Unpicking the Finances of the GP Forward View

Ben Gowland has read the new GP Forward View a number of times – despite its length! The question on his and everyone else’s lips is “Is there real coffee underneath the froth?”

The new GP Forward view is full of headline promises, but at the same time it is a marathon read (60 pages), repetitive and unwieldy.

Everything hinges on the money. The headline is an additional £2.4bn investment in General Practice. But what is that money, and is it really ‘additional’? How much will practices actually receive? You have to work hard to unpick this from the document, but here is how I think it breaks down:

This year’s GP contract (previously agreed) contains an uplift of 3.2%, totalling £220m. If this is replicated over the next 5 years General Practice will end up with a total funding rise of c£1.1bn. Remember, following the government’s 5-year funding settlement for the NHS at the end of 2015, NHS England had already promised investment in General Practice of 4-5% each year until 2020/21.

Capital investment of £900m. Capital investment promises to General Practice are hard to track. In 2014 £1bn was promised over 4 years from 2015/16 to 2019/20 as the General Practice Infrastructure Fund. This then became the Primary Care Transformation Fund, and then the Estates and Technology Transformation Fund. It looks like £100m of this was spent in 2015/16 (my assumption), and that the existing fund (£1bn less the £100m) has been re-announced as £900m with the deadline extended until 2021. We await the new name…

Recurrent investment of £500m for extra primary care capacity. This money is essentially for 7 day working, and is not for everyone. Hidden away in the document it explains this funding, “will be tested with the current GP access fund sites during 16/17”, meaning (I assume) it includes the funding NHS England has already promised to continue the services at the existing Prime Minister’s Challenge Fund sites. It will be “linked to” investment in 111 and out of hours, raising questions as to whether the money will even make it to core General Practice. This money is only accessible for “groups of local practices and other providers”.

These three pots together make a total uplift of £2.5bn, by my calculations. The promise is for £2.4bn, and the difference must therefore mean that the core expectation of GP practices should be that the annual rise in core contract value will be slightly less than that received this year, over the next 5 years. The only recurrent money that is ‘new’ is the additional funding available to those who pursue the government’s 7 day working agenda. More froth, it seems, than coffee.

This funding “will be supplemented by” a £508m sustainability package. This is essentially non-recurrent funding that will be invested over the next 5 years. It breaks down into 3 distinct pots:

  1. £56m of what is essentially crisis support: £40m to continue the £10m investment that was made into vulnerable practices in 2015/16 for another 4 years (bizarrely it is going to start with £16m investment in 2016/17); and £16m for specialist services for GPs suffering burn out and stress.
  2. £206m for ‘workforce measures’: the part funded pharmacist programme will be extended (£112m); a new Pharmacy Integration Fund (described as “£20m in 2016/17 and rising by £20m each year”) which is essentially for community pharmacy; a £15m practice nurse development programme; a £6m practice manager development programme; £3.5m in “multidisciplinary training hubs” to develop a wider workforce; plus an unspecified investment in GP recruitment and retention measures. 3000 new mental health therapists were also announced, but the document is silent on the source of funding for these.
  3. £246m to ‘support the redesign of services’: £45m to stimulate the uptake of online consultations; a £30m national development programme ‘Releasing Time for Patients’ for all GP practices; plus CCGs to come up with £171m to stimulate providers of extra capacity, to implement the 10 ‘high impact changes’ for General Practice, and to improve in-hours access.

So there you have it: the uplift in core funding over the next four years will be equal to or less than that received this year, the £500m of additional recurrent funding is not really available to the average practice, and at least half of the non-recurrent funding will be focussed on improving access. The lack of clarity in the document I suspect was designed to make the promise of funding look greater than it actually is, and on first reading it did exactly that. Once the reality of what is actually on offer sinks in, there may well be more heartache ahead for both General Practice and the Government.

What planet are you on?

After years of studying General Practice, Ben Gowland has achieved something that has eluded many great scientists: he has found empirical evidence that parallel universes exist…

I have recently discovered evidence of a new universe, centred on Planet Alpha. Planet Alpha appears, to all intents and purposes, very much like our own planet. The inhabitants breathe an oxygen/nitrogen-mix, the humans are bi-pedal and no-one can fully explain the attractions of Donald Trump.

But Planet Alpha demonstrates some marked differences from Earth. It is overly endowed with policy wonks and Whitehall mandarins, a disproportionately large percentage of its movers and shakers have never held a real job and, tragically, many of its citizens suffer from selective deafness.

It is in Planet Alpha‘s approach to General Practice that we can really see the differences between them and the planet inhabited by you and me. On Planet Alpha the problems of General Practice are that it is not available 7 days a week, that not every GP surgery is offering Skype appointments and, therefore, not ‘embracing technology’, and that it is not uniformly operating at scale.

On Planet Alpha the push is to “modernise” General Practice using an army of robotic entrepreneurs with unlimited private equity that is hanging around just waiting to be invested in primary care. On Alpha there are huge efficiency savings to be made by using other professionals to support GPs and, ultimately, make them redundant. But, frustratingly for the policy-makers, many of the Alpharian GPs won’t get their acts together by offering more modern services such as 24/7 access to primary care through supermarket-like chains of super-practices stretching across the country.

Things are very different on Planet Beta (also known to scientists as Planet Reality). Beta is inhabited by GPs and practice managers with very different problems. On Beta demand has skyrocketed to unmanageable levels. Staff are leaving and there is nobody to replace them. Indemnity costs, regulation costs and locum costs are forever rising, while PMS reviews and the withdrawal of MPIG protection have stolen income away. Many staff on Planet Beta are at breaking point.

GPs on Beta know their premises are too small, are not DDA compliant and they constantly worry about the future. They look for the queue of investors waiting to sign cheques for them – but it never materialises. Increasingly sick and demanding patients arrive in their surgeries with sheets of conflicting information downloaded from the internet. The GPs want to make changes, but they don’t have time to meet the other GPs in their own practice, let alone anyone from the outside world.

Parallel universe Alpha is a much happier place because Health Ministers there are currently working to manufacture 5,000 new all-singing, all-dancing GPs to populate their alternate world and bring joy and relief to all concerned.

My research has left me reflecting; isn’t it a good job that parallel universes remain parallel and never intersect? Aren’t we lucky that the hard-pressed GPs on our own planet won’t ever have to meet the top-down loving, one-size fits all, single-minded-against-all-the-evidence autocrats on Planet Alpha? Wouldn’t it be truly awful if the Alpharians set the strategy and made the policy decisions for our own GPs to follow?

How do you solve a problem like General Practice?

Who has the answer to the crisis facing General Practice? Ben Gowland argues that it is not the politicians, or indeed anyone who believes in an imposed, top-down intervention. The solution has to come from General Practice itself.

We all know General Practice is in crisis. What we seem to be lacking is a sensible plan for how to tackle it.

The Government’s approach is relatively straightforward. They have promised more money (4-5% each year until 2021), more doctors (5000 more by 2020) and less bureaucracy. They are going to encourage GP practices to operate ‘at scale’ by offering a new voluntary contract for practices that cover a population of 30,000 or more. And in return they want 7-day access to GP services.

Sounds simple. But there is a fundamental problem with this approach – we know it is not going to work. The financial problems in General Practice are NOT going to be solved by the additional funding (less than half of GPs think it will have a significant positive impact on the problems they are currently facing). The recruitment problems are NOT going to be solved by the extra GPs: GPs are leaving, retiring and emigrating far faster than new ones are joining. And a huge 90% of GPs think that the introduction of 7-day working will only make their problems significantly worse.

The current crisis in General Practice will NOT be resolved by a new contract, a 10-point plan, or a series of ‘interventions’ from on high. Offering more money to GPs for working harder or longer hours when they are already at breaking point is just likely to send them over the edge. Shouting louder at practices that are struggling or increasing the number of inspections or applying stricter and stricter contract penalties are NOT going to work – they will simply make the situation worse.

So what WILL work? However dire the current situation you can’t just force or manipulate General Practice into changing. A completely different approach is required. It needs leadership that will inspire those working in General Practice (who are variously tired, frustrated and burnt-out) to believe that change for the better is, in fact, possible. The group interest of General Practice (and thus their patients) needs to be set as the priority, as a means of stimulating followership. Change needs to start with, and build on, the values, ideals and needs of General Practice.   And it needs a focus on innovation, on doing things differently and doing different things – rather than the execution of someone else’s plan that no-one really believes will work.

Where this type of approach has been used, we have seen the green shoots of success. I spoke recently with Mark Newbold, the Managing Director of Our Health Partnership, the new ‘super-practice’ formed from 32 previously existing practices in Birmingham. Inspired by the vision presented to them, the member practices committed to the new model. They dissolved their old partnerships and created a new one. The model is working because the organisation has created trust between the leadership and the members. This is because its primary focus is on the needs of the members and their patients and because it is striving to deliver on its promise that the benefits of operating together at scale will outweigh the loss of independence and start-up costs. In Mark’s words, it remains a “grass roots movement”.

But it would be a foolish Whitehall mandarin who interpreted this as meaning that super practices must be the “answer”. What this example demonstrates, though, is that the “answer” must come from locally-led change, focussed on listening, collaboration and leading by example. The plan for General Practice can’t start with the answer. Imposing change on General Practice will make things worse. But a plan that strives to build trust, to create an environment that encourages new ways of working, and to enable and empower GP practices to transform themselves, is the one most likely to succeed.

Why scale isn’t the answer for General Practice

Ben Gowland argues that working at greater scale is not the panacea for General Practice that some would have us believe.

To many outside observers the problems facing General Practice seem quite straightforward. There are nearly 8000 small businesses, many of whom are finding their current business model to be unsustainable. Clearly what is needed is for there to be a consolidation of the businesses, so that there are fewer, each of a bigger size, with greater operational and financial resilience.

But is this really the answer? Reports have emerged recently about a federation in Doncaster going into administration after running into financial difficulties. Not only did operating at scale in this instance fail to provide the answer to the current pressures for this set of practices, but it also cost them as much as £20,000 each to find this out.

Operating at scale can help practices. But it is not a solution in itself. Rather it enables other solutions to be put in place. It means the practice can cope better with staff who want to work part time, it creates the critical mass to introduce new roles, and it enables the provision of sufficient management capacity for further change. Larger practices can access more capital, invest in buildings and technology, and play a much larger role in changes across the whole system.

But these benefits are not automatic. They are not delivered simply because the practice is now operating at a greater scale. If two or three practices merge or form a federation these benefits will not necessarily follow.

This is because the journey is often not straightforward. As one GP put it to me recently, “(these changes) have the potential to help the practice but if they are introduced badly they could also make things worse… Working as a group could definitely improve things if developed well, but could also drain effort and resources without giving enough benefits in return”.

Ultimately it is the way the change is made that is important. Not the practical legal governance issues (these are straightforward enough), but the engagement of hearts and minds, the development of a shared set of values, and the setting of common goals that will determine success or otherwise for those parties deciding to get bigger together.

The right question is not to ask whether operating at scale is an answer for General Practice. Rather it is to ask; are practices capable of changing the scale at which they operate? Does the expertise exist in General Practice to ensure the benefits of getting bigger outweigh the effort and resources required to get there?

In pockets the answer is yes but in general it is no. Some practices can, and have, made changes that have delivered huge benefits for them. But many practices are stuck in a vicious circle of increasing workload and worsening finances, and haven’t the capacity for a discussion about whether to make a change, let alone to implement anything significant. Telling them to operate at scale, or even employ a pharmacist, or introduce web-based triage simply is not going to help. And using a contract to try to force the change misses the point: the issue is capacity and capability to change, not resistance to trying something new.

Operating at scale is an answer for General Practice, but not the answer. The answer is headroom for practices to make changes to the way they operate; it is help with the process of identifying and making these changes; and it is resources to make these changes happen.

General Practice or CCG: Time for GP Leaders to switch?

I recently tried to persuade a GP leader (Dr S) to leave his CCG and spend his time helping core General Practice instead. Here is how the conversation went:

Me: The time has come for you, and GPs like you in leadership roles in CCGs, to step down from your CCG role and instead use the skills you’ve developed over the last 6 years to lead General Practice out of its current crisis.

Dr S: I can’t begin to tell you how bad an idea I think that is! First off, I don’t think it is my job to change General Practice.

Me: So whose job do you think it is? Seriously, if it is not your job, whose job is it? NHS England do not think it is their job, and you certainly cannot believe it is the Government’s! Only GPs really understand General Practice. You are now a trained system leader. General Practice needs you.

Dr S: But I‘m needed where I am. CCGs have to be clinically led, and need GPs like me to stay in place. Otherwise they will become just like PCTs.

Me: You yourself are always telling me how serious the crisis in General Practice is. If it really is in such a bad way, why are you not switching your efforts? What is more important, the badge of clinical leadership for CCGs, or the future of General Practice?

Dr S: I have invested a lot in the CCG. I want it to succeed. I don’t want to let down all those I work with in the CCG. I would feel like I am abandoning them.

Me: I understand how you feel, but at the same time you are letting down your GP colleagues, current and future, by not focusing your efforts on General Practice. It is the system’s job to look after the CCG – it is, after all, a statutory body. It is no-one’s job to look after General Practice.

Dr S: But I can do more benefit for General Practice here in the CCG. I control the money here and I can make real change happen.

Me: First, the CCG bureaucracy around conflicts of interest means the change you can effect in General Practice from within the CCG is extremely limited. Second, contractual change is not the answer General Practice needs. It needs to change from the inside, with leaders like you working across practices, winning hearts and minds, finding a way forward.

Dr S: Even if I wanted to leave I couldn’t because my practice needs the CCG money. I won’t get anything for working with General Practice. If I left the CCG I would just have to go back to full time clinical work.

Me: You are right that the incentives in the system encourage GP leaders to remain in CCGs rather than support General Practice to change. At Ockham Healthcare we make the case that the money you earn in the CCG should be transferred with you if you want to make this move, so that you are paid the same for carrying out work to support the development of local General Practice as you are in the CCG. (You can read the report here)

Dr S: But we are talking about over £70K per year. How would this work in practice?

Me: Your CCG could choose to fund you, or indeed any of the GP leaders in your CCG, to work in General Practice by seconding you on full pay on the basis of the benefit this would bring to the system as a whole. You don’t need anyone else other than the CCG itself to agree it.

Dr S: But in the CCG I have a clearly defined leadership role, and everyone understands what it is. What would my role be if I If I left the CCG? Would there even be a role?

Me: There won’t be a marked out role, but there is a huge leadership challenge. You will have to establish your role and gain acceptance from your peers for it. No-one said this would be easy!

Dr S: The problem is I have burnt bridges with many of my colleagues as a result of my CCG role. I am not sure my GP colleagues want my help!

Me: First and foremost you are a GP. You understand General Practice. The fact you have made tough decisions in the past and stood by them in the face of peer resistance shows you are a leader of courage and integrity. You are exactly what General Practice needs. General Practice has to make some difficult decisions about how it is going to change and adapt going forward. Some are not going to like it and the challenge is going to be taking everyone with you.

Dr S: That is very generous, but I am not sure however hard I try that I will be able to persuade my GP colleagues to change.

Me: If you don’t believe that General Practice can get out of the situation it is currently in, do not expect anyone else to. Everyone can change with the right leadership, resources and support. If anyone is capable of helping your colleagues to change, it is you.

Dr S: But where would I go? What would I do? I am not sure I would even know where to start.

Me: You could do worse than following the advice of John Kotter. You would start by listening to your colleagues and really understanding their problems. You would share the experiences and ensure everyone understood the urgency of the situation and the need for change. You would create a change team around you. You would build a vision for the future. You would make sure everyone bought into it, and you would communicate it over and over and over again. You would move to action, creating quick wins to develop momentum. You would build on early successes and make bigger and bigger changes. Eventually you would embed these changes in the way that General Practice operates, completing the transformation.

Dr S: Maybe the idea is not as ridiculous as I first thought! I am not sure what to do

Me: Either General Practice is in trouble or it isn’t. If it is, it needs your help. Don’t leave it to others. Don’t take the easy route of staying put. Take up the challenge. Make the move. Use the skills that you have developed in the CCG to give General Practice a chance. Don’t do it for yourself, do it for your colleagues, do it because you believe in General Practice and the role it plays in the system and the difference it makes to patients. Do it because it is the right thing to do.

Should GP Leaders be leaving CCGs and supporting core General Practice? Let me know what you think: email ben@ockham.healthcare or via twitter @BenXGowland

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