Letter to the profession on the General Practice Forward View
From Dr Chaand Nagpaul, GPC chair
Today, NHS England has published the General Practice Forward View, setting out support for primary care over the next five years. This strategy has been long-awaited by the profession. Key elements in this roadmap represent the culmination of many years of lobbying and calls for action by the GPC. We have worked closely with NHS England to represent the profession and the urgency of the need to support and invest in general practice and to influence their final strategy.
In our most recent paper, Responsive, safe and sustainable: our urgent prescription for general practice, we set out the urgent actions which need to be taken to alleviate the current significant pressures on the service. It is particularly notable that a large number of our proposals have been accepted by NHS England and included in their roadmap for the future. These include:
Fair and sustainable funding and resources
NHS England has acknowledged our arguments that funding going into general practice must be increased, and the funding deficit addressed. GPC called for £2.5bn to be invested in general practice and NHS England has now outlined plans as to how this will be delivered. It is positive that, after the intensive lobbying which GPC has done on this issue, recurrent spend in general practice will be increased by £2.4bn back to 10.4% or more of NHS England’s healthcare budget by 2020/21. NHS England expects this to be supplemented by CCGs for out of hospital care. GPC will push for this to be a national directive so that this increases to at least 11% of the NHS budget which will be essential for the future sustainability of general practice.
Following pressure from GPC, NHS England has also committed £500 million for a one-off sustainability and transformation package. We have consistently highlighted the urgent need for immediate support for practices in crises, and are pleased that £56 million has been allocated as part of this package for a practice resilience programme, starting in 2016/17, and which will include support for GPs suffering burnout and stress. As described in Responsive, safe and sustainable: our urgent prescription for general practice, the introduction of practice resilience teams will be considered to provide much-needed practical and tangible support for practices.
GPC has also lobbied for resource to be provided to support an increase in the number of GPs and other professionals, to ensure that the workforce is able to support the mounting demands on the NHS. As part of the £500 million package, £206 million has been allocated for workforce measures to grow the medical and non-medical workforce.
As highlighted in Responsive, safe and sustainable: our urgent prescription for general practice, practices must be provided with organisational development funding to support different ways of working, including working at scale and collaboration with other practices. It is positive that this call has been recognised with £246 million of the sustainability and transformation package identified to support practices in redesigning services.
NHS England has also responded to GPC’s highlighting of the need for action to address rising indemnity costs and which is resulting in GPs declining to maximise their working potential and reducing workforce capacity. We are clear that this must translate into tangible action which tackles this significantly increasing pressure on GPs.
In terms of access to GP services, GPC has influenced NHS England to ensure that no practice will be contractually required to be open beyond current hours.. In addition it will be for local areas to determine what service arrangements are appropriate for their local population and, as we insisted, these must be integrated with urgent care and GP out-of-hours services. Importantly, the previously available non-recurrent funding for improved access to meet locally determined demands has been replaced by recurrent resource, which will reach over £500 million by 2020/21.
Reducing workload and bureaucracy
Responsive, safe and sustainable: our urgent prescription for general practice set out a number of practical steps which should be taken, particularly in relation to the primary/secondary care interface, to stem the inappropriate shift of work into general practice.
NHS England has recognised the need for action to address GPs’ workload with a three-year £30 million ‘Time to Care’ development programme, which will support the release of up to 10% of GPs’ time by enabling practices to work together and consider new ways of care delivery.
We are pleased that the NHS Standard Contract will be amended to ensure that hospitals will no longer refer patients back to GPs for re-referral, and also that hospitals are able to make internal referrals where this is for a related, non-urgent condition. We also support that communicating the results of hospital investigations must be the responsibility of the hospital, not the GP. As part of the 2016/17 GMS contract agreement, NHS England committed to working with GPC on a national approach to reducing bureaucracy and workload management. The General Practice Forward View also commits to a new interface working group to improve the primary/secondary care interface and GPC will be an integral part of this critical work.
GPC has highlighted the different ways in which practices can be supported, including the possibility of locality hubs to which practices could refer patients when they have reached the capacity threshold for safe care on any given day. These hubs could also provide a number of other functions, as outlined in our paper. NHS England’s proposals for considering a network of locality Primary Care Access Hubs are welcome and we will be working with them to develop and deliver this.
An expanded workforce
We have long called for clear and credible plans to recruit more GPs, as well as a strategy for how the wider workforce can support general practice.
NHS England has recognised that resource is needed to support workforce growth, with £206m allocated for workforce measures to grow the medical and non-medical workforce. Following our pressure, NHS England has committed to double the rate of growth of workforce to create extra 5,000 doctors working in general practice by 2020/21. A number of proposals have been made for taking this work forward, including the need to increase GP training recruitment to 3,250 a year and targeted support for GPs returning to work.
NHS England has also responded to pressure from GPC to commit to developing the wider workforce, with new funding of £112 million for clinical pharmacists in practices, leading to a further 1,500 pharmacists in addition to the current 470 in general practice by 2020. A Pharmacy Integration Fund, worth £20 million in 16/17 (which will rise by £20 million each year), will be introduced to look at how pharmacists, their teams and community pharmacy fit into the wider NHS services in the local area. It is positive that a £15m national investment for practice nurse development, over £50m to support training of reception and clerical staff and practice manager development, and a plan for the training of 1000 physician associates.
NHS England has also replied to GPC’s demands for support for mental health services, with £16m committed for specialist mental health services to support GPs suffering with burn out and stress.
Reducing the regulatory burden of the Care Quality Commission (CQC)
GPC has repeatedly called for the replacement of the content and pattern of CQC visits and ratings. While NHS England has responded to our concerns with a commitment to reduce the number of inspections once all practices have been inspected, for example with a maximum interval of five-yearly inspections for good/outstanding practices, we are clear that this does not go far enough. We will continue to argue for a radical scaling down of the current regulatory system. NHS England has also committed to recompensing GP practices for any future increases in CQC fees; while this is positive, it does not meet GPC’s call for CQC fees to be fully reimbursed.
Infrastructure and technology to deliver practice and system resilience
GPC has been particularly tenacious on the issue of premises, and we are pleased that this hard work as led to the commitment of £900 million for capital investment, including the vital step that, as from July 2016 new rules on premises costs will enable NHS England to fund up to 100% of the costs for premises developments. GPC has also secured agreement that NHS England will fund stamp duty and land tax costs for practices signing leases with NHS Property Services from May 2016 until the end of October 2017. We have also negotiated a commitment that NHS England will develop new funding routes to enable transitional funding support for practices seeing significant rises in facilities management costs in the next 18 months in leases held with NHS Property Services and Community Health Partnerships. GPC has also secured a commitment that NHS England will work with NHS Property Services on the issue of how to allow underwriting lease arrangements or buying out GP owned premises where this fits in with wider commissioning gains.
Responsive, safe and sustainable: our urgent prescription for general practice highlights a number of actions needed to improve technology for practices, including the delivery of a fit-for-purpose, fully-funded IT package. We support NHS England’s recognition of the need for a number of these proposals; these will have a positive impact on the working day of GPs, as will the commitment for an 18.5% increase in revenue funding allocated to CCGs. GPC has continually highlighted the local inconsistency in the access which practices have to IT services and products, and NHS England’s commitment to develop a nationally accredited catalogue and framework for IT products and services is much needed.
In the 2016/17 GMS contract agreement, GPC secured an important commitment that NHS England will work with GPC on a national approach to workload management, including promotion of self-care and appropriate use of GP services. The General Practice Forward View acknowledges this work as a vital step in managing demand and meets GPC’s call for action with a commitment to fund workforce and technology to support practices in assisting patients to manage minor self-limiting illnesses and signposting patients to self-care and minor ailment schemes. As outlined in our paper, GPC believes that the widespread adoption of minor ailment schemes, such as Pharmacy First, is a “must-do” in order to ensure patients have access to appropriate care without always needing to see a GP.
We are clear that NHS England’s proposals, are a much needed, if overdue acknowledgment of the state of general practice and build on what GPC has been lobbying for over the last three years. As such, they represent a significant and comprehensive package to support general practice, both in the immediate and longer term.
At the same time, we are equally clear that there are a number of areas which require a lot more clarity, as well as other areas that do not go far enough. There remain a number of important elements in the GPC’s urgent prescription document which are yet to be acknowledged and addressed. You can be absolutely confident that we will continue to work with NHS England to ensure that these are also addressed.
We believe that this document is a framework for what needs to now happen, with many of the proposals and funding a floor not a ceiling. Working out the detail and implementing these plans is critical and, to this end, we have therefore secured a commitment that an Advisory Oversight group, on which the BMA, RCGP and patients will sit, will be created to steer and drive the implementation of the measures. In order for this framework to have the confidence of GPs, it is critical that they see tangible and rapid delivery against these commitments. GPC, will continue its work to ensure that NHS England’s words are translated into action so that practices receive the support which is so urgently needed.