The ‘new deal’ (that wasn’t)
The health secretary has revealed the direction of policy under the new Government, and it does not look good for GPs finds Jaimie Kaffash
It was one of the most anticipated announcements about general practice in years.
Crowded into a room inside a brand-new health centre in south London, the nation’s media waited for the health secretary finally to reveal his ‘new deal’ for GPs.
And it was a huge miscalculation.
Because the supposed ‘new deal’ that he had promised would tackle burnout and ease the pressures on practices turned out to be nothing of the sort.
Indeed, there was virtually nothing that was ‘new’ in his announcement, apart from a token £10m fund for struggling practices and a promise to recruit 5,000 additional practice staff by 2020. And Mr Hunt said his patently one-sided deal had ‘two parties’ so GPs should be prepared to open seven days a week as their side of the bargain.
The reaction from GPs was almost immediate. The Pulse website was deluged with comments decrying the ‘deal’ they had not agreed to. ‘This will not make one iota of difference to the crisis,’ said one. ‘It’s insulting,’ said another.
The DH-approved ‘#GPnewdeal’ hashtag was quickly outstripped by the ‘#GPnodeal’ hashtag on social media. A petition denouncing Mr Hunt’s speech collected more than 2,000 signatures in the first two days after the announcement.
And GP leaders were caught off-guard by the strength of reaction from a profession fed up with empty political promises. Many GPs were particularly critical of the RCGP’s optimistic response that the ‘new deal’ could put the profession on a ‘more stable and secure footing for the future’.
The BMA scrambled for an appropriate response, and eventually passed an emergency motion at its Annual Representative Meeting in Liverpool, accusing the health secretary of putting the ‘very existence’ of general practice in danger.
The strength of feeling among GPs was all the more acute given that there had seemed to be signs of a sea-change.
The Prime Minister used his first speech after winning a majority at the general election to announce a ‘new deal’ for GPs, and the profession was heartened by his promise of ‘more investment, more training and a more personal link with patients’.
The health secretary went on national radio to say he was determined to look at the ‘terms and conditions of general practice’ and that he understood many GPs felt they were on a ‘hamster wheel’.
The rhetoric had changed after months of uncomfortable national newspaper headlines illustrating the intense pressures on GPs and the number of practices facing closure. Many GPs hoped the Government had realised it had pushed the profession too far. But this optimism was misplaced.
Mr Hunt’s speech did speak of the value of GPs’ work and how ‘the jewel in the crown of the NHS is feeling rather unresplendent now’.
He said NHS England would be running workshops on reducing GP workload and confirmed that £750m in premises funding – as promised by the Treasury before the election – would still be spent over the next four years.
He also promised a £10m fund for to help struggling practices survive, but Pulse later learnt this fund will not be new money, but would be reallocated from the premises fund.
He also reaffirmed his commitment to recruiting 5,000 more GPs and promised 5,000 more practice staff – including physician associates, nurses and pharmacists by 2020 (although he later diluted the commitment of 5,000 new GPs, saying this was the ‘maximum’ he expected to recruit).
The rest of the speech was a repackaging of previously announced policies, with no real detail on how they would be implemented: golden hellos to tempt GPs to work in under-doctored areas, a marketing campaign for medical students to promote general practice and a returners scheme for GPs who had left UK general practice.
Quid pro quo
All these ideas were included in NHS England’s recruitment strategy published in January, which received a lukewarm reaction at the time.
And after these ‘offers’ to GPs, he revealed the quid pro quo, saying: ‘So, plenty of commitments from me. But now perhaps the more tricky part: your side of the bargain.’
He said practices needed to improve ‘the quality and continuity of care for vulnerable patients’ and deliver ‘better access, seven days a week, for everyone’.
Mr Hunt added that opening seven-days a week was ‘much more than convenience… it is about making sure precious hospital capacity is kept clear for those who really need it.’ But he failed to explain how a 40% increase in GP opening hours could be afforded, other than mentions of ‘local solutions’.
He also chose not to mention that, as Pulse has reported, several seven-day GP access schemes have been scaled back or scrapped altogether recently after either proving unpopular with patients or failing to reduce the pressure on A&E departments.
GP practices would also be given a ‘scorecard’ of their clinical outcomes to compare them on how they are treating their most vulnerable patients. GP leaders compared this to the CQC’s disastrous attempt to risk-rate practices under its ‘intelligent monitoring’ scheme.
The whole speech left GPs wondering why they had believed the Government would listen to them and change direction.
And with five years of Conservative rule ahead, many are predicting the ‘new deal’ could be remembered as the last straw.
1. ‘£10m’ for struggling practices
He said he had asked NHS England to work with NHS Clinical Commissioners to develop a ‘programme of support’ for struggling practices.
‘This will include advice and support for the practice itself and help for the practice to work with others to change its business model,’ he said.
This initially looked like a small, but significant, announcement, but it later emerged that this was not new money, and would be taken from the £750m of premises funding already promised for primary care over the next four years.
He also said that £7.5m of this funding would be used to support community pharmacists with ‘training and appropriate tools’ - although it was later revealed that this would all go to giving pharmacists access to summary care records, which was a previously announced policy.
But Dr Dean Eggitt, chair of Doncaster LMC, said: ‘We are not looking for sticking plasters, we are looking for long-term investment, so we can continue long-term viable businesses. The £10m will probably go as far as paying the consultancy firm fees.’
2. Practices to be rated on outcomes
Practices will be given a ‘scorecard’ to rate how they treat their most vulnerable patients as part of Mr Hunt’s ‘new deal’. A review into how this will be delivered will be led by Dr Jennifer Dixon, chief executive of the Health Foundation, with input from the CQC and NHS England.
The Health Foundation says the review will be completed by September and ‘may be used by the Government to develop a “scorecard” of indicators for each GP practice to be published on the MyNHS website’.
The think-tank adds that the review will look into whether such indicators will help practices improve quality, and whether they would enable patients to gauge the quality of care.
But GP leaders warn that this is what the CQC hoped to achieve with its ‘intelligent monitoring’ scheme, which quickly ran into problems with its comparative data.
Dr Andrew Green, chair of the GPC’s clinical and prescribing subcommittee, says it will be difficult to extract ‘useful information’ on outcomes. He adds: ‘We have seen with CQC the trouble that organisations can get into if they approach such figures in a simplistic way.’
NHS England has already published data revealing the number of GPs per thousand patients at practice level.
But Pulse contacted a number of practices with particularly low rates and they said the figures were wrong, warning they could suffer if patients believe they have fewer GPs than they actually have.
3. 10,000 more primary care staff
Jeremy Hunt reiterated the Conservatives’ manifesto pledge to increase GP numbers by 5,000 by 2020, and announced 5,000 additional practice staff – including nurses and physicians associates – would be added to this target.
He made a specific pledge on physician associates, saying the Government planned to introduce 1,000 new physician associates into general practice by 2020.
But in the Q&A session after his speech, Mr Hunt muddied the waters on his pledge to recruit 5,000 new GPs, suggesting there may be some ‘flexibility’ built into this.
‘We are leaving some flexibility because in some parts of the country it is very hard to recruit GPs,’ he told the audience. Mr Hunt has since confirmed that 5,000 is the ‘maximum’ figure he thinks is achievable.
The GPC was quick to emphasise the implications of the health secretary’s change in tack. Chair Dr Chaand Nagpaul said: ‘With such a limited workforce, he now needs to rethink his plans for seven-day services, which cannot be practically delivered with the current shrinking numbers of GPs.
‘There must also be serious steps taken to address the fundamental reasons why doctors do not want to be GPs, including delivering real and sustained investment to struggling practices, countering the negative stereotypes of GPs, reducing the burden of bureaucracy and enabling GPs to spend more time with patients.’
The health secretary had little else new to say in his ‘new deal’ about the workforce crisis in general practice, merely repeating many of the policies already announced by NHS England in January.
These included a marketing campaign to encourage medical students to join general practice, allowing trainees in under-doctored areas to do a year’s placement in a relevant specialty and a retention plan for older GPs to be worked out with the BMA and RCGP.
Mr Hunt also supported the plan to offer financial incentives, or ‘golden hellos’, for GPs to work in under-doctored areas, although Pulse has reported that a scheme in Leicester has had to be dropped because it failed to attract enough applicants.
The health secretary also said he was rolling out a ‘pre-GP year’ for graduates who had failed the GP training entrance criteria that year, to help build their skills. He claimed a scheme in the Midlands had an ‘82% success rate’. But Pulse revealed that this was based on a mere 14 graduates taking up the 17 roles on offer last year.
4. Expanding seven-day GP access
The GPs’ side of the ‘new deal’ – as set out in Jeremy Hunt’s speech – is for practices to join the 2,500 pilot sites already trialling seven-day access to routine appointments.
But the health secretary gave little detail about how this would happen in practice, instead saying that there will be different local solutions to achieve the Tories’ manifesto pledge of nationwide access to seven-day services by 2020.
He did, however, claim that seven-day services involved ‘much more than convenience’, saying they were also about freeing up ‘precious hospital capacity’, citing ‘clear evidence’ from Imperial College London that a lack of access to GPs at weekends results in more urgent hospital admissions.
But a Pulse investigation has revealed that even pioneers are getting cold feet, with the pilots of the ‘Challenge Fund’ – the Prime Minister’s £150m investment to support seven-day services – already rolling back on their commitments due to poor demand.
NHS Hambleton Richmondshire and Whitby CCG dropped its scheme to provide Sunday access, just four months after it was fully rolled out.
In Hertfordshire, the Watford Care Alliance network – specifically cited in Mr Hunt’s new deal speech – has already slashed Sunday appointments after they were ‘frequently empty’.
NHS Kernow CCG has already stopped some Sunday services, with a spokesperson telling Pulse that various projects ‘reported much lower use on Sundays than on Saturdays and in those cases the pilots have stopped offering a Sunday service’.
Outside the Challenge Fund, a seven-day pilot in east Kent – funded by resilience winter pressures money - was discontinued after local commissioners found it had not helped to reduce pressure on its urgent care services.
But there have been successes, claims NHS England. It says schemes in Morecambe, Derbyshire and Nottinghamshire, Brighton and Hove and in the Care UK super practice in Colchester and Clapham, south London, have increased opening hours as demand has picked up.
In Manchester – the first area to roll out seven-day access and a blueprint for Challenge Fund projects – NHS England has claimed a success as commissioners extended the scheme.
The independent evaluation of the scheme showed an overall 3% reduction in A&E attendances compared with other areas of Greater Manchester, although this was driven by only two of the four areas offering seven-day access.
GPC chair Dr Chaand Nagpaul may have used his LMCs Conference speech to rail against the ‘political pipe dream’ of seven-day access, but the health secretary is determined to press ahead.