The GP Forward View and the new GP Contract: Spot the Difference

On the surface the new GP contract and the GP Forward View (GPFV) appear very similar.  Both contain promises of money and staffing, as well as a determination to create a sustainable future for general practice.  But nearly three years on from the publication of the GPFV, things don’t feel much better.  Workforce, finance, workload and morale all remain challenges for general practice.  Will it be any different this time round?  We’ve been examining the differences between the two documents, and have identified 5 that give cause for optimism.

  1. Type of document

While both are written documents, there is a big difference between the GPFV and the new GP contract.  The GPFV was essentially a commissioning plan – it was how NHS England, as the commissioner of general practice, was going to improve it.  It was full of aspiration, but lacking in detail of how it was going to be delivered, a concern that ultimately proved well-founded.  The new GP contract, however, is just that – a contract – and as such is clearer and more transparent, making the promises feel much more concrete than in the GPFV.

  1. Money

On the surface the promise of money is similar.  In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years.  The problem the GPFV ran into was transparency in relation to the money.  The RCGP and others set up tracking mechanisms to try and check the promises made were being adhered to.  In the end, because the £2.4bn was actually to be delivered over 8 years (a retrospective starting point of 2013 was used), and because a huge chunk of it went on access and so not to core general practice, it never made the difference it should have.  The new contract is different.  Yes £1.8bn of the £2.8bn comes via the new networks, but it is still coming to practices, and how the money will be delivered is clearly laid out.

  1. Implementation

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.  This time the money will come via the contract, either directly to the practice or directly to the network set up by the practice.  It feels like control of the funding will sit at practice level and then work up, rather than (as with the GPFV) start at the top and slowly trickle down.

  1. Policy Objective

Politicians and commissioners always want a return for their money.  In the GPFV the primary policy objective was extended access (‘we will invest this money in general practice if you deliver 8-8 working 7 days a week’).  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 private providers.  In the new contract the primary policy objective is the introduction of primary care networks.  These networks are to enable general practice to integrate more effectively with the rest of the system, and allow a more robust system of out-of-hospital care to be created.  The great news for general practice is that, done well, these networks can support and enhance the delivery of core general practice.  This alignment of the needs of general practice with overall policy provides maybe the greatest hope for the new contract.

  1. Workforce

One of the biggest failings of the GPFV has been its inability to successfully tackle the workforce crisis in general practice.  The service is still waiting for 5,000 of the promised 5,000 additional GPs.  The new contract, however, takes a more realistic approach.  The focus on new GPs isn’t lost, but is enhanced by a much more pragmatic (although still challenging) plan to recruit 20,000 additional non-GP non-nurse clinical staff, with the funding being directly provided to the practices via networks.  This realistic plan for staffing creates a strong foundation for optimism.

The Obsession with Access is Destroying General Practice

If you ask the government what is important about primary care, it is clear there will only be one response: access.  Access is determined to be important to voters, and so it is access politicians care about.  Whatever the cost to general practice itself.

Looking back to 2016, the GP Forward View feels very much like a solution to the strong governmental desire to introduce extended access, despite the crises befalling general practice.  Here is a headline £2.4bn…with the condition you deliver extended access.

Indeed, recent reports suggest a huge investment in recent years into general practice.  This is not what it feels like to practices.  Much of the investment never reached practices, but instead went to extended access providers.  As these providers deliver general practice, it all “counts” as investment in general practice.

The reality is, of course, that the introduction of extended access has made things worse for practices.  The root cause of the workload and financial problems, alongside the inexorable rise in demand from a growing, ageing population, is the lack of GPs.  Fewer GPs means more work for those who remain, plus an increased expenditure on locums which in turn creates a huge financial pressure on practices.  The introduction of extended access simply creates an additional demand for GPs, stripping down further the numbers who can work in core, in-hours general practice.

The pledge to increase the number of GPs by 5,000 was a central part of the GP Forward View.  But despite an increase in the numbers entering training, the numbers leaving has exceeded those arriving.  GP numbers (FTE excluding locums and registrars) fell 3.4% between September 2016 and September 2018.  The pledge to increase access to 8am to 8pm seven days a week, on the other hand, has been delivered.

What, then, do we get in the Long Term Plan?  Yet another access pledge.  “Digital first primary care will become a new option for every patient improving fast access to convenient primary care.  Some GPs are now offering their patients the choice of a quick telephone or online consultation…. Over the next five years every patient in England will have a new right to choose this option – usually from their own practice or, if they prefer, from one of the new digital GP providers” (Long Term Plan 1.44, p26).

So now, in addition to GPs who choose to work extended access hub shifts (convenient, without the pressure and hassle of core general practice), we are going to have GPs who choose to work for “one of the new digital GP providers” (potentially ‘working from home’ for GPs).  Further dilution of a precious and diminishing workforce, all in the name of access.  All piling yet more pressure on a general practice that is creaking at the seams.

Amidst the plethora of documents that have come out already in 2019 (with potentially the most important, the new GP contract, due this week), there is one ray of hope.  Dr Nigel Watson’s Partnership Review did explicitly recognise the pressure access is causing core general practice.  His recommendation 5a states, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends” (p32).  He explains, “Extended access services in many areas are attracting GPs away from practices. NHS England should therefore consider how existing funding for extended access and opening could be allocated through PCNs as they mature, to enable local decision making on managing demand appropriately. This should also support partnerships to feel a greater sense of control and influence over managing the safety of their working day.  It could also reduce fragmentation of services and increase opportunities to improve continuity of care.

It is not a recommendation, however, that has been picked up in the Planning Guidance or the Long Term Plan.  Whether it will turn into anything remains to be seen, but the priority this government has placed on access to primary care, regardless of the consequences for core general practice, makes me, for one, sceptical as to its chances. However, it is certainly a recommendation fledgling primary care networks would do well to remember as they move forward, as its chances of implementation probably relies on pressure from them.

BMA Council Chair Chaand Nagpaul summed it up well when he said, “There is no use opening the digital front door to the health service if we don’t have the healthcare staff behind it”.  The current obsession with access is dangerous, because it is making a bad situation worse.  A resource can only be stretched so thinly, and it is only a matter of time before more holes begin to show.

Primary Care Networks are the new black

Reading the NHS Long Term Plan (LTP), the GP Partnership Review, and the Planning Guidance for 2019/20 (not something I would recommend for a single sitting!), one thing stands out for general practice above everything else – Primary Care Networks.  When it comes to general practice, the documents make it clear that Primary Care Networks, based on neighbouring GP practices that work together typically covering 30-50,000 people, are the new black.

They are seen as the enabler of “fully integrated community based healthcare” (LTP p15).  They will have expanded neighbourhood teams, which “will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and AHPS such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.” (LTP p14).

And not just an enabler of integration.  The GP Partnership Review wants more.  It says, “Multi-professional community health teams should be based in Primary Care Networks and work under the clinical and service direction of the Primary Care Network.  They could remain employed by their existing employer while being more closely partnered with, and embedded in, practices day to day.  This should include creating a single team using a common health record, sharing the same caseload, and removing the need for referrals.  Wherever possible, the community teams should also be co-located with the constituent practices of the network.” (Partnership Review 4.46 p30).

The future role of Primary Care Networks does not stop there.  They are the vehicle for online consultations: digital-first primary care is to become a new option for every patient, and to enable this the NHS, “will create a new framework for digital suppliers to offer their platforms to Primary Care Networks on standard NHS terms” (LTP p26).  The GP Partnership Review recommends an even stronger role in relation to access, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends…NHS England should consider how existing funding for extended access and opening could be allocated through Primary Care Networks as they mature, to enable local decision making on managing demand appropriately” (Partnership Review p32).

They will provide around the clock cover for care homes, “Primary Care Networks will also work with emergency services to provide emergency support (to care homes) including where advice or support is needed out of hours” (LTP p16)

They should be training hubs.  Dr Nigel Watson in his review recommends, “every Primary Care Network should be in partnership with, or become, a Training Hub, ensuring the place-based delivery of education and training in primary care for GPs and other staff working in general practice and staff aligned with the Primary Care Network” (Partnership Review 4.51 p31).

They are to be the new voice of general practice.  “Every Integrated Care System will have… full engagement with primary care, including through a named accountable Clinical Director of each Primary Care Network” (LTP p30).

They will be responsible for health outcomes.  “Primary Care Networks will from 2020/21 assess their local population by risk of unwarranted health outcomes and, working with local community services, make support available to people where it is most needed” (LTP p17).  They will also be encouraged to reduce expenditure.  “We will also offer Primary Care Networks a new “shared savings” scheme so that they can benefit from actions to reduce avoidable A&E attendances, admissions and delayed discharge, streamlining patient pathways to reduce avoidable outpatient visits and over-medication through pharmacist review” (LTP p15).

How is the move to Primary Care Networks going to happen?  Well I suspect we will find out more when the new GP contract is finalised.  For now, the LTP says, “As part of a set of multi-year contract changes individual practices in a local area will enter into a network contract, as an extension to their current contract, and have a designated single fund through which all network resources will flow.  Most CCGs have local contracts for enhanced services and these will normally be added to the network contract” (LTP p14).

In 2019/20 CCGs are required, “to commit a recurrent £1.50/head recurrently to developing and monitoring Primary Care Networks so that the target of 100% coverage is achieved as soon as it is possible and by 30 June 2019 at the latest.  This investment should be planned for recurrently and needs to be provided in cash rather than in kind” (19/20 Planning Guidance p17).

It remains to be seen if that sets a “running cost” of £45-75K per network (assuming 30-50,000 population), or whether it is a starter fund with more to be added later.  One place we might find out is in the primary care strategy that every ICS or STP must have in place by 1 April 2019.  This strategy is to set out, “how they will ensure the sustainability and transformation of primary care and general practice as part of their overarching strategy to improve population health… This must include specific details of their: local investment in transformation with the local priorities identified for support; Primary Care Network development plan; and local workforce plan” (19/20 Planning Guidance p17).

The ambition for fledgling Primary Care Networks, that in some places do not even exist yet, is breath-taking.  They are clearly a crucial building block in the design of the new system for the NHS.  Whether they can live up to the expectations remains to be seen, but they represent a huge opportunity for general practice.  Like them or love them, because even funding is being channelled through them, they are a trend that will be almost impossible for general practice to ignore.

Guest Blog – the NHS long term plan, a GP at-scale view

You’ve seen the summaries of the NHS Long Term Plan but now, thanks to a guest blog from Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) we offer you a more in-depth look from the particular perspective of general practice operating at-scale…

I’m a long-term cynic when it comes to NHS long-term plans.  They’re usually unnaturally narrow, overly prescriptive and with the flexibility of a Soviet Five Year Plan.  This new one is different: it’s broad (scattergun broad in places), with vision statements instead of hard plans, and enough scope for local areas to interpret this in a way that makes it work for their area.

Be open when you read it, if you don’t like one part then don’t write off the entire plan.

The sections below are my commentary on each chapter in the plan, concentrating on Chapter 1 and putting a very strong at-scale bias on it.

CHAPTER 1 – SERVICE MODEL

The changes to the existing NHS service model in this plan are generally well thought through and represent some good innovative thinking.  There is substantial work needed, though, to turn it from vision into actual plans.  For at-scale General Practice, the Plan has plenty of changes:

The focus around Primary Care Networks (PCNs) is interesting as it’s a deliberate step away from discussing “providers” and into defining geographically bound GP-led organisations.  There is almost no other way they could have phrased this without allowing a way-in for out-of-area and private company poaching of work.  How this is funded is a different question, as it’s vague.  I would prefer a capitated block budget with a deprivation supplement (see Chapter 2 notes).  It will be interesting to see how this will work with looking-out GP Federations mixed with looking-in PCNs.

Additionally, it refers to CCG procured “enhanced” services.  This is a particular issue of mine as cash-rich CCGs can afford lots of these enhanced services while cash-poor ones can’t.  It’s a built-in inequality that directly impacts the way clinicians can offer patient care. It would be good to see a national index of enhanced services offered in each area.  Maybe this is something for NHSE to do, enabling GPs and providers to hold CCGs to account for the reduced capabilities they have.

A very welcome change in this Plan is the addition of “shared savings” where GPs and PCNs will be rewarded by getting part of any savings made in other care settings.

There is now a focus on “digital first” for GPs.  I think this partially misses the point as it does not account for the system-wide savings through continuity of care in General Practice. Neither does it work for the “have-nots” of society who can’t or won’t use technology. This is where GPs must step up and be the patient advocates for the have-nots, especially in deprived areas.

I would recommend a priority for GPs is to address this themselves to protect their own service.  For example, it’s allowable in this for patients to be offered telephone appointments OR online conference ones.  Show that you offer patients a teleconference option and change your model to prioritising it and you’ll be half-way to meeting this objective. Do it yourselves or you’ll find it mandated and patients going elsewhere under promises of remote unicorns of same-day GP appointments by phone.

The outpatient redesign part of this chapter concerns me as, unless it’s done properly, it’ll result in General Practice being dumped with patients overly quickly discharged or there being clear rationing or higher bars on referring patients.  The Plan risks getting this wrong.  Patients don’t just go away because they can’t get a referral to hospital.

A major focus is placed on moving all of England to the ICS model by 2021. This is too aggressive as some areas just will not be ready in time.  Areas with large system-wide deficits or strict system controls are most likely to have difficulties in setting up effective ICS because it’s just not a priority compared to that big financial black hole

Another aspect of ICS is the move to Integrated Care Provider contracts. This will require legislative change to enable, but will effectively shortcut alliances of NHS public providers into formal status while also allowing a complete removal of the necessity for procurement for work in the area. A concern is the Plan suggests only allowing this for statutory bodies.  While this will exclude the big private providers, such as Virgin, it will also exclude GP Federations.  Much is required to make this work, and the elephant in the room of Brexit makes legislative changes unlikely for quite a while.

CHAPTER 2 – PREVENTION AND HEALTH INEQUALITIES

This chapter concerns itself with the prevention agenda and addressing health inequalities.  It does it very well and makes a strong case for addressing deprivation related health inequalities.  For this alone, this Plan succeeds and deserves support.

The Plan is clear that more funds will be targeted at areas with high deprivation and high health inequalities.  The concern for many areas with high deprivation is that they’re often grouped with areas of middling or low deprivation and any aggregation of their “scores” would see a loss of any such deprivation premium.

I would like to see a central strategy of highlighting discrete areas of high deprivation and high health inequalities and mandating special funding for them.  A secondary, but just as important, strategy is that this extra money must not be allowed to be diluted across an ICS/system; it must be provided to help health inequalities among the most deprived patients in England, not to give extra to areas that don’t need as much help.

CHAPTER 3 – CARE QUALITY AND OUTCOMES

This chapter is a mixed bag of strong content matching chapter 2 and defensiveness over the consequences of previous decisions.

The cancer prevention and early diagnosis parts of this Plan fall heavily on primary care with extra resources being made available for urgent referrals and diagnostic tests.  It will put pressure on GPs to deal with the turnaround and meet targets but it is achievable and will help patients.  A critical component is the funding though and ensuring it comes before the targets.

There’s a strong focus on mental health with distinctions between CYP and adult MH, as well as plans for addressing the current service gap of 18-25-year-old patients moved from CAMHS to adult MH services. Much of the load from this will land on primary care through IAPT extensions, and it’s worth dedicating time to what this will mean for both individual practices and at-scale General Practice. I’d recommend that GP Federations make this a core part of any clinical strategy they’re developing.

One thing that will benefit patients is the commitment to get 70% of acute hospitals to the Core 24 standard on emergency MH support by 2023/4 and then to 100%. This will give GPs a much needed emergency referral source that is missing at present across the greatest part of England.

The less good side is learning development and autism where the plan seems disjointed and is proud of the fact that inpatient provision will be halved by 2023/4 considering that it was already effectively cut in half from its 2010 numbers by 2015.  As always, the load from these patients moved back to the community risks landing on primary care and often take GP time.  Again, we need a GP at-scale strategy for these patients to treat them with the dignity and care they deserve while also not impacting overall workloads.  The relatively low numbers would suggest this may be best dealt with in practices with at-scale support.

Interestingly, there are some changes to the planned vs urgent care model that will help primary care. There are plans to provide funding for increased planned care capacity, but not necessarily in acute hospitals.  This is a welcome change from the now habitual “cut referrals” strategy to reduce waiting lists.  Also, there are plans to force physical separation between urgent/emergency care and planned care so that disruptions such as winter pressures will have fewer major impacts on planned care.  This would be a major expense though, and I doubt the government will provide the capital needed for the physical building separations.

CHAPTER 4 – NHS STAFF

Of greatest importance to GPs in this section is the confirmation that GP indemnity will be cost neutral.  This means it will be paid for but then clawed back through other parts of GP funding, most likely GMS/PMS contracts.

The remainder of chapter 4 shows this is the weakness of the whole Plan. It needs a robust workforce strategy and struggles without it.  Treat this chapter as a placeholder for the proper strategy later.

There is too much concentration on the centralised functions writing the plans and far too little recognition that it’s locally that workforce fails when grand strategies are applied.

It also shies away from changing previous poor decisions, such as materially defunding the NHS Leadership Academy, but talks about improving training & CPD coverage.

CHAPTER 5 – DIGITALLY-ENABLED CARE

There’s some blank cheques written in this section that recognise the aims of the Health Secretary, but these haven’t yet been fleshed out beyond bare skeletons.

A key example is the paragraph about improving IT to make work more satisfying (“faster, better and more reliable”).  Yet with no ideas on how they’ll do that when programme after programme has failed to touch the subject.

It also fails to deal with the massive infrastructure upgrade of resilience that is essential if the NHS is moving away from on-site presence to off-site coverage.  If a system goes down or is slow when the patient and clinician are face-to-face then it’s often simple to work around; if a system goes down when it’s a virtual consultation then it usually stops. This is a massive expense, based on my own experience of grand-scale upgrades, doubling the capital IT budget for a few years MIGHT just achieve this.  There’s no getting away from this, to make it “faster, better and more reliable” will require huge and probably politically unbearable capital investment with revenue uplifts.

CHAPTER 6 – TAXPAYERS’ INVESTMENT

The Plan bakes in a 1.1% annual “productivity growth” dividend.  This is unlikely as there’s very little “fat” left in the system.  The NHS as it stands is far more efficient than the vast majority of even the best private sector organisations.  Any more cuts will be right into muscle.

It does make an interesting comment that community care clinical staff spend more time doing admin and non-patient facing work than patient-facing work. I would put that this is a recognition that admin cuts have gone too far and investment in specialist admin staff and tools would more than repay themselves in freed time to deal with patients.

Finally, it makes the point that the central admin budgets of the NHS, including provider Trusts, will be expected to be cut by £700m/year.  Again, from where?

CHAPTER 7 – NEXT STEPS

An interesting point here is the Plan’s aim to provide five-year indicative budgets.  My hope is that this will remove the year-by-year short-termism of the NHS and allow long-term efficient and multi-year budgets. This is an area where Federations and private providers can outperform the NHS at present as we’re not bound by in-year spending of funds.  It will only be good for the rest of the NHS to catch up.

The legislative changes required to make this plan work are also interesting.  The bits that impact at-scale General Practice are around the ICS/ICP and integrated care Trusts and the removal of procurement mandates.  The latter would allow CCGs to make direct contracting between NHS organisations easier and remove the significant wasted costs we see in NHS procurements of very low-level services.  Both are items that should gain strong support and advocacy from GP at-scale groups.

WHAT IT’S MISSING

I hope some readers are still here!  As a bonus to those of you who made it, I noted two major areas that this Plan misses that I’d hope would make it.

Point 1: National detailed minimum standards of care matched to local needs.  Targets are fine in their own way (same with CQC inspections) but they’re negative and, regardless of what they say, just are not patient focussed. I would like a grand programme that sets standards of care across all health issues and provokes discussion on prioritisation for care to help the NHS set its own localised plans.  For example, what’s unique about a deprived area’s health inequalities that explains WHY it has lower levels for patient care?  What does that mean and how does the area plan to meet, and exceed, national minimum standards of care?  Long-term local plans should then be externally funded for removing health inequalities matched with central funding for delivery that supplements local commissioning funding.

Point 2: Demand analysis.  The NHS is woefully unaware of its actual demand.  How many patients don’t bother when they can’t get a GP appointment?  How many GPs won’t refer clearly ill patients because they know they’d be rejected?  The NHS is terrified of these figures as they’d be spun out of all proportion by the media, but they’re needed to model demand properly.  The NHS needs an adult conversation on demand and how it should be met, including what we expect the public to do themselves.  It’s a weakness to continue scaling services by supply rather than demand.

As mentioned, this is my interpretation with my tinted glasses on of at-scale General Practice. I instinctively wanted to dislike this Plan before I read it but I actually do like it.  It’s honest and doesn’t pretend to be complete, it also is a vision statement where you can forgive the lack of detail as long as there’s a genuine aim to produce proper plans in a relatively short time.  With that in mind, give it your own read with that in mind rather than “that won’t work”. https://www.longtermplan.nhs.uk/

My Top 3 General Practice Podcast Episodes of 2018

We have had quite a year on the General Practice podcast.  We kicked off in January with episode 93, with Martin Ramsay explaining the technicalities of setting up a super-partnership, right through to December when ex-RCGP president Terry Kemple introduced the Green Impact for Health toolkit that practices can use to play their part in making the planet sustainable.

Our most popular guest without question was Dr Rachel Morris.  In April she talked to me about the Red Whale Lead, Manage. Thrive! Course and their new working at scale course – an episode downloaded over 1750 times, making it the most listened to episode of the show.  She followed this up with the second most popular episode in November, when she shared her insights into GP burn-out, stress and resilience.

We tried out panel discussions on the show for the first time.  We brought some of the leading thinkers and practitioners together to discuss how technology will shape the future of general practice (here and here), what the infrastructure of general practice will look like in the future – including whether the partnership model will survive (here and here), how much impact the new models of care, including developments such as the primary care home, will have on general practice (here and here), and how much millennials, both as GPs and patients, will change the way general practice operates (here and here).  It all made for fascinating listening, and has certainly changed the way I think about how general practice will develop into the future.

But none of these made my own personal top 3.  Our own efforts to think about the future of general practice were somewhat put to shame by the work of Andy Wilkins and the authors of a report entitled “Beyond the Fog”.  They took all the current trends, such as technology, personalised medicine and systems biology, and worked out what they all might mean for the future delivery of healthcare.  The results are fascinating.  Over the course of two episodes (here and here), Andy describes ideas such as “always on” healthcare (24/7 digital monitoring of our health) and a “digital health coach” (think Alexa offering you personalised health advice), and gives his own insights into the implications for general practice.

What we most love featuring on the podcast are practical examples of innovations that have made a real difference to practices and to their patients.  For me this was exemplified in episode 132 by Alison Halliwell.  She told me the story of how she had set up a mental health service within a GP practice in Fleetwood.  When she started (back in 2004) 42% of patients were presenting with a mental health component to their illness.  Since then, down to the hard work and persistence of Alison and her team, only 8% of GP time is spent dealing with mental health issues.  Real innovation, delivering real benefits for GPs and their patients alike.

The final episode in my top 3 is another example of inspiring local innovation.  It came in June, when I was invited to Peterborough to visit Dr Neil Modha at Thistlemoor Medical Centre.  I am fortunate in my work to visit lots of different GP practices, but I can honestly say I had never been anywhere quite like this before.  They have adapted their model to meet the demands of a large non-English speaking population and a local shortage of GPs by training members of the local community to be healthcare assistants who take histories, translate, and present patients to the GPs.  On top of that, the practice sees more patients per day than many A&E departments!

These were my top 3, but I would love to know yours!  Get in touch and let me know. Finally, a big personal thank you from me to all of our guests, for the generosity of their time and the inspiration they have provided, and to all of our listeners for all your support and encouragement.  I can’t wait to see what 2019 brings!

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