The health secretary’s vision for general practice
Jaimie Kaffash grills health secretary Matt Hancock on his approach to primary care following the publication of the NHS long-term plan
matt hancock 06 580x387px - by Pulse photographer
Few GPs would have heard of Matt Hancock before July of last year. Our only clue about how he sees general practice has been his Tigger-like enthusiasm to accelerate its use of technology. This is the man, don’t forget, who launched an eponymous app.
So when Pulse speaks to him just days after the publication of the NHS’s 10-year strategy – his first interview with the trade press since then – it feels significant. Because his tenure is likely to define general practice for decades to come.
Mr Hancock is a ball of energy. There is a cricket bat nearby, which he is known to use for impromptu net sessions in the office. He seems characteristically upbeat – not surprising given the reaction to the plan, which knocked Brexit off the front pages for a few days. And primary care is central to the plan.
‘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,’ Mr Hancock says. ‘Hence the £4.5bn for community and primary care – this is the biggest uplift in the plan.’
The interview throws up good and bad signs. GPs may be wary of the idea that other healthcare professionals will solve the workload crisis, and will be angry at hints that the state-funded indemnity scheme will be paid out of the global sum. Mr Hancock’s heavy focus on technology may also be a source of frustration; he is unrepentant about his positive comments on private company Babylon that infuriated many GPs.
A more realistic approach?
But there are also positive signs suggesting that, unlike his predecessor, he does not wish to pick a fight with GPs. He accepts the deadline for increasing GP recruitment is unachievable, acknowledges the problems with ‘last man standing’, and – most surprisingly – reveals he is in discussions with the Chancellor to reform the pensions tax rules that drive many GPs to early retirement.
But there’s no doubt the main focus is on the long-term plan and the funding uplift. And the £4.5bn is a significant investment – totaling 21% of the £20.5bn annual increase in NHS funding by 2023/24 – and includes a bonus £1bn on top of the £3.5bn announced by Theresa May in December last year.
Much of this funding is earmarked to support the rollout of ‘primary care networks’ – large groups of practices covering 30,000-50,000 patients each. This will even form part of the 2019/20 GP contract, trailed as the ‘biggest GP contract reform since 2004’. Until its release – expected early this month – we don’t know exactly how this will work, and there are real concerns for those practices that, due to geography, or other local factors, are struggling to join a network. Indeed, even those that are part of a larger organisation worry they might not be classed as a ‘network’ when the contract comes to define it.
For all GPs, though, there is a more pressing matter – will they receive any of the funding now to relieve the huge pressure on practice?
‘Absolutely,’ Mr Hancock exclaims. ‘I get the fact that there is too much pressure 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.’
GPs could be forgiven for their cynicism. They’ve been here before, with funding inevitably tied to providing extra services and uplifts to the global sum nowhere near what is required.
And there are indications that this might again be the case this year. The BMA’s GP Committee and NHS England are in dispute over whether the new state-backed indemnity scheme will be funded from the global sum. If the Government does raid the global sum to fund the scheme, could it claim to be serious about easing the pressure on GPs?
On this Mr Hancock provides little reassurance: ‘Those costs have to fall somewhere. Our goal is to stop the rise in those costs and I very much hope we can support GPs in making sure that system works far better in the future.’
GPs are the bedrock of the NHS
So if something as vital as indemnity costs isn’t funded, how will the pressure on GPs be relieved? Mr Hancock suggests it will be through support from other healthcare professionals – not exactly what GPs would want to hear.
He says: ‘I was struck by a figure when I first arrived as health secretary that in a hospital setting there are two nurses for every doctor. But in primary care, there are two doctors for every nurse. There are lots of things that can be delivered by other professionals that GPs currently do.’
This might not be what GPs want to hear, but it might also just be an acknowledgement of the state of GP recruitment. But recruitment barely features in the long-term GP plan beyond vague notions of networks and technology appealing to young graduates. GPs will have to hope for greater detail in the workforce plan, due later in the year.
Since the 2015 pledge to increase the GP workforce by 5,000 by next year, the number of full-time-equivalent GPs has shrunk by 387. At least we can finally put that deadline to bed.
Deploying doublespeak, Mr Hancock says: ‘The target of 5,000 more GPs than the 2015 figure exists and we’re going to meet it. Clearly the timing will be slower than originally envisaged before my time.’
Will there be any timescale? ‘The workforce plan is on the basis of five years. I would hope we can meet the 5,000 goal much sooner. We haven’t put a date on it. We’re just getting on with it.’
Yet there are signs that Mr Hancock is starting to appreciate the recruitment crisis. He raises the problem of ‘last man standing’ ahead of the findings of the GP partnership review (released a few days later, see box right). And most surprisingly he brings up another critical area for the profession: ‘The biggest concern I have heard is the tax treatment of pensions. Of course, tax is a matter for the Treasury, but I’ve had conversations with the Chancellor about the details because I understand the impact of that.’
Under current rules, anyone with a pension pot worth more than £1m faces a huge tax hit on additional contributions. For many GPs nearing retirement, continuing to work makes little financial sense. Yet Mr Hancock is willing to take this battle to a reluctant Treasury, despite the risk of negative headlines about tax breaks for higher earners.
Emphasis on technology
Despite these positive words, he has his work cut out if GPs are to forgive his comments last year on Babylon, the private company whose promise of speedy online consultations has seen it hoover up younger patients in London (including Mr Hancock himself). One of his first acts as health secretary was to extol the company’s virtues. Does he regret this?
‘No! I’m a big supporter of technology in the NHS. I’m delighted companies are investing money in the UK. I’ve always been clear that what I care about is technology being used effectively.’
I get the fact that there is too much pressure on primary care and on GPs
How about Babylon’s cherry-picking of younger, healthy patients and its effect on funding of neighbouring practices?
‘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 – you don’t reject the technology, you change the rules so they work fairly for everyone.’
Is that something he is looking at?
‘Absolutely. A level playing field for practices is important to me.’
Compared with Jeremy Hunt’s seemingly endless DHSC tenure, Mr Hancock barely has his feet under the table. No doubt he has learned from his predecessor’s mistakes and is adopting a more conciliatory tone with the profession. But GPs will measure him by how he is able to improve their working lives. A lot rests on the new GP contract.
NHS long-term plan
What is it and what does it include?
Released by NHS England, this sets out how the pledge of £20.5bn a year by 2023/24 should be spent. Many of the changes to general practice will be detailed in the 2019/20 GP contract, with others to be developed by NHS England:
• Increased funding for primary and community care of £4.5bn a year by 2023/24
• All practices to join ‘primary care networks’, which will make a greater use of other healthcare professionals and provide extra services
• Digital appointments to be provided for any patient who wants them by 2023/24
• GPs to be offered ‘shared savings’ for efforts to reduce avoidable A&E attendances, admissions and delayed discharge through their networks (see page 10)
• NHS 111 to book GP appointments directly from this year
What do we know so far?
The contract, due this month, is set to be the ‘biggest GP contract reform since 2004’. We know many of the changes outlined in the long-term plan will be included in the contract, as well as some other major reforms previously outlined:
• Practices will be mandated to join primary care networks, and it is likely that funding will be attached to the networks. The contract will provide full details
• The details of the state-backed indemnity scheme will be revealed. NHS England wants it funded out of the global sum – a move opposed by the BMA GP Committee
• Changes to QOF, which will see a new Quality Improvement (QI) being worked up with the RCGP, NICE and the Health Foundation, as revealed in the long-term plan. The ‘least effective indicators will be retired’
• A ‘fundamental review of GP vaccinations and immunisation standards, funding, and procurement’ in 2019 in a bid to improve immunisation coverage
• A reform of the ‘out-of-area’ rules that have allowed private company Babylon to attract young patients from across London to use their digital services on the NHS to the reported disadvantage of other practices
What is it and what does it recommend?
A review led by Dr Nigel Watson, chief executive of Wessex LMCs and a member of the BMA’s GP Committee, which has made a series of recommendations to ‘reinvigorate’ the partnership model:
• Different legal structures must be made available to partners to avoid the scenario of ‘last man standing’ – a move supported by Mr Hancock – with a call for the Government to review the options and report in six months
• Medical training should be refocused to increase time in general practice and boost understanding of partnerships
• GPs need ‘greater flexibility’ in their pension scheme, such as being able to choose how much they pay in, so they can avoid breaching their annual or lifetime allowances
• CCGs should fund data protection officers to help overworked practices cope with patient data requests