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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)

  • 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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