House of Commons Public Accounts Select Committee Report on Access to General practice, April 2017
This report was published at the end of April and made two headlines: one was that the number of GPs had, in fact, fallen slightly last year and so work towards hitting the “5000 more doctors working in general practice by 2020” target was not going well; the other less helpful and more prominent headlines were about “GP closures [in core hours] putting pressure on A&E.” The report actually stated that, “NHS England explained that three-quarters of half-day closures are concentrated in about a quarter of clinical commissioning groups, with particular areas such as North-East London more heavily affected. It told us that there did not seem to be any obvious reason for these patterns and it believed it to be due to cultural and historical circumstances… practices that are open for 45 core hours or less per week having, on average, 8% more A&E attendances per 1,000 patients.” This did not of course stop the anti-GP (anti-NHS?) popular press from making sweeping generalisations. NHSE will be speaking to all practices which report regular weekday closures by 3pm to find out what provisions are made for patient services and stopping the DES money from the 76% of them that currently provide extended hours from October.
GMS and PMS contracts speak of meeting the “reasonable needs” of patients but the Committee believes that historically the “high trust” (sic) inherent in these contracts has left it to GPs to decide what these reasonable needs might be. NHSE is to work with the GPC and LMCs to set out a “common sense list” of what people should expect. Examples given include picking up a prescription, making an appointment, dropping off a specimen and having someone available to act upon an urgent test result. The Committee was also concerned that, although quality schemes and QOF existed to reward practices, there were very few ways of penalising practices which did not meet reasonable needs. Incidentally NHSE submitted that QOF was probably time-expired and would be replaced by a “primary care web tool to measure quality of care and outcomes.”
On the promise to extend access contained in the 2015 Conservative Party election manifesto the Committee is concerned about the value for money of such schemes which the National Audit Office (NAO) has judged to cost 50% more than core hours care. It also is worried about potential overlap with existing OOH services and the potential for CCGs to end up paying twice for the same work. This seems to be about fewer people using OOH services because they can book in to see someone at their practice instead. This seemed to miss the point of routine booked appointments versus urgent care for things which will not wait until core hours. Incidentally, I believe that this represents a fundamental flaw in NHS thinking about new models of urgent care, leading to, for example the demand that all A&Es have a GP on site to see routine GP work by the Autumn. The NAO also found that patients whose practices had longer opening hours already reported less continuity of care but NHSE suggested that this was because pilot sites had bought in additional capacity. What this means for the sustainability of the rest of the service, that is the non-pilot sites, was not explored. Damningly, however, the report goes on that, “The Department and NHS England have pursued this commitment to extend hours without fully understanding how patients’ needs are currently being met during core hours. They do not have data on the availability and use of appointments during core hours, including those periods that might help improve access for working people, such as before 9 pm or after 5.30 pm. They also do not know when and how long practices spend with patients.” However, “NHS England said that from April 2017 it is introducing a ‘practice workload tool’ that will measure how appointments are utilised at practices. It also said that during the course of this year it will start collecting data on the availability of routine GP appointments, and that it would seek to publish these data so that the public can see waiting times at different practices.” NHSE does not believe that the present lack of data undermines extending (in Somerset “improving”) access but it has certainly, in my experience, been a frustration to local groups studying urgent and emergency care provision.
Progress on the “pledge” to increase GPs by 5000 (which subsequently developed “flexibility” according to the Secretary of State) was examined next. Health Education England (HEE) filled 250 more training places to total 3019 in 2016-17 than the year before but this still left a gap of seven percent of places unfilled. Applications were up 4.7% this year. Regarding Brexit HEE said that there had been no impact so far on European Economic Area (EEA) nationals applying to work in the NHS. Doctors trained outside the UK but within the EEA account for only 4% of the GP workforce but even that is 4% we cannot afford to lose.
With progress of the 5000 more GPs “flat lining” with nearly as many leaving as joining since 2010 NHSE has been surveying leavers who cite workload as the greatest factor for their departure and still had hopes that the various schemes in the GPFYFV would make more time to care. “To improve retention” NHSE is considering plans to “lock in (“sentence”?) young doctors to at least years’ service in general practice” while at the other end of the scale, the GP Career Plus scheme is cited. The Committee was concerned about pension arrangements encouraging GPs into retirement but the DH, whilst admitting that these may make a contribution, said that pensions were not the main reason.
The widening of the workforce was the subject of the final section of the report. The 5YGPFV committed to increase not just doctors but mental health therapists, clinical pharmacists and physicians’ associates all in able to free GPs’ time to allow them to spend the majority of their time doing things that only GPs can do. The Committee remained concerned about how the best use of these clinicians could be made in small and rural practices where there may be insufficient demands to sustain a service. NHSE admitted that more than the £1b allocated over the next four years would be needed for better premises and infrastructure. NHSE also said that better equity of funding by reviewing PMS contracts and phasing out the MPIG but had pledged to tread carefully before changing the Carr-Hill formula which will not now happen until April 2018 to “protect practices from financial stability or uncertainty.” Perhaps the words “even more” should have figured in that sentence?
Dr Barry Moyse
Deputy Medical Director