This site is intended for health professionals only

At the heart of general practice since 1960

Revealed: the effect of the Government's NHS long-term plan on general practice

Will the Government's £3.5bn funding injection in general practice prove to be a Christmas gift or a chain around GPs' necks, asks Nicola Merrifield

the ghost of general practice ©matt kenyon

The ghost of general practice

Source: © Matt Kenyon

General practice is being promised a different future. Along with the rest of the health service, it is being gifted a long-term plan by the health secretary and NHS England.

Prime Minister Theresa May has committed an additional £20.5bn a year to the NHS by 2023, which will be used to implement what NHS England is calling its 10-year plan.

And, in a break from the past, it seems the Government is serious about increasing investment into general practice. The PM has announced £3.5bn a year will be given to primary and community care – on top of the £2.4bn a year announced in the GP Forward View.

The announcement specifies that there will be new ‘community-based rapid response teams’ – made up of doctors, nurses and physiotherapists – who will provide emergency support closer to patients’ homes. The Government has also announced the rollout of a ‘successful’ pilot that sees teams of healthcare professionals, including GPs and pharmacists, assigned to care homes, including providing out-of-hours care.

'The status quo is not an option’

Dr Chandra Kanneganti

The details still need to be fleshed out – especially where the funding will go. Yet the whole direction of travel set by health secretary Matt Hancock and NHS England has been clear, and provides major clues about how the money will be allocated. They want a focus on prevention and greater use of technology. They want larger practices. And they want GPs to specialise in chronic diseases, supported by other healthcare practitioners who take on acute cases.

GPs recognise the need for radical change. Worn down by the conveyor belt of 10-minute appointments, increasingly complex patients and lack of clinical staff, they have reached breaking point. They need new ways of working, crucially with sufficient additional funding to deal with rising demand for services. As one says, ‘the status quo is not an option’ anymore.

Primary care networks

Primary care networks, serving around 50,000 patients, are becoming standard. Around half of NHS England's £508m Sustainability and Transformation Fund, announced in the GP Forward View in 2016, was earmarked for redesigning services, including practices working together at scale.

The Estates and Technology Transformation Programme, part of a £1bn fund, was set up for new premises and IT systems to integrate practices. NHS England said, as of March, 970 projects had been delivered, with 700 in development.

Interim findings from the review of the GP partnership model highlight `increasing collaboration between practices', claiming 5,000 practices are now part of networks. 

What we can expect in the 10-year plan

The PM and health secretary have already announced `rapid response teams' of doctors, nurses and physiotherapists to provide urgent care in the community. There are few details, but it is a safe bet they'll be provided by primary care networks.

In fact, it is likely that much of the £3.5bn will go to these networks to provide services traditionally termed `community care'. 

In fairness to ministers, the £3.5bn a year – 17% of the total NHS funding uplift – will go some way to addressing the funding discrepancy between primary and secondary care. But it may also be redefining what is meant by primary care – begging the question, is the NHS’s vision the right one for general practice? GPs could be forgiven for greeting the funding with some trepidation.

There is no doubt that some consistent themes are coming from ministers and NHS England. High up the agenda will be the focus on prevention, after Mr Hancock last month revealed his ‘vision’ for the NHS is to shift the focus onto prevention by empowering patients to take more care of their own health.

He said the Government wants a ‘radical shift’ from ‘a hospital service for the ill’ to a ‘nationwide service to keep us healthy, where those on the front line of the NHS, including the GPs who are its bedrock, feel confident to remind people of their responsibilities too’.

This shift will involve more social prescribing, with GPs recommending services such as art clubs, sports or walking groups – as a way to complement medical treatment and help people self-manage long-term conditions.

The use of technology will be pivotal, with GPs’ initial contacts with patients likely to be digital. The health secretary is known to favour this route; he endorsed the national rollout of Babylon’s GP at Hand app, which offers NHS patients a video consultation within hours.

Mr Hancock believes technology can ‘where appropriate, reduce the need for travel and face-to-face appointments’.

The use of technology

It is no secret that health secretary Matt Hancock is a fan of digital technology and wants to see the NHS using more of it, especially in general practice.

Since he is a patient of Babylon's GP at Hand video consultation service for NHS patients himself ± and has said he would like to see it `available to all' ± it is clear that the online consultation model is one Mr Hancock favours.

The NHS is due to launch its own app shortly, and it's already been encouraging GP practices to introduce online consultations through its £45m fund.

What we can expect in the 10-year plan

NHS England medical director, Professor Stephen Powis recently revealed GPs could soon be referring patients to outpatient appointments that will be conducted via Skype in a bid to cut down on unnecessary trips to hospital.

Meanwhile, GPs can also expect more initiatives encouraging remote monitoring ± so they can view a patient's data in real time ± and more primary care consultations via video or through online forms.

Meanwhile, the NHS’s own app is due to launch this month. It will enable patients to book appointments, check symptoms and order repeat prescriptions. Future updates could also support GP video consultations.

Stoke GP Dr Chandra Kanneganti, the BMA GP Committee’s lead on working with NHS England on investment, says: ‘I imagine the future will look like this: the patient has symptoms, which they put into an app and it tells them to carry out self-care, or that they need to see a pharmacist. Or if a GP is needed they’ll be given access to an online triage consultation – or even the chance to book an appointment.’

Superpractices and larger groupings in general also feature in general practice’s future. There is a shift to primary care networks, whereby groups of practices serve populations of around 50,000 people, sharing workforce and technology. Already, the NHS has given millions of pounds to practices willing to work ‘at scale’ in this way (see below).

‘Why is it not going into core general practice?

Dr John Ashcroft

Family Doctor Association chair and Swindon GP Dr Peter Swinyard says: ‘The way practices have come together in the last year has been quite dramatic.’

NHS England has been incentivising practices to merge, federate and offer secondary care services, and there would be little surprise if the £3.5bn a year is conditional on pursuing this agenda.

Prevention

Prevention will become the focus of the NHS, health secretary Matt Hancock announced last month in his new vision for the health service.

For GPs this will mean increased social prescribing: recommending activities such as volunteering, arts, group learning, gardening, cookery, and sports.

Social prescribing is being seen as a successful way to help patients manage long-term conditions. The Government announced £4.5m earlier this year to fund 23 such services in England, after lobbying by NHS England's clinical champion for social prescribing GP Dr Michael Dixon.

What we can expect in the 10-year plan

More money for prevention will be key. In his speech on prevention last month, Mr Hancock said that `in the UK, we are spending £97bn of public money on treating disease and only £8bn preventing it'.

GPs will be expected to take on a wider role ± advising patients on non-medical treatments and positioning themselves as public health doctors. 

Making social prescribing available in every local area by 2023 is expected to be high on the agenda, as are efforts to reduce childhood obesity and to ensure earlier diagnosis of disease through genome sequencing.

And the role of the GP is to be revolutionised within these large-scale practices. They will specialise in long-term conditions, and supervise nurses and physician associates, who will see patients with acute problems.

pulse november cover 183x231px

pulse november cover 183x231px

At the same time, as last month’s Pulse reported, GPs want greater flexibility in working patterns and the opportunity to hold a variety of roles as part of a portfolio career, instead of being restricted to full-time work in surgeries.

Official NHS Digital figures show the percentage of partners and salaried GPs in England working less than full time has steadily increased from 66% to 69% over the past three years. Working in networks with access to a shared wider workforce gives GPs more time to pursue other clinical interests, according to the initial findings of the Government’s GP partnership review, led by Wessex LMCs chief executive Dr Nigel Watson.

The shift to part-time/portfolio GP working

GPs are already turning to portfolio careers, which offer them a variety of roles alongside their work in surgeries, as Pulse reported last month. 

This is often an attempt to cut time in practice to reduce stress and provide a better work-life balance. NHS Digital figures show 69% of partners and salaried GPs in England work less than full time, the highest proportion ever.

What we can expect in the 10-year plan

HEE has launched its latest GP trainee recruitment drive by extolling the flexibility of general practice, so there seem likely to be new schemes to encourage GPs to widen their portfolio of work. As practices work together more opportunities for GPs to specialise may arise.

Scotland is leading the changes in how GPs work. Its 2018 GMS contract repositions GPs as ‘expert medical generalists’ who focus on undifferentiated presentations and complex care, while leading an extended primary care team.

Dr Kanneganti is broadly in favour of these changes, which he says will unlock access to a shared multiprofessional workforce and allow GPs to move away from the ‘risk’ of 10-minute appointments.

‘There has to be a way of working differently,’ he says. ‘The status quo is not an option.’

Yet concerns remain about this general direction of travel. As Doncaster LMC chief executive Dr Dean Eggitt puts it: ‘We are not choosing this because it is the best way of working; it is the best way of working with the resources that we have.’

Dr Eggitt is worried that the GP partnership model won’t survive such changes. He fears there will be a more radical shift to a version of accountable care organisations (ACOs), which will bring together not only general practices but also district hospitals, acute trusts and mental health services – all using the same pot of funding and sharing risk. NHS England consulted on this type of organisation earlier this year but has yet to publish its findings.

Dr Eggitt warns the GP partnership model will largely not survive a shift to ACOs: ‘To enable that, the GP partnership model is likely to die out.

‘This is because it is based on profit from an efficient system. Risk sharing with acute and mental health trusts is not that. Any profit from working together would not be returned to general practice as it is now.’

General practice will instead morph into small outpatient departments or ‘primary care outlets’ run by the bigger parent organisations, he suggests.

The skill mix: GPs becoming `expert generalists'

In the future, GPs are expected to deal predominantly with complex patients ± those who have multimorbidity and long-term conditions ± while a larger workforce of physician associates and nurses will take care of acute on-the-day appointments.

This could involve GPs becoming known as `expert generalists' ± as is the case in Scotland, where a new contract this year aims to ensure GPs focus on the skilled work only they are trained to do and can pass on more routine tasks to other professionals.

There have been moves by Health Education England to expand the physician associate workforce ± and the health secretary has recently confirmed those in the role will be regulated in the future.

What we can expect in the 10-year plan

Renewed efforts to ensure 1,000 physician associates are trained for primary care by 2020, as pledged by HEE in the GP Forward View. The latest official figures show just 79 working in general practice as of March 2018.

Funding may also potentially be allocated to train more of other healthcare professionals to work closely with general practice, such as pharmacists and paramedics to assist with prescribing and home visits.

Dr John Ashcroft, an executive officer of Derbyshire LMC, has similar concerns about the redefinition of primary and community care funding. He says: ‘My big problem is that when you start lumping this all together with community, will this money just end up in the community trust?

‘Why is it not going into core general practice? Is it ring fenced? If not, then why not?’

Dr Ashcroft, and many GPs, are worried about how these reforms will affect some of the most fundamental elements of general practice.

He adds: ‘The Government and the Department of Health and Social Care don’t believe in general practice, don’t believe or trust general practice. It’s all about supporting work at scale, but the other side of the coin is they don’t understand what traditional general practice can do with continuity of care. We need more of that and not less.’

Dr Swinyard says: ‘We will have a fight on our hands to try to preserve the essential part of general practice, which is the lifelong doctor-patient relationship.

‘We will undoubtedly be playing more with email, skype consultations, all the remote-access things which mean people don’t have to speak to a doctor.’

The doctor-patient relationship will also be put under further strain when more consultations are taken on by nurses and physician associates.

Of course, the major elephant in the room – and one of the biggest drivers behind these reforms – is the shortage of GPs. The Government has all but abandoned plans to increase the workforce by 5,000 full-time-equivalent GPs from 2015 to 2020, having lost more than 1,000 FTE GPs in the past three years.

'It certainly doesn’t go all the way'

Professor Helen Stokes-Lampard

Dr Eggitt says this highlights a fundamental problem with NHS plans for general practice. He notes the new schemes announced under the £3.5bn ‘are extra to the care we already offer’.

‘The [rapid response] scheme itself sounds great – how could we not want care in the community for patients who urgently need it, diverting them away from A&E so genuine emergencies can be seen in the A&E department?

‘But practically speaking, we don’t even have enough doctors and nurses to staff the hours of 8am to 6pm five days a week.’

What the pledged £3.5bn does do is begin to redress the disparity in funding between primary and secondary care. An analysis by Pulse in July revealed the percentage of NHS funding going to core general practice has been falling year on year since 2015/16, to its current level of just 7% (see below). 

gp funding proportion

gp funding proportion

But RCGP chair Professor Helen Stokes-Lampard says the increase is ‘an important step forward to meeting our calls for our service to receive 11% of the overall NHS England budget… but it certainly doesn’t go all the way.’

For other GPs, the experience of years of disappointing plans and empty promises have left little hope that this latest announcement will change things for GPs on the ground.

London GP and GP Survival campaign group chair Dr Nicholas Grundy says: ‘The recent history of similar plans in primary care has been uninspiring and profoundly depressing.

‘If you look at the GP Forward View, on pretty much every marker it has failed. I don’t think there has been any material change in the general practice working environment and I think that’s because a lot of it has not been thought through.’

 

Readers' comments (23)

  • Pathetic rearrangement of the chairs again.

    Unsuitable or offensive? Report this comment

  • Cobblers

    I read this and am I inspired? Have I hope for the future? Do I see money going into GPs budgets? Do I see pay even matching inflation let alone increasing in a real sense? Do I think the politicians care, let alone understand what they are doing? Is Prof Double-Barrel on the same planet as I am?

    I am afraid the answer is ‘NO’ to the lot.

    RLE you know it makes sense.

    Unsuitable or offensive? Report this comment

  • It is not clear if the £3.5b - reaching that figure in SIX years’ time - is in excess of any inflationary uplifts, or uplifts to account for increasing demand. If not, it is just more work for the same money, with most of the money being diverted away from core general practice to ‘community teams’ and networks. Can our Great Leaders please clarify these things before publicly offering warm words to the government (I mean you, HSL).
    Time for a new contract, and a fair deal for General Practice.

    Unsuitable or offensive? Report this comment

  • Doctor McDoctor Face

    This isnt new money, its money that we have been starved of over the last ten years. None of these proposals are going to mend the current dire state. Two of our largest local practices are about to fail due to recruitment issues. Its only small practices that seem to be coping.

    Unsuitable or offensive? Report this comment

  • David Banner

    There is nothing here that would encourage younger doctors to become GPs, nor persuade older GPs to not retire early.
    More guff about “Primary Care investment” (with not a penny to small partnerships), waffle about “social prescribing” (didn’t that used to be somebody else’s job?), and Futurama style fantasies regarding hi-tech consultations that most GPs and patients over 40 simply don’t want or need.
    Reads more like the Last Rites than another Forward View.

    Unsuitable or offensive? Report this comment

  • Sounds like the final nail in the coffin to me

    Unsuitable or offensive? Report this comment

  • Business as usual???

    Unsuitable or offensive? Report this comment

  • Sounds like partnership is dead. It’s going to be an expensive process to pay us all as salaried. Maybe then they’ll realise how hard we’ve been working as partners. All too late.

    Unsuitable or offensive? Report this comment

  • It is very clear that the government does not want to afford general practice in the old meaning of the phrase.
    It’s walking dead.
    If you cannot face working as a soulless employee of non medical/professional bosses then you need to plan getting out within the next 5 years.

    Unsuitable or offensive? Report this comment

  • From Dr.net- more bilge- poor loves- it's them that's got the problem with discrimination, bullying and poor pay and conditions, not us GP's- ship in more managers without any knowledge of the NHS- a bit like anyone from anywhere in the world can now join, and command, in the British Army!

    FFS:



    Stressful conditions and large responsibilities have all contributed to a negative working culture, according to the report on leadership by Sir Ron Kerr.

    Sir Ron, a former London NHS trust chief executive and a non-executive director of the Department of Health and Social Care, said the working culture in the NHS “must change.”

    His report, commissioned by former health secretary Jeremy Hunt, sets out proposals to improve the quality of leadership in the NHS.

    These include recruiting leaders from other sectors. This might include the armed forces, according to some reports today.

    The report says that problems are worsened by “conflicting” messages from the organisations that oversee the NHS, such as NHS England.

    It says: ”The conditions in which leaders operate are stressful and difficult, with great responsibility and the highest stakes.

    “Over time, this has led to a negative working culture in which both bullying and discrimination are prevalent and accepted.

    “This must change and should be led from the top, with NHS leaders ensuring they model the highest standards of behaviour.”

    It adds: “The review recommends a number of actions to build a modern working culture in which all staff feel supported, valued and respected for what they do and can challenge without fear.”

    Health Secretary Matt Hancock is to tell a conference today: "We need the best leaders in the NHS, whether they are from inside the system or from outside.

    “What matters is that we create the right leadership culture: one of learn not blame, continuous improvement and the highest standards of patient care."

    Unsuitable or offensive? Report this comment

  • That's what you get with comprehensive socialised ...... and state intervene....... lol

    Unsuitable or offensive? Report this comment

  • No. That’s what you get when you don’t let the experts doing the job, day in and day out, get on with the job and make decisions. It’s what happens when you allow people who haven’t a clue to make the decisions and just leave their jobs ( with a pay out) when it doesn’t work out , leaving the workers behind.

    Unsuitable or offensive? Report this comment

  • Take it a step further, cavalry. You want to let the experts aka us do the job and make decisions? Well whoever supplies the funding has the power to regulate and control. And the worst possible body to do that is the state, as we all know what the state tends to do with more power...

    Unsuitable or offensive? Report this comment

  • Decisions at the top in each hospital is often taken by non clinical managers who have a different set of moral/ethical/drivers. This is why it has all become about measurable targets and finance. Tail wagging dog.
    Most clinicians think that the health service needs to be stripped back to the basics and do those well. Not everything and more badly. Healthcare focus on ill health and suffering. Other government departments deal with the prevention

    Unsuitable or offensive? Report this comment

  • Let common sense prevail

    Remove acute presentations from the GPs portfolio and we will soon have(may already have) a generation of GPs who cannot recognise chicken pox, diagnose ringworm or otitis media, or instinctively know when a child is ill or not. Not a forward step.

    Unsuitable or offensive? Report this comment

  • NHSE are promoting a "model"of community care they think will be affordable,Accept a basic,emergancy care NHS for "the many"and an enlarging Private Service for "the few"! Not an advance!!

    Unsuitable or offensive? Report this comment

  • The government, media, patients and many doctors must stop this ridiculous suggestion that we are preventing illnesses. We postpone them, everyone still dies, often after a spell of serious illness. Life expectancy has increased almost 30yrs in the last century but is still finite. We won't prevent cancer, MIs, CVAs etc we will postpone them until later in life than they used to occur or do now, people need to understand this and realise that many of their poor lifestyle choices will impact adversely on their health. I walked away aged 50 just sick and tired of unrealistic expectations, old age is not a treatable illness.

    Unsuitable or offensive? Report this comment

  • David Banner

    Why is this article accompanied by a picture of Harry Potter’s weird uncle? Do you have to be a wizard to figure all this gobbledygook out?

    Unsuitable or offensive? Report this comment

  • |Ian Brooman | Locum GP|29 Nov 2018 1:42pm

    What's so bad about that idea? Unless of course you're happy to throw more money (taxes) at the state for them to be liberal with it...
    And I already know what you're going to say to reply to that. lets see if I'm right...

    Unsuitable or offensive? Report this comment

  • Saw the Director of Primary care in Kent this week. He knew nothing about it, had no plans. Noone knows much. Local Community Health Trust (nice DNs dysfunctional Admin) is denying access to anyone seeking details of their contract, KPIs or even the service specs. Joined up isn't it?!?

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say