GP Forward View two years on: NHS England's assessment
NHS England has released its analysis of the GP Forward View - its support package for general practice. Read the full assessment here
The General Practice Forward View (GPFV) was published in April 2016. It is a package of support for general practice, backed by increased investment, which addresses immediate challenges, and facilitates longer term transformation. The following gives an update on the progress we have made on the key commitments of the plan, two years in.
1. An extra £2.4 billion for general practice is on track to be delivered each year by 2020/21 (up from £9.6 billion in 2015/16 to £12 billion per annum by 2020/21). This represents a 14% real terms increase for general practice, against 8% for the rest of the NHS.
2. Over £10 billion was invested in general practice in 2016/17, an increase of over £1 billion compared to 2014/15.
3. The global funding sum paid to practices increased by 5.9% last year (2017/18) from £80.59 to £85.35 per weighted patient and a further 3% to £87.92 for 2018/19.
Rising indemnity payments remain a key issue for the sustainability of general practice. They are a major operating cost for GPs, and a disincentive to the out-of-hours working needed to improve the accessibility of general practice for much of the public. Several initiatives are in place to address the problem:
4. £30m was invested in 2016/17 to offset average GP indemnity inflation rises. A further £60m has been allocated for 2017/18 and practices have now been paid their share accordingly.
5. We have continued to fund Winter/Easter indemnity schemes to support GPs with indemnity costs when working additional sessions in out-of-hours settings.
6. In October 2017, the Secretary of State for Health announced that the government is planning to develop a state-backed indemnity scheme which would drive down indemnity costs for GPs.
NHS England aims to deliver support that will help practices to become more sustainable and resilient, better placed to tackle the challenges they face now and into the future, and secure continuing high quality care for patients.
7. Of the £40m funding made available to practices through the GP Resilience Programme, £16m was spent in 2016/17 and we are on track to spend the committed funding for the programme’s remaining years (up to 2020). In 2016/17, over 2,100* practices benefited from this resilience funding and in 2017/18 initial data indicated around 3,000* GP practices were supported. Further analysis is underway to determine the total number of individual practices supported over the first two years of the programme (some practices may have received funding in both years).
*The same practice may feature more than once in this figure if they are receiving more than one package of resilience support e.g. hub and individual support. The 2017/18 data is provisional and will not be audited until July 2018.
Care Quality Commission (CQC) inspections
Quality assurance is essential to ensuring a world-class general practice service, but can put staff under pressure. The following initiatives are working to streamline the quality assurance process to free up time for patient care whilst maintaining high standards:
8. NHS England has been working with the CQC, General Medical Council (GMC), Nursing and Midwifery Council (NMC) and General Pharmaceutical Council (GPhC), as well as all other bodies responsible for regulation and oversight in general practice, to coordinate and improve the overall approach to the regulation of general practice in England. This joint effort will result in a programme of work that will streamline working arrangements and minimise duplication and burden. The Regulation of General Practice Programme Board has published high level guidance to support a shared view of quality in general practice, helping to give providers a clear, common vision of the kind of service that all general practices should provide and that all patients in England are entitled to expect.
9. Together with the CQC and supported by NHS Clinical Commissioners, we developed a joint working framework to help reduce duplication and burden in the regulation and oversight of general practice.
10. We have reimbursed practices for costs incurred as part of CQC inspections.
Clinical commissioning group (CCG) investment
CCGs, the local organisations which commission the majority of health services in a region, are empowered to spend money in ways which best reflect the needs of the population they serve. The GPFV laid out a new plan for investment in CCGs, which is underway:
11. All CCGs have produced plans to set aside at least £171m (£3 per head) over 2017/18 and 2018/19 to support practice transformation. The first year’s (2017/18) investment figures in transformational support by CCGs will be posted on our website following the annual NHS Digital publication of the Investment in General Practice report in the autumn. We fully expect CCGs to invest at least £3 per head over the two years of the fund.
Improving access to general practice
12. As part of an extra £2.4bn going into general practice by 2020/21, over half of the country now has access to general practice appointments in the evenings and weekends, beating the target of 40% by March 2018. Plans have been brought forward to ensure that everyone will have more convenient access to appointments by October 2018, including on bank holidays and over the Christmas, New Year and Easter periods.
13. The number of appointments available within core and extended hours will be determined locally, according to the needs of the local population. As a minimum, appointments should be available from 6.30pm-8.00pm each weekday evening and on Saturdays and Sundays. Additional appointments can also be offered between 8.00am and 6.30pm, or between 7.00am and 8.00am, to ease pressure on general practice, if it is determined there is a local need.
14. In 2016/17, £123m was invested to improve access to general practice and we remain on track to invest at least a further £258m in 2018/19 in improving access as planned. Investment for 2017/18 will be included in the annual NHS Digital publication of the Investment in General Practice report in the autumn, following completion of the annual audit in the summer.
Primary care networks and working at scale
15. The ‘Next Steps on the NHS Five Year Forward View’ set out that one of the key ways for longer term transformational change, would be to:
‘Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care networks or hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access. Primary care networks or hubs also involve working more closely with community pharmacists, to make fuller use of the contribution they make. This can be as relevant for practices in rural areas as in towns or cities, since the model does not require practice mergers or closures and does not necessarily depend on physical co-location of services. There are various routes to achieving this that are now in hand covering a majority of practices across England, including federations, ‘super-surgeries’, primary care homes, and ‘multispecialty community providers’. Most local Sustainability and Transformation Plans are intending to accelerate this move, so as to enable more proactive or ‘extensivist’ primary care. Nationally we will also use funding incentives – including for extra staff and premises investments – to support this process.’
Estates and Technology Transformation Fund
16. As at March 2018, the Estates and Technology Programme, which funds general practice infrastructure like buildings and technology, has delivered 970 projects to date with a further 700 schemes in development. The 2017/18 Estates and Technology programme has seen a continuation of the planned investment. We are now seeing examples of extended buildings and new technology which are delivering benefits to practices and patients.
GP Health Service
The NHS GP Health Service is a confidential NHS service for GPs and GP trainees in England. The GP Health Service can help doctors with issues relating to a mental health concern, including stress or depression, or an addiction problem, in particular where these might affect work.
17. Since the GP Health Service was launched in January 2017, over 1,200 GPs have accessed the service (a mixture of existing and new users).
18. A 2018 survey with users of the service found that (of those that responded):
- 78% of GPs stated the service had a positive impact on their ability to work or train.
- 93% of GPs are likely to recommend the service.
19. The service will continue to be funded as set out in the GPFV.
Primary and secondary care interface
The General Practice Forward View made a commitment to establish a new working group to drive action to improve the current interface between primary and secondary care and reduce unnecessary workload shifting from hospitals to general practice.
20. We have worked with partners across the system to develop national guidance clarifying responsibilities for prescribing between primary and secondary care. This will ensure GPs only take on appropriate responsibilities for prescribing from secondary care, reducing GP workload and improving patient care. We are identifying examples of good practice where primary and secondary care is working well together.
21. Feedback from GP practices has been overwhelmingly supportive of a patient leaflet developed to inform patients about what they can expect from their care as a result of the contract changes, when they are referred by their GP to secondary care.
22. Recognising that people’s health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address people’s needs in a holistic way. It also aims to support individuals to take greater control of their own health.
23. Social prescribing schemes can involve a variety of activities which are typically provided by voluntary and community sector organisations. Examples include volunteering, arts activities, group learning, gardening, befriending, cookery, healthy eating advice and a range of sports.
24. Nearly half of all clinical commissioning groups (CCGs) across England are investing in social prescribing programmes.
25. 1 in 5 GPs regularly refer patients to social prescribing.
26. There is increasing evidence that social prescribing is positively affecting GP consultation rates, A&E attendance, hospital stays, medication use, and social care. The University of Westminster led an evidence review, looking at the impact of social prescribing on demand for NHS Healthcare. They found an average of 28% fewer GP consultations and 24% fewer A&E attendances, where social prescribing ‘connector’ services are working well.
GPs are vital to the NHS, but there are fewer than there were two years ago, with many GPs retiring or leaving the profession early. The General Practice Forward View set out actions to expand the workforce over the coming years by retaining more of the GPs we have; training and recruiting more; and providing better support for GPs to return to practice. At the same time, there has been a significant increase in the range of other health professionals that work alongside GPs, like clinical pharmacists, nurses and mental health therapists. This wider workforce provides vital services for patients with around 4,500 more (Full Time Equivalent) working in general practice than two years ago.
27. As at end of March 2018, provisional data indicates that 92,759 full time equivalent (FTE) non-GP health professionals were working in general practice, an increase of 4,484 from September 2015, against a target of 5,000 by September 2020.
28. Over 720 (FTE) GP practice based clinical pharmacists were actively working in general practice (as at March 2018), an increase of over 550 since September 2015. We anticipate that 1,200 FTE clinical pharmacists across over 3,000 practices and benefitting 34 million patients, will be in place by summer 2018 - with more planned as we move towards our target of 2,000 clinical pharmacists in post by 2020/21.
29. GP practice-based clinical pharmacists work as part of the general practice team to improve value and help patients get the best outcomes from their medicines. This includes providing extra help to manage long-term conditions, advice for those on multiple medicines and better access to health checks. It improves patient safety and frees up more time for GPs, with one practice alone saving 80 hours of GP time per fortnight. We are on track to spend the £112m in full and the 2017/18 investment in the clinical pharmacist phase 2 programme will be posted on our website following the annual NHS Digital publication of the Investment in General Practice report in the autumn as planned.
30. We announced £15 million to develop practice nursing in 2017. We are on track to invest this in full and the 2017/18 investment in the practice nurse training programme will be posted on our website following the annual NHS Digital publication of the Investment in General Practice report in the autumn as planned.
31. In July 2017, NHS England published a General Practice Nursing (GPN) ten-point plan which brings together key actions to meet general practice workforce challenges under the themes of ‘recruit, retain, return’. Implementation of these actions will be managed at local level, supported by the four Regional GPN Delivery Boards which have been established during the past year. A national marketing campaign to engage the system to deliver the ten point plan has been developed and is being rolled out across the regions to support implementation and engagement with the GPN workforce.
32. A number of nursing ambassadors are supporting implementation of the GPN Action Plan, specifically action 1. A national network of nursing and midwifery ambassadors, which includes GPNs, is actively seeking to change perceptions of nursing by addressing myths and stereotypes linked to the profession. The GPN Ambassadors are also working within the national network to engage with colleagues and peers to support retention.
33. The Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed treatment of adult anxiety disorders and depression in England. Over 900,000 people now access IAPT services each year, and the Five Year Forward View for Mental Health committed to expanding services further, alongside improving quality. As at the end of 2017/18 there were over 630 additional mental health practitioners working in primary care from the IAPT early implementer sites.
Doctors working in general practice
Serious action is being taken, working with our partners, to help increase the number of GPs in England. This will be done by retaining more GPs, by supporting more GPs that have left the profession back into practice, and by training and recruiting more GPs. The following initiatives are in progress:
34. As at end of March 2018, provisional data indicates there were 33,574 full time equivalent (FTE) doctors working in general practice. This is decrease of 1,018 FTE since September 2015 against a target of an additional 5,000 FTE by September 2020.
35. The GPFV committed Health Education England (HEE) to expanding the number of GP training places available to 3,250 per annum from 2016. In 2017, HEE filled 3,157 GP training places against this target. This represents the highest number of GP trainees ever recruited. Recruitment for the 2018 intake is now underway.
36. In August 2017, NHS England announced a significant expansion of this programme to identify at least 2,000 appropriately trained and qualified overseas doctors currently working abroad to come and work as a GP in England by 2020. This will initially be from the European Economic Area, but also looking further afield.
37. To date (end of March 2018), 58 GPs have joined the International GP Recruitment Programme in the pilot sites in Lincolnshire, Essex, Cumbria. A further 68 applicants are being assessed in Humber Coast and Vale. While the Lincolnshire pilot has ended, recruitment to the other pilots continues, in parallel with those GPs coming through the new national programme. One of the key aims of these pilots was to test different approaches to recruitment and learn lessons to help design the significantly expanded national programme, which got underway in March this year.
Return to practice (Induction and Refresher Scheme)
38. Increased financial and practical support for doctors on the Induction and Refresher Scheme was introduced in November 2016. This includes reducing the length of placements required for high-scoring GPs and increasing the frequency of quarterly assessments to every six weeks. Since April 2017, NHS England has also funded DBS checks for doctors on the scheme.
39. At the end of February 2018, a total of 433 GPs have been accepted onto the scheme against a target of 500 by 2020. 195 GPs have now completed the scheme and are now able to work in practice without conditions. A further 238 are currently on the scheme, either undertaking assessments or placements.
GP Career Plus
40. Pilots were established in 2017/18 to test models of employing doctors in multi-practice pools and will continue until September 2018.
GP Retention Scheme
41. The latest statistics published in February 2018 show that there are 254 retained GPs being supported. This includes 54 GPs being supported through the GP retention scheme, exceeding the indicative target of 50 GPs. Practices and patients alike are benefitting from retaining the services of an experienced GP.
Supporting hard to recruit areas
42. The Targeted Enhanced Recruitment Scheme offers a one-off payment of £20,000 to GP trainees committed to working in a select number of training places in England that have been identified as hard to recruit to for the past three years. 133 practices and GP trainees benefited from the scheme in 2017, out of 144 places on offer. As a result of its success, 250 places will be available in 2018/19, benefiting an additional 106 practices and GP trainees.
General Practice Development Programme
43. In 2016/17 £8m of the £30m fund was spent, and spend continues in line with the commitment laid out in the GPFV. The Time for Care programme, which supports practices to use innovative techniques to free up staff time for patient care, continues to grow; as of 30 April 2018, 169 CCGs covering 5,587 practices are engaged in the planning and delivery of a Time for Care programme locally. Support is provided to move through planning and engaging practices, to implementation. Currently 63 of those CCGs have completed planning and are now engaged with practices in implementing changes. Additionally, 1005 practices have so far received intensive on-site improvement support from Quick Start productivity facilitators.
10 High Impact Actions
44. The £45m Online Consultation fund was launched on 30 October 2017. The fund is split over three years. In early adopter practices, 40-60% of consultations are resolved without the patient needing to attend in person.
Case studies on “consultation”, some of which are about specifically online consultations
45. Nearly 1,100 GPs, nurses and practice managers have been engaged in the General Practice Leaders Improvement programme as of 31 January 2018. 100% of participants in the core programme rate the input as ‘very good’ or ‘excellent’, with 84% being ‘very likely’ to recommend it to a colleague. At 6 months, 50% report that the project has released staff time. A further third of participants report that the chief benefits are cost savings, improved practice morale, improved collaboration, patient safety improvements and improved patient health and wellbeing. To provide additional coaching and ongoing peer support, a new national primary care improvement community has been created, hosting regular workshops and facilitating peer connections and sharing of best practice. The membership has grown to over 2,300 in the first year.
46. We are investing £6 million to develop practice managers with £1m being spent in 2016/17. Funding has continued to be spent in line with the GPFV commitment through 2017/18 and is expected to spend in full.
47. We are investing £45 million to upskill practice reception/admin staff to divert workload from GPs with £6m spent in 2016/17.
Case studies related to releasing time for GPs by training reception/admin staff:
Groups and networks
GP at Scale
48. Hosted by the Royal College of General Practitioners (RCGP) and the Nuffield Trust, the GP at Scale scheme has nearly 1,000 members. It enables regional and national networking and evidence sharing, including developing guidance and resources to help providers working at scale – in networks, federations, multi-site practices, etc. – to create safe and resilient organisations. It is also developing a new evidence base and guidance regarding quality improvement and management of services provided in primary care networks.
49. Launched by the National Association of Primary Care (NAPC) and NHS Alliance, NHS Collaborate has engaged over 300 leaders to date in collaborative practices such as peer-to-peer mentoring, support for leaders of innovation in primary care, community services and new care models.
Next Generation GP
50. Hosted by NHS England. Next Generation GP is about informing, inspiring and equipping GP trainees to make a positive difference. The first programme in London included 80 trainees and young GPs. The second London programme has now launched. Plans are underway to establish new programmes in Wessex, Oxford, the North West and the North East. Where possible, these are being led in partnership with local deaneries.
National Collaborating Group on Primary Care Leadership Development
51. A national programme to develop a new framework for leadership development for the future of primary care and to stimulate the creation and uptake of new development offers.
52. Nearly 14 million patients across England are now securely using online services with their GP practice to book appointments, order repeat prescriptions and view their records - saving time for themselves and busy GP practices.
53. Latest figures show an increase of 42% in the number of people who are signed up for online services compared to the same time last year. Moving services online helps to ease pressure on GPs and their staff – and saving patients’ time and money.
54. It means 24% of patients – 13.9 million - in England are now registered to book appointments, order repeat prescriptions, view their patient records and see their test results without having to phone or visit their GP surgery.
55. The NHS Digital figures from February 2018 show that an average of one million appointments are being made or cancelled online every month, and that nearly 2.3 million prescriptions are being ordered online, as practices and their patients are increasingly using digital technology.
56. GPs whose practices have embraced online services are already seeing some of the benefits, with fewer patient calls and fewer people failing to attend – saving time that could be used on other activities within the GP practice.
57. 40 million people in England now have free Wi-Fi in their GP practice.