GP Forward View LMC Commentary
Mr Hunt’s much vaunted package finally arrived to a brief news fanfare last month. There was an unedifying difference in emphasis in the responses made by the GPC and RCGP. Dr Nagpaul (eventually) denied that it contained enough to dispel the chance of mass resignation, whereas, for the RCGP, Dr Baker sent an enthusiastic email to the whole profession inter alia scolding those who were being negative and cynical, welcomed it as the best news since the 1960s. This reviewer was, once again, struck by the internal inconsistencies of the document. Simon Stevens praises primary care and decries the cut in share of NHS funding it receives, acknowledging the pressure on GPs (and patients wanting more access), the strength of its “personal response to a dedicated list” but putting forward potential solutions that will per force undermine this intimate relationship. There is also regrettable “spin” with nationwide financial figures accumulated to 2020-21 making the increases seem far bigger and more significant than will appear at any given time. For example the Sustainability & Transformation Fund is described as totalling “over half a billion pounds over the next five years” but no emphasis is put on this representing about the annual budget of a reasonably sized DGH spread over the whole country. The whole NHSE 5YFV was predicated on making “efficiency savings” of £20b by 2020 in exchange for “extra” funding of £8b by the same time. Investment in primary care services was to be made at the expense of secondary care. Yet trusts are in deficit and it is not mentioned
that much of this money is already earmarked for acute trust deficit relief. So the funding will inevitably be less important and come with more strings attached so that it can only be spent on the “right” way forward. Changes to the CQC inspection regime turn out to mean visits “no less than every five years.” “Tackling indemnity costs” turns out to mean holding a consultation and ruling out Crown indemnity. The, in most people’s view, more-or-less mythical figure of 5000 “more GPs” is still cited as being just over the horizon. It was, of course, always naïve for anyone to assume practices would be given the tools to finish the job and then left alone to get on with doing it. As Dr Stevens says “…be that as it may, the vital thing is to roll our sleeves up, get practical, and together begin to make a tangible difference, now, for practices and for our patients.”
Dr Arvind Madan, the new NHSE Director of Primary Care (and part of Dr Claire Gerada’s group in London) gives a splendid summary of a “typical morning in general practice” which deserves quoting in full:
“…a long arduous struggle through appointments, phone calls, repeat prescriptions, results, letters and home visits. Before you get time to look up, much less take a break, it is the afternoon and you have to start all over again. Running the practice or having meaningful conversation with staff is relegated to the edge of the day…Clinicians increasingly feel unable to provide the care they want to give, and understandable resentment of working under this pressure is growing.”
The GP as an “expert medical generalist” and the core values of the profession providing holistic, person-centred care for undifferentiated illness,…with a continuous relationship should be valued and these attributes must be preserved. However, shortage of GPs and ever growing demand means that GPs no longer have the time to use their expertise on matters that can be safely dealt with by others. It seems to this reviewer that a great deal of confidence building will be required in the “others” as well as amongst GPs who will have to learn to let go. The question of who will bear ultimate responsibility will always be a limiting factor. This will make Dr Madan’s “key and most pressing priority,” the elimination of the burden of time-wasted on dealing with the effects of fragmentation of the health service with its duplication and often irrelevant communications challenging. In a profession where, for example, some doctors view the personal summarisation of medical records as vital to their practice and others see it as a pointless, bureaucratic task best done by somebody else, how will consensus be reached amongst equal partners? Surely a more directive en haut en bas approach will be needed as practices work at scale? The problems with spiralling indemnity costs could be dealt with by MCPs taking out corporate policies.
Workforce targets are admittedly ambitious. GP trainee numbers are to be increased to 3,250 a year (what is the number now?) and there will be “major recruitment campaigns” both within England and abroad. Targeted bursaries and post-certificate of completed fellowships will be created in the areas hardest to recruit into. A thousand of the 5000 will come from abroad (500 “or possibly more”), be returnees to practice (with £2300 monthly bursaries) or GPs otherwise retained in practice. This latter group will be interesting to count! Mental health therapists will average one WTE for 2-3 average practices and one clinical pharmacist per 30,000 patients not in the initial pilot. Practice nurse training will receive an extra £15m and there will be £45m to help receptionists better signpost patients elsewhere. Again, the cynic will ask about responsibility. Physician associates will be in training and medical assistantships will be piloted. There will be £16m extra for supporting GPs suffering from stress making £18.5m over the next four years. To put this into context, Somerset tends to attract 1% of national spending on population, so this means about £46,250 spent annually in our county or £115.62 per doctor. The scheme will however be national and procurement will start in June to be up and running by December. Working at scale should help “embed a more locally focus team based approach which incorporates locums.”
Chapter 3 deals with workload and is an interesting chapter. I will continue in part 2…
I hope that this isn’t too cynical for you or for Dr Baker: “I'm sure a small minority of you will be reading this with your head in your hands,..[b]ut, seriously, do you really think relentless pessimism about the future of our profession, when we have just seen the most positive announcement on the future of general practice in many years, is a better option?”
Reasons to be cheerful, part 2.
Chapter 3: Workload is subtitled “we will reduce practice burdens and help release time.” Practices have told NHSE that one way to do this is to assist patients to look after self-limiting illnesses as well as their long term conditions. There will be a national programme support this latter work by September with practices offered “tailored support” to offer high quality care to those patients that need it. This means “equip[ping] the workforce with the tools and skills…to improve patient outcomes and, over time, reduce the demand in general practice.” At risk of sounding even more like Eeyore than usual, this does sound more like something else for primary care to do than a rescue package. Of course it is pointed out GPs will also be able to influence commissioning in this field thus deflecting demand. Access hubs, social prescribing and evidence-based minor ailment schemes will all help. Practice resilience will be bolstered by more support for struggling practices but, from now on, funding will need to be matched although this may be “in kind” and not just in cash. Presumably this is because more practices needing help are anticipated? Changes to NHS standard contracts to hospitals are supposed to relieve some of the administrative burdens on practices and it is interesting to note that strict injunctions about speed of discharge summaries, outpatient prescribing, the wider acceptability of internal referrals and the unacceptability of blanket policies on the need for GPs to re-refer DNAs. LMCs will have a role to make sure that contracts are strictly adhered to. There will be pilots to review better ways of managing outpatient demand with practical schemes such “consultant hotlines” and what sounds like advice and guidance schemes. This is also the section with the rather disappointing news about CQC inspection regimens but NHSE will look at trying to ameliorate “any further fee increases.” The future of QOF is being reviewed with the GPC and no-one in Somerset will be surprised to hear that “there are already areas of the country exploring local alternatives to QOF.” The new voluntary Multispecialty Community Provider (MCP) contract will see the end of QOF. It is hoped that by 2020 all clinical correspondence between NHS providers will be paperless. One day, the end of that particular rainbow may well be reached. NHSE is to work with the relevant bodies to see if the amount of mandatory training can be reduced. The document states that whereas it is “…easy to see the justification behind each one, the sum of them all creates a significant burden on staff,…”
Chapter 4 is on practice infrastructure promises £900m over the next five years and that capital projects will be speeded up. “At scale” projects will be favoured with support for them to move quickly through legal and financial processes. Those projects that can be funded by NHSE will now be fully funded rather than capped at two thirds. There will be short term support (from May until the end of October 2016) to support practices with Stamp Duty Land Tax and VAT on premises and transitional support for practices suffering increases in PropCo fees. Information technology funding for CCGs will be increased by 18% and there will be a £45m national programme to stimulate the uptake of online consultations. In 2017-18 there will be funding for all staff and patients to enjoy free Wi-Fi in practices. It will be a priority for NHSE to facilitate the enabling of booking appointments between federated practices or via administrative hubs using different clinical systems. Security standards will be set in the forthcoming National Data Guardian’s review.
The final chapter concerns care redesign including delivering extended access in primary care. This is the much vaunted “seven-day NHS” manifesto commitment for primary care. Primary Care Access Hubs are the favoured vehicle and it “…is not (their bold font) about every GP or practice nurse having to work seven days a week. Nor does it mean that every practice…needs to be open seven days a week.” Local providers will work together. Local commissioners will be charged with making sure that schemes reflect demand and offer value for money. There will, of course, be some “minimum requirements” but these will not be published until later in the year. More evening and weekend appointments will reduce the demand in day-to-day general practice. The new MCP contract will be published in framework form “shortly” with the aim that it should “go live” on April 1st 2017. Apparently “The majority of GP practices are now working in practice groups or federations” and these are producing benefits with economies of scale, quality improvement, workforce development, enhanced care and new ways of working, resilience and system partnership which means primary care has a larger (not louder) voice in localities. This chapter also speaks about the “10 High Impact Actions” discussed inter alia at the recent NHSE/GPC joint study day in Bristol which was reported on separately.
Like Dr Baker we should welcome this plan. Sadly the confusion that has now been uncovered between Crown indemnity and Crown immunity as stated in this document does not bode well. Attention to detail is what is most required and NHSE must understand the need to make sure that the regulators are squared and tax, pension and VAT details ironed out before significant, meaningful change can occur. Recent events concerning practice payments systems bear this out. It is wonderful to talk about the bright future and importance to the nation’s health of a vibrant primary care sector but there needs to be a primary care sector left in order to transform it.
Dr Barry Moyse
Deputy Medical Director