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GPs buried under trusts' workload dump

In full: Pulse's Q&A with Matt Hancock

Health secretary Matt Hancock is grilled by Jaimie Kaffash on his approach to primary care, recruitment and NHS pensions. 

matt hancock 03 580x387px

matt hancock 03 580x387px - by Pulse photographer

Source: Pulse

JK: One thing we noticed with the long-term plan was a lack of detail on recruitment. GPs say you can’t really have a long term plan without looking at recruitment. The last figures said that there were 387 fewer full time equivalent GPs than in September 2015. Can we definitively say the target for 2020 is going to be missed now?

MH: Well, the target of 5,000 more GPs than the 2015 figure exists and we’re going to meet it. Clearly the timing of that will be slower than was originally envisaged - before my time - but what matters is making sure that we get that figure reached. It’s interesting that you talked about it in terms of recruitment. It’s very much a matter of recruitment and retention because the recruitment in terms of training is actually going quite well. We’ve got record numbers in training - we beat the target for the numbers in training - the challenge is retention because a combination of people retiring and people moving from full time to part time has reduced the full time numbers.

JK: So what kind of timescale we looking at now?

MH: The plan is on the basis of five years. I would hope that we can meet the 5,000 goal much sooner than that. We haven’t put a date on it. We’re just getting on with it.

JK: So you’re saying much sooner than five years from now?

MH: Yeah absolutely, yeah.

JK: Can we actually implement the long term plan without these new GPs?

MH: GPs are the bedrock of the NHS and the long term plan is predicated on reducing demand for expensive hospital treatments by having more support for people in the community and trying to keep people healthy in the first place. Hence the £4.5 billion for community and primary care. This is the biggest uplift within the plan, and when you put £4.5 billion into an area then you are going to need more people. That’s true across the whole NHS.

About 70% of current NHS spend is on people, so when you’re putting in the whole £20bn you’re going to need more people. That means holding on to the brilliant people we’ve got and it involves recruitment, both at home and internationally. All of these things matter.

The next stage is the implementation plan and the workforce implementation plan is a critical part of that. The training budgets will only be settled in the spending review - and we in this department are not responsible for the timing of that - hence the need to have the next stage. I essentially see the next year as a transition year to the long-term plan. It’s a transition year in the acute sector because they’re being given a one year budget this year and then a four year budget from next year. We’ll take the next year to listen to clinicians, to talk to GPs and others in primary care to get the workforce plan right and the implementation so that it works on the ground.

JK: Sorry to stay on recruitment, I realise there is going to be another plan coming out, obviously for GPs this is the biggest issue by quite a long way - recruitment…

MH: And retention!

JK: And retention sorry yeah, when I say recruitment…

MH: I think this has been part of the problem in the past. We talk about recruitment and then the focus goes on training. That has gone quite well and I’ve arrived to find a target that is higher than ever and then us exceeding that target. I think that’s terrific in terms of the numbers of GPs. The recruitment of non-GP practice staff is also on track and going very well. This is about GPs having more support in their practices so that they do the task that they are trained for and others can do tasks that don’t need the depth of training that GPs have. More on recruitment, yes, but let’s also focus on retention.

JK: But there has still been quite a bit of focus on retention already, there was a retention scheme brought in a couple of years ago agreed with the BMA a couple of years ago. What is it that you’re going to do that is different?

MH: There are two ways of doing this. The number one concern brought to me by GPs is workload, which is in a sense is circular, because poor retention leads to problems of workload. You have to get under that. The biggest concern I have raised with me is around the tax treatment of pensions. Of course tax is a matter for the Treasury but I’ve had conversations with the Chancellor about looking at the details of tax treatment of pensions because I understand the impact that it has.

JK: That’s a really interesting point. Is that with regard to NHS pensions, GPs’ pensions or is it pensions taxations in general?

MH: I’m not going to go into the details of the conversation because we’re not ready to publish anything on it. I know how important it is and I’ve being having discussions with colleagues about it. The next question of course is also the model of partnership and how we have a financial structure that works in the modern age. As property prices have risen, the partnership model has been beneficial on the property side, but this is now a problem for new partners rather than a benefit. I look forward to Nigel Watson’s partnership review for recommendations on how we can ensure the partnership model and different models, many of which are discussed in the LTP, can really be made to work for GPs.

The number one concern brought to me by GPs is workload

JK: So are we looking to tackling idea of ‘last man standing’ when GPs are left with premises liability?

MH: It’s something I’m very concerned about. I’m looking forward to Nigel Watson’s review coming out very soon and the recommendations that we’ll take seriously. [The review has since been released]. ‘Last man standing’ is an issue. There’s also the idea of switching to a mutual rather than a partnership model which some partnerships have done and done very effectively, where all members of staff are involved and the individual asset ownership is less of a problem. We’re bringing in the changes on indemnity but of course the liabilities on a partner are broader than just the medical indemnity, so all of those questions are in scope.

JK: Speaking with GPs, there’s a concern the state funded indemnity scheme is going to come out of GP’s core funding. Is that a discussion you’ve been having?

MH: NHS England are leading on that because it’s intimately tied with where the next GP contract ends up because clearly the costs of indemnity have been rising sharply. Those costs have to fall somewhere. Our goal is to stop the rise in those costs and I very much hope that we can support GPs in making sure that system works far better in the future.

The exact nature of where the future liabilities and cost sits as opposed to the risk is tied to the negotiations around the GP contract. Crucially, the GP contract negotiations are also about incentivising and supporting modern ways of working, and the primary care networks that the Long Term Plan wants to roll out across the board. We are absolutely taking on the risk and trying to stop these rises year on year. We’ve got to work out where the cost of that falls.

JK: Now we’re on funding…You’ve announced £4.5b on primary and community care. How much of this funding will be linked to GPs providing more services?

MH: Well the first thing is we need GPs to be able to provide the services that people expect in the first place. It’s too difficult right now for patients to see their GP and we need to change that. That’s first and foremost.

However, it’s also tied to the need to reform the ways of working, both in terms of movement to networks but also making sure there’s a whole group of people to support the patients at the right level. I was struck by a figure when I first arrived as health secretary that in a hospital setting, for every doctor there are two nurses, but in primary care there are two doctors for every nurse. You don’t necessarily want the figures to be exactly equivalent because the settings are different by their nature. Nevertheless, there are lots of things that can be delivered by other health professionals that currently GPs do, freeing up GPs to make the interventions that their full training is needed for. GPs tell me this all the time. I get it from GPs but it’s clear from the system as a whole. So the extra money is about making it easier to deliver the services that GPs want to deliver and should be able to deliver now and relieving that pressure and also supporting them to move to new ways of working.

JK: Just reiterating that. Some of that money will be for relieving pressure now…

MH: Absolutely! I get the fact that there is too much pressure now on primary care and on GPs. And some of the money is specifically aimed at relieving that pressure and ensuring that it’s easier for a patient to see their GP and trying to take some of the pressure out of that system. It is an improving access to GPs and therefore reducing the burden is an important part of that.

I get the fact that there is too much pressure now on primary care and on GPs. Some of the money is specifically aimed at relieving that pressure and ensuring that it’s easier for a patient to see their GP and trying to take some of the pressure out of that system. Improving access to GPs and therefore reducing the burden is an important part of that.

 It’s too difficult right now for patients to see their GP and we need to change that

JK: Is that mainly going to be in terms of seven-day working?

MH: It’s more broad. I’m very pleased with the way that the seven day access standard has now been delivered. It’s been delivered six months early. And I’m glad about that. It isn’t about pushing further in that space. I regard that as a goal achieved. It’s about making sure that services are more widely available across the board. Now, of course there’s another part of this that people know that I’m interested in, which is different ways of access both in terms of what patients want and expect in the modern world and also in a way that can reduce pressure on GPs. If you talk to GPs who already use digital solutions, they wouldn’t go back. It can be much more efficient as well as benefitting patients.

JK: One thing we hear repeatedly from GPs is that the idea of seven day access and digital consultation means that we’re just creating more demands. We’re saying to patients, ‘we can give you everything you want’. Most GPs would say that we should be giving them what they need.

MH: Yes.

JK: Is there a risk that the LTP is going to be creating more demand?

MH: I don’t want us to see us stoking up demand. I want to be reducing the pressures of demand. Good high quality use of modern technology and access can help to solve this problem. At the moment people find it very hard to access their GP, and one of the results of that is more people going to A&E, which is a much more expensive setting so that doesn’t help at all. The idea that having to wait to get a GP appointment helps with managing demand is completely for the birds because it leads to people shipping up to A&E which is much more expensive. You’ve got to look at the whole system.

Take 111 for example. Lots of people worried when 111 was introduced that it would increase demand because it’s easy to access. But high quality assessment of the patient’s need means that 111 has reduced - according to the surveys that have been done in a pretty scientific way - the demands for access to A&E even though the 111 service sometimes directly suggests going to A&E . Primary care has to be more discerning in terms of access, and sometimes I entirely understand how on the frontline that is tough because that’s saying to someone that they do not need to see a GP - they can see a nurse or a pharmacist. Or indeed they’re going to get better. So I get that.

JK: Would that be the responsibility of GPs or practices themselves to say ‘you don’t need to see a GP’?

MH: If that is their clinical judgement, absolutely yes. One of the things I’d like to do is support the primary care system as a whole as much as possible to be clear to people when something might be their personal responsibility rather than needing an NHS intervention. Good GPs are brilliant at this. They are some of the best people in the world at empathetically explaining to people that no further intervention is necessary. Empathetically but firmly in many cases! But I know that there are pressures of society and pressures of expectations from patients – ‘I’m here for a drug and I’m not leaving till you prescribe me something’ - and we need to make sure the system has the permission and the capability, when the clinical judgement that no further intervention is necessary, to be able to say that. This also is about who you see when you go into primary care because I know that some people fully expect to see a GP for some things that you don’t need to see a GP for and could easily see a pharmacist say for a prescription or a nurse for a minor ailment. We need to be clear to people - and I’m happy to play my part in this - to explain to the population that there is a shared responsibility here for the discerning use of the NHS. We all have our responsibilities.

JK: That’s a really good point. How you going to do this, how you going to tell patients to think about their responsibility to the NHS?

MH: I certainly hope to lead that in the national debate, talking about how both the NHS has responsibilities to care for us when we need it but we all have responsibilities to the NHS to ensure that it’s sustainable and that we don’t put undue burden on the health service. I do think that technology can help in this space. It’s about being clear to people in advance about what they can and can’t expect. As health secretary, I will always support GPs to make the clinical decision that somebody doesn’t need NHS support if that is their view.

 What you need to do is not reject the technology but change the rules so they work fairly for everyone

JK: Just moving on slightly. Do you regret some of your statements about Babylon in the past?

MH: No! I’m a big supporter of technology in the NHS. I’m delighted that companies are investing money in the UK and I’ve always been clear that what I care about is modern technology being used effectively.

JK: Of course a lot of people including RCGP have picked up on what Babylon has done to general practice in general - they are cherrypicking the young, healthy patients…

MH: That absolutely needs dealing with. Even when I’ve been talking with Babylon I’ve been clear on this point. If the rules don’t work with new technology, for instance the idea that all Babylon patients are registered in one practice in Hammersmith & Fulham, what you need to do is not reject the technology but change the rules so they work fairly for everyone.

JK: And that is something you’re looking at?

MH: Absolutely. Having a level playing field for practices is incredibly important to me. I think what happened is this: in the past, the location of the GP practice was a decent enough proxy for the location of the patient, that the geographic allocation of resources could reasonably follow the practice location. However, when you have a practice claiming that that address is the GP’s surgery for tens of thousands of people who live all over the city, in this case London, then clearly the rules need to change to address that. I’m very excited that there are so many other people coming forward with technological support for GP practices and I hold no brief for any individual company. What I want is technology to support clinicians and support patients and address the user need. That’s what matters to me.

JK: Theresa May has repeatedly said that leaving the EU has given us the funds to be able to support the long term plan. Is the £20.5 billion dependent on us leaving the EU?

MH: The £20.5b increase is guaranteed in all Brexit scenarios. So the budget for the NHS has been set, I’ve set out the cash totals to parliament this week, rising from £115b this year to £148b in 2023/24.

JK: Thanks a lot

Readers' comments (1)

  • Matt and that ‘Charlie’ from ‘The Thick of It’ would make a sublime double-act?

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