The Hewitt Review was published on the 4^th 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.

The revised PCN DES was published on 30^th 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 3^rd 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 6^th 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.