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Gold, incentives and meh

Practices to offer routine Saturday appointments in £810m a year bid to reshape general practice

Exclusive Practices will be expected to merge or federate to offer routine opening on Saturdays and offer flexible appointment lengths as part of London local area team’s £810m a year bid to reshape general practice in the capital.

The NHS England (London) ‘transformation framework’ - led by former RCGP chair Professor Clare Gerada, who is now chair of the Primary Care Clinical Board at the local area team - encourages practices in London to begin to move towards a range of new services from April, in the first indication about how local area teams will be implementing NHS England’s recently published Five Year Forward View document.

It will incentivise practices to merge or federate as ‘Multispecialty Community Providers’ (MCPs), which will provide a range of enhanced services, and could lead to some providers voluntarily opting out of the national GMS contract for a hybrid of APMS and the NHS Standard Contract.

The new services will include widening access, actively seeking out patients who are not visiting the practice and holding team meetings with social services, housing and finance advisors on a regular basis.

The document says that offering this new ‘specification’ for general practice in London will cost up to £810m a year, representing a 5.36% shift in the overall health care budget - plus an unspecified amount of ‘transition’ funding.

In addition, the report said London practices would also require the £1bn investment for premises recommended in the Better Health for London report.

The plans, which represent the first detailed proposal for how GPs may work within the planned new models of practice in England, would see the groups of practices:

  • provide routine opening from 8am-noon on Saturdays;
  • provide extended access seven days a week, typically from 8am to 8pm, to be delivered via a network of practices, with a larger practice ‘in most cases’ providing the service on behalf of other practices;
  • use a telephone triage system;
  • provide flexible appointment lengths to patients;
  • provide add-on services such as citizen’s advice and probation services;
  • liaise with schools and workplaces to improve health literacy within their patient population;
  • have staff reach out to patients not currently seeking healthcare, such as ‘gypsies, travellers, sex workers, homeless people, vulnerable migrants, people in care homes, and people with learning disabilities or severe mental illness’;
  • working to joint contracts with other GP practices, primary care, social care and hospital providers;
  • identify all patients that need ‘coordinated care’ and manage their care through multidisciplinary teams.

The report emphasised widening access to GP services.

It said: ‘There is… evidence that some patients go to A&E with minor issues because they can’t get a same day appointment with a GP – especially at weekends when many practices are closed. So we’ve proposed that all patients should be able to access a consultation with a GP or senior nurse from their own practice on the same day in routine opening hours and on Saturday mornings. We’ve also suggested that patients should be able to access a primary care health professional seven days a week, 12 hours a day in their local area.’

It also promotes continuity of care, by suggesting that patients should be able to book appointments of ‘flexible duration’ with the GP of their choice in advance.

The report said: ‘Patients, such as those with long term conditions, tend to need more frequent consultation and value continuity and familiarity - but are willing to wait a little longer to be able to do so. So this specification outlines that patients should be able to book at least four weeks ahead if they wish and see their GP of choice in an appointment with a flexible duration.’

The report said the new patient offering ‘can only’ be delivered by GPs working in federation and with other primary, secondary and social care providers, which could be contracted via the NHS Standard Contract, alongside the core GMS contract.

It added that some practices may volunteer to give up their GMS contracts to become APMS-contracted ‘super partnerships’ or take on a new APMS/standard contract hybrid model.

Londonwide LMCs chief executive Dr Michelle Drage reacted to the plans with cautious optimism, saying: ‘For the first time in over a decade there  appears to  be an appetite from the NHS in London to shift resource into primary care, and to support GPs with better community services. The commissioning specifications are ambitious and will need to be implemented in a way that supports GPs and practice teams doing tough jobs, day in day out.’

Dr Brian Fisher, a GP in south east London and patient and public involvement lead for NHS Alliance, said: ‘I am delighted that it is absolutely clear that it demands a significant investment into primary care. It is less clear where that investment should come from. In my opinion it is unacceptable for this to come from hospital bed cuts.

‘The main limitation is as usual there is no way of delivering the programme. There is no mechanism across London to make this happen. So it now goes down to localities who may or may not be committed to this process.’

But Dr Louise Irvine, a GP in south London and the National Health Action (NHA) party parliamentary candidate for South West Surrey, said Saturday opening would be ‘fine’ if resourced with funding and GPs, adding that this ‘will be a challenge as both GP funding and GP numbers are falling’.

She also warned it could lead to privatisation and inequalities, saying: ‘For me the most worrying aspect of these proposals is the idea of GP practices being subsumed into Accountable Care Organisations run by a “lead provider” who could be a private provider.

‘I would urge extreme caution with the direction of travel of these proposals and do not feel that GPs should support them.’

The plans echoes the five-year vision set out by NHS England last month, which proposed primary care should receive more funding in return for reorganising into multidisciplinary care organisations doing both traditional GP work and services usually provided in hospitals, either via GP practices employing hospital specialists or hospitals employing GPs.

Writing in the introduction to the London report, which is being discussed at a large-scale meeting of commissioners in the capital today, Professor Gerada said: ‘General practice has served patients, the public and the NHS well for over 60 years. It has delivered accessible, high quality, value for money care.

‘However our patients are changing, both in the complexity of their conditions and in their expectations. This means that if the NHS is going to continue to provide the excellent standard of care to which we all aspire, we will have to be more innovative.

‘Tweaking at the edges is not an option. London needs solutions that will sustain primary care for the next 60 years.’

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Readers' comments (72)

  • No comment...

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  • Vinci Ho

    Interested to read comments from colleagues in London.
    Do you believe this 'solution'?

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  • I believe London is being targeted first because recruitment is less of an issue.
    However, be in no doubt that this will come to you wherever you are.

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  • £810 million pretty expensive funeral!

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  • Why just Saturday? what about Sunday till noon? will home visits have to be done on saturdays as well after the surgery till noon. that makes the day finish much later than noon. also will our secondry care colleagues be doing "routine" clinics along side us in hospital? Will the routube phlebotomy service and routine x-rays service be available? will all consultants be readily available at the end of the phone or in their clinic on Saturday morning to offer help and support/advice. No. Great it will work fine then. and really cheap, ongoing funding.

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  • So this is what Jeremy's little cunning stunt was trailing .

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  • I'm sorry but surely the response to "..evidence that some patients go to A&E with minor issues because they can’t get a same day appointment with a GP – especially at weekends" is better patient (and media) (and politicians') education, not to compound the misconception that minor issues need to be seen by a doctor at all, let alone require a same day appointment at whatever cost to the health service in this country.

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  • Una Coales. Retired NHS GP.

    @4:19 pm. I was asked for a comment. I like your response. Concise and to the point. Nothing working class NHS GPs can do to stop this runaway locomotive driving out the remaining GP partnerships. It's now a case of run for your life! Get out as soon as you can. It won't get any better.

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  • Vinci Ho

    So this is the follow up to Agent Hunt saying he had to take his kids to A/E as he did not want to wait . That's why we have to open on Saturday , then Sunday.
    Is anyone actually happy with this philosophy?
    I wonder what time he was talking about in the weekend? Really we should be open 24/7 to satisfy his 'appetite' ?? No wonder out of hours colleagues are so underfunded......

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  • If that's £810 million of new funding, plus £1 billion for new premises, then that's a significant investment. If London GPs don't want it, send some of that up North!

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  • Sadly "significant investment" with significant strings attached that'll further distort health priorities, fragment care and be disadvantageous to small practices.

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  • ...all a plan to destroy the profession - all this change being brought in with maddening speed ...I am worried about the kind of healthcare our and future generations will be left with once the nhs has been sold off by stealth .....this government that promised so much in the running up to the last election .....

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  • Well as long as London is sorted out to the satisfaction of the hard working politicians there that's all that's needed. I guess they plan on staffing this service with Drs from the developing world.

    Isn't it time London became an independent country...like Scotland (almost) has?

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  • Funny thing is, we used to open every Saturday and do home visits between 9and 12.
    In retrospect I have no idea why!

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  • £1 bn won't buy much investment in premises in London.

    The cost of land and any building project in London is several orders of that anywhere else.

    The fact this is so London centric is obvious but it does feel it will be the template for the rest of the nation.

    The test case will be if any APMS contracts will be able to make a profit...which I doubt and again we'll make no progress.

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  • gosh. What negative comments from you all. Maybe this is exactly what it seems - inward investment to our profession to help it out of the tight hole it is at the moment. Of course there are strings attached - there always are, but maybe its for the better for us all. The strings - that we change the way we work, work across practices , improve skill mix, extend opening hours (and not just us delivering this), modernise our premises, give our nurses a career etc etc. As someone said- the potential for £2b investment and all the comments are so negative. What ever next......

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  • Looking from the outside well away from the NHS the reason surely for the negativity to this "inward investment" is that it does nil to address the problem as Primary Care would see it... How is increased access for all going to improve the retention of GPs....if more leave under insatiable demand then access will deteriorate and more will leave.....first surely the terms and conditions need to be stabilized, impositions stop and GPs actually listened to before yet another restructuring to deliver something very few really need but politicians would like...... I think this might explain the negativity..... These were the Reasons I left for Canada 3 yrs ago and nothing I have heard since makes me believe it was the wrong decision... These ideas just reinforce my relief at being well shot of this insanity.

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  • Clare the mechanism is there already - extended hours payments which were slashed under this government. Why not reboot this with appropriate funding?

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  • Claire, it is the average list size is the problem. In spite of seeing 40+ patients a day, patients cannot get appointments for weeks in some practices. Our Contract is to provide GMS services and it is wrong for patients to wait for weeks. If we moved to an appointment based payment system, then the DOH would have to fund more appointments.
    If we keep the current list based system, where consultations have doubled per patient year in 12 years, consider the future.
    Diabetes and dementia will double in 10 years and so will the numbers over 75, with multi morbidity.
    GP land will collapse. We are already seeing 92% of the consultations on 8% of the budget and yet Mr Hunt complains that he has to wait for appointments. They so laud A+E, which sees about 2% of the total consultations, and we are the reason they are so overworked. How absurd!!
    But, we have to shoulder the blame. If we stay with average list size Contracts, then we have to provide appointments. That is our Contract and we are failing in our duty.
    We Have to, is imperative, MUST change. Otherwise we will forever be criticized, no matter how many we see each day.
    LMC s need to see this and change Contracts. The current one is untenable.

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  • GPs traditionally only investigate and refer when clinically appropriate. This is about to change.

    In the future patients will choose what they want and use their NHS tokens to pay for this. However this will not be enough to pay for their care so they will have to top up the cost.

    There will be on going adverts for bariatric surgery, full body scans, diabetic care programmes etc.

    Large private corporations (some owned by present CCG GP board members) will employ health care workers who will be worked to death.

    By then there will be no locum jobs as all workers will have to cover others sickness. There will be no option to this as similar organisations will have taken over in Canada, Australia and New Zealand

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  • Clare what do you expect when the profession is being trampled on - I only wish the negativity was consolidated in to some form of active resistance (thank you BMA and RCGP)
    Maybe you're being naive or have your own agenda, or maybe the rest of us are right to be cynical - equally maybe the government cares about maintaining effective affordable primary care and is not driving towards private healthcare- we shall see

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  • Clare
    The main problem is that the vast majority of GPs simply do not agree with your vision of future GP services and feel that the government have removed money from the pot in order to give it back only if we move to large, impersonal organisations.
    You say you like evidence based medicine, so let's look at the evidence for your proposed services. Figures for the Hurley group ( no individual practices identified,Pulse).

    Patient satisfaction recorded on NHS choices
    3, 2, 4.5, 3.5, 2.5, 3, 2, 4, 1, 1, 2.5, 2.5, 2.5, 1.5, 4

    And independent....
    82, 63.2, 86, 73.6, 71.4, 72.8, 78.8, 94.2, 48.5, 51.5, 48.5, 83, 56.4,

    So the patients don't like your system much and there appear to be 3 high scoring practices, 5 low scoring practices and the rest are low average.

    Please, please explain how this is better for patients than my old practice which scores 5 and 86.3.

    If the funding was restored to what it was 5 years ago we could have been even better.

    Please do not delete this comment, I really feel that people like Clare should answer these questions. If she does not, it will be even more clear that this is a politically driven dictat with no evidence behind it.

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  • Abolish the formula. If I have 4150 patients, don't pay me for 3600. It is unfair that with a increase of 1000 patients ( weighted) I have an increase only of 28000 per year. Was it not 73 per patient?
    If other Practices in Medway and Kent offering similar services were paid on average to 450000 per year, how does NHSE explain that one Practice has ' historical' low weightage.
    We don't have students but we do have depression rates 3.5 times the national average, the highest concentration of LD patients in a Practice in Kent and almost 400 children below the age of 4. Council housing galore but we are not a deprived area!
    The utter lack of transparency reflects in global sum payments per weighted patient. Some citizens of this country are better than others, so for an average Strood citizen registered with Marlowe Park Medical Centre and weighed down by the formula, NHSE pays 55-60 pounds per year but there are Practices who are paid signficantly higher rates than the 73 stipulated per patient in same GMS Contracts offering similar services and LES/DES.
    The day we are able to get payments on an equal footing, we may be able to consider other options.
    Meanwhile, NHSE will know where to stuff the money they are offering for opening 7 days a week.

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  • Vinci Ho

    Take one step backwards and go back to the basics of politics:
    It is about the trust and credibility of those who 'talk' in front of the public ,no matter how 'noble' the speech is.
    Same argument was applied to care.data.
    What JH did and said about his usage of A/E instead ,was premeditated and carefully calculated ,out of desparation, to make his mission impossible possible(if this makes sense).

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  • why wouldn't GP's be cynical about these plans.

    The goodwill and trust which is needed to drive any change has gone.
    Senior partners are rushing towards the door, junior GP's are increasingly looking at emigration or leaving medicine.

    We can all see the government agenda..we are dancing to the tune of want. But with limited resources those with real needs will suffer and that is the tragedy.Further reorganization will create uncertainty until the next cycle of change.

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  • Oh goody gum drops.

    How exciting.

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  • Its simple. Please can govt do the sums.
    Currently recognised working hours: 8 - 18:30 = 52.5hrs/week.
    Proposed: 8 - 8 = 84 hours/week
    53.5/84 = 62.5%

    i.e we would need to increase our capacity by 37.5% to match these increased hours.

    Given that we are already at maximum this would mean needing 13000 more GPs alone ignoring all the other additional staff (primary and secondary care) that would be needed to make this system safe

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  • Bloody damn exciting if you consider that you are paid 259000 per year for the same nr of patients for whom another gms is given 450k.......Wonder what Bevan might be ruminnating about considering Equality and Dsicrimination issues in this civilized country.

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  • What negative comments from you all.

    Can't think why this might be?

    Maybe this is exactly what it seems

    Unlikely based on recent evidence - attacks on pensions, pay, more onerous terms, increased regulation and overbearing paperwork have become normalised despite the harm done to General Practice, including a recruitment crisis and practice closures.

    Of course there are strings attached

    Why does no-one trust us? Do we really need to be micromanaged to an agenda? Why can't we take back control of our profession?

    As someone said- the potential for £2b investment and all the comments are so negative.

    Obviously increased resources are welcome but this does little to address the structural problems in primary care. There is life beyond London.

    What ever next......

    That's what we're afraid of!

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  • There is life beyond GeneralPractice.

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  • Yes, but not as we know it!

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  • There used to be lots of independent shops in our high streets.

    Now it's all Tesco's, Sainsburys, Morrison's, Asda, with the workers paid a pittance, all working to push the brand of their employers. How many of the workers actually get to know their customers, as the shopkeepers of old did?

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  • Secure environments GP

    No comment....(again)

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  • Mum mum ( aged 85) , while battling with the Tesco website said
    " I wish Clements was still there!"
    How true, and how sad that the selfish young have wrecked personal service for those who care.

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  • Yes and wait until healthcare goes german provided by Aldi and Lidl.

    Perhaps that's what they mean when they say 'Aldi access'

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  • I'm a GP trainee, so relatively new to trying to understand the GP contracts, but my question is why out of hours cover doesn't qualify as '24/7' GP provision? Isn't that why 'H'unt should have called 111 instead of pitching up to ED?

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  • the reshaping of general practice will take place when NHS England starts folowing cost effective evidence Medicnre;not imposing for example sulphonyureas on GPs as second line treatment.Though sv=ceap to buy the costs of hypoglemia with frequently occurs with it to public and purse should reseve that drug only for MODY

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  • Quite frankly why would anyone now pick medicine as a career choice.

    Paid next to nothing, responsible for all the ills of the world, micromanaged, 60+ hours a week, no home life, living in fear of the GMC, CQC and shortly our corporate masters

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  • So we will be responsible for probation, housing and citizens advice, in addition to most of secondary care.

    Have you seen the queues outside citizens advice bureaus?

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  • as with all these drivers - all this is is so simon steven and then the PM can say ' we have delivered 7 day access'.

    The real impact is covered up. The one positive is that the system is broken so there is no room to go. No capacity in terms of doctors, locums will be too expensive. there aren't even enough nurse prescribers or physician assts.

    Much of this is hot air and just will not happen.

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  • Una Coales. Retired NHS GP.

    @8:26. While many NHS GP partnerships are hit by CQC ratings, large providers are given more time...http://www.cqc.org.uk/provider/1-199742634.

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  • "have staff reach out to patients not currently seeking healthcare, such as ‘gypsies, travellers, sex workers, homeless people, vulnerable migrants, people in care homes, and people with learning disabilities or severe mental illness"

    If this actually happens, it will hopefully be a real step forward. Healthcare should be there to meet the needs of the patients - we should not expect patients to always fit around the needs of HCPs.

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  • Clare, that's because we can see through it, see where it's going and don't like it.

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  • @una
    Thank you, how very interesting that the link takes you to a list of practices which have not yet been inspected.
    I have just had a quick look at the Hurley practices on the " intelligent" risk assessments. Can't find them all but have so far seen 7 graded 1, one at 2, one 5 and two at 6.

    So are we to assume that the Hurley practices will be in the first tranche of inspections?

    Clare, you really need to answer this. I am not having a go at you personally but see no evidence whatsoever, on cqc and nhs choices that the services you so strongly advocate are good.

    So a WHY should we go down this route????

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  • So if we do not give up our GMS contracts we will get no extra resources for our patients. So our patients will reregister at the new large healthcare organisation and we will wither on the vine and eventually join the large organisation, retire or resign. So there is going to be no future for small practices.

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  • So who will own the contract for this large new health care organisation in London?

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  • re Dr Gerada,i recently attended a meeting in Exeter where Dr Gerada was guest speaker.It was clear that her vision was the end of the partnership model and the use of federations to re-employ us as salaried GP's but with us maintaining our 'independance'.I can think of nothing worse-what happened to local services and personal care this will be lost.As for a provider of services sitting on the board-all screems of conflict of interest to me.

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  • Una Coales. Retired NHS GP.

    The cat is out of the bag...

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  • Why personalise this against me! and my organisation? I am trying to do the best for my profession and our patients. I do think there should be different models and different employment structures - and yes, Hurley does do badly in some areas and better in others - so what. This is not about me. I think we GPs are our own worst enemies. We fight, and split and are nasty to each other, using anonymous posts. I am not going to engage on this fora - for my own mental health. I gave up on DNUK and whilst I think Pulse is a great news paper, the comments after are so disparaging.

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  • Clare It is not just about 'different models and different employment structures'. Once this new organisation is formed there will eventually be NO other model. All GPs will be salaried.

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