staff without the requirement for 24-Hour retirement, which for single-handed practices or those in dispute with the ICB could prove to be extremely useful!

Has the inflation issue been fixed?

A huge cause of concern was that the growth of individuals’ pension pots would exceed the Annual Allowance in 2022/23 simply because of the inflationary rise it would receive.  This is because historically the ‘allowed’ growth for inflation was based on the rate from a different year to that in which the growth was incurred.  There has now been adjusted in a way that will effectively allow the use of the higher CPI figure for the current year by delaying the addition of the growth until the 6th April, thus nullifying the issue.  However, it is imperative to secure updated Annual Allowance Growth histories from NHSBSA and to ensure membership details are correct ahead of the various changes ahead.

Where can people find out more information about their own pension position?

I strongly recommend everyone obtains a statement from the Total Rewards Statement website:

Changes to the 23/24 GP Contract – What is Missing is What is Important

NHS England has issued an update on next year’s contract.  For the second year running no deal has been reached between the GPC and NHS England, and as a result the 5th year of the contract agreed in 2019 will be imposed on the service. The update essentially outlines the changes within that contract that NHS England is able to make without it being a formal variation of the contract.

The changes that have been made by NHS England are not the real issue.  What is important is what is missing from the contract.  It is easy to be distracted by the headline noise around access, but the main problem with this contract is the lack of a funding uplift.

The 5 year contract was agreed at the start of 2019.  The inflation rate at the time was 1.8%, and at that point inflation had been low and relatively stable for some time.  The rises to the core practice contract (ie excluding the PCN DES) were set as follows (p51), based on predicted inflation levels:

  • 2019/20 – 1.4%
  • 2020/21 – 2.3%
  • 2021/22 – 2.8%
  • 2022/23 – 2.5%
  • 2023/24 – 2.7%

Of course what has happened over that time period is that the cost of living has risen significantly beyond what was predicted back in 2019.  Inflation had risen to 8.5% in March 2022, peaked at 11% in October 2022 and currently remains above 10%.

The number one and overriding issue is that the imposition of the contract last year meant a 7-8% real terms cut in funding for the service last year, and means a similar cut this year (because of the difference between the rate of inflation and the agreed rise to the core contract).

The agreed NHS pay rise this year was 4.5%-9.3%, depending on your starting salary.  The little over 2% that was provided to general practice does not cover this kind of rise.  So it is not just GP partners it is all practice staff who are suffering as a result of the refusal of NHS England to negotiate a reasonable level of uplift.

I am sure the counter argument will have been that additional funding beyond the increase to the core contract has been provided via the PCN DES.  But practices know better than anyone else that PCN funding does not pay the staff, or any of the other eye-watering practice bills that are dropping through the surgery door.

General practice cannot survive this year on year cut in funding levels.  All the discussion about access is just noise, obscuring this core issue.  General practice is agile and nimble and can manage the access changes. There are plenty of solutions out there (e.g. here).  The bigger risk is that the access issue, for which general practice will have little or no public support, is allowed to obscure the lack of funding to meet inflation issue, for which support is likely to be much greater.

It is up to the BMA team and national GP leaders to keep the issue focussed on the money, and away from discussions about access.  Losing sight of this is the biggest error general practice could make right now.

A lesson for general practice must also be that 5 year deals have to become a thing of the past.  NHS England have demonstrated quite clearly that they cannot be trusted with the level of variables that 5 years creates.  A trustworthy contract partner would have recognised the discrepancy between predicted and actual inflation and made good on the gap.  Now we know this won’t happen all future deals need to be kept short term.

We wait to see how the GPC and national GP leaders encourage the service to respond to the imposition of next year’s contract.  I don’t think the same quiet acceptance that we saw last year is likely this time round.  A key part of getting the response right will be making sure that whatever it is it is clear, simple to understand and focussed on the cut in funding.

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