Editor Jaimie Kaffash deciphers what NHS England’s letter on the contract really means for the profession
Yesterday, NHS England laid out its changes for the 2024/25 contract. It is an imposition – like last year, it hasn’t been agreed with the BMA GP Committee.
The BMA will ballot GPs on whether to take further action, with industrial action later in the year a distinct possibility. But with no more negotiations on the horizon, this will be enforced from April 2024.
We take a look at what it means for practices.
FINANCIAL ASPECTS
The total increase in funding for general practice in England will be 2.23% next year – an increase in investment of £259m taking overall contract investment to £1,186m. However, it is highly unlikely that the global sum will increase by this much. NHS England gave a breakdown of how it calculated the £259m funding increase:
- 2% pay increase for all GPs and practice staff – which it said could increase once the DDRB has given its recommendations;
- 2% uplift to the ARRS;
- 1.68% inflation – which it claims is in line with the Government’s November 2023 GDP deflator;
- 0.38% ONS population growth.
This is all pretty bad news for GPs and practices. The £259m extra incorporates the population growth, which means that much of this funding will be covering the extra patients, and won’t increase payments per patient.
As well as this, the way the staff portion of the funding is calculated has been criticised by some GPs as being unrealistic – so if the DDRB does recommend increased pay for GPs and staff, the funding boost may not cover them, therefore eating into practice funding.
The upshot of all of this is that the increase in the global sum is – at best – going to be around 1.68% that is ‘in line with the Government’s November 2023 GDP deflator’.
But it is on this final point where the real scandal lies. Because anyone who has turned on the news, or had to pay a bill of any kind will know that there is a cost-of-living crisis due to inflation way beyond 1.38%. And even if it is argued that inflation is slowing, general practice missed out on inflationary increases in the past couple of years due to the five-year funding agreement from 2019.
As a further kick in the teeth, NHS England have said that any unspent ARRS money will be clawed back – with no commitment to keep it in general practice.
This obviously has gone down badly with GPs, the GPC and accountants. GPC England chair Dr Katie Bramall-Stainer said the ‘GP business model is now non-viable’, adding that this is ‘an intentional, predetermined, strategic, non-evidence based, ideological dismantling of NHS general practice’.
Andrew Pow, board member of the Association of Independent Specialist Medical Accountants, said ‘This is a disappointing announcement and the third year running when uplifts in the value of the GP contract have been significantly below inflation. While the contract is based on an assumption of 2% pay growth for staff, practices face significantly higher wage growth from April as a result of the near 10% increase in the minimum wage. This will also filter through to other pay bands.
‘The contract uplift allows for inflation at 1.68%, yet inflation is running at 4% in the economy. While energy costs may be on a downward trajectory and loan interest costs have hopefully flatlined, these costs remain far higher than they were a couple of years ago and were not funded in contract uplifts in the previous two years.’
QOF
Andy Pow says that there is good news for practices. Aspiration payments for QOF will increase from 70% to 80%, which will help with cashflow as more money will be paid through the year. Meanwhile, 42% of the QOF indicators will be suspended, with practices being paid for these based on previous years’ performance (though it is unclear which years).
The ‘protected’ indicators include:
- Mental health MH021: Providing physical checks to mental health patients, such as smoking status, alcohol consumption and BMI (6 points);
- Depression DEP004: Reviewing patients with a new diagnosis of depression (10 points)
- Asthma AST008: Recording smoking status of patients with asthma (6 points)
- COPD COPD014: Referring patients with COPD to a pulmonary rehabilitation programme (2 points)
- Smoking SMOK005: Offer of support to smokers with respiratory or certain mental health conditions (25 points)
- Cancer CAN004: Cancer patient who have had a Cancer Care Review in the previous 12 months (6 points)
- Cancer CAN005: Cancer patients who have had the opportunity for a discussion and informed of the support available from primary care, within three months of diagnosis (2 points).
The majority of the protected points come from the disease registers, however – making up 81 points.
But for GPs in reality, this might be a bit underwhelming. The register indicators involve no clinical workload and only minimal administrative workload. Dr Gavin Jamie, a GP in Swindon who runs the QOF Database website, says: ‘The income protection for disease registers is meaningless.’
He points out that the only income protected indicators that will help workload ones are those for cancer.
That said, there is also income protection for the QI indicators, which involve the wellbeing of staff, optimising capacity and reducing avoidable appointments – these are worth 74 points. ‘These do genuinely take up a lot of admin time,’ says Dr Jamie.
The significant changes to the QOF are more likely to come as a result of the QOF consultation, which remains open until 7 March. Dr Jamie adds: ‘I am not sure why there is this “income protection” thing rather than just amending QOF. I suppose that they are keeping their options open for next year. This feels like a holding position!’
ARRS
The major change to the additional roles reimbursement scheme involves the inclusion of ‘enhanced nurses’. If this sounds confusing, that’s because it is.
Currently, advanced nurse practitioners are part of the ARRS. ‘Enhanced nurses’ is not a particularly well known term in general practice. As our sister title Nursing in Practice has reported, it is not currently a job role recorded by practices or PCNs for workforce data collection and there are no further details from NHS England about the new ARRS role at present. A core capabilities framework states that they are a level above registered nurses and below advanced and consultant level practice nurses.
It is likely that these are therefore going to be experienced practice nurses with a specialism in long-term conditions – but this remains speculation.
The other main change – other than the removal of unspent ARRS money – is the removal on caps on numbers of ‘direct patient care roles’ that ARRS money can be used for. These include ANPs, pharmacist, physiotherapist, paramedic, occupational therapist, dietitian or podiatrist.
Although, of course, the bigger problem is that the funding hasn’t increased beyond the not-even-inflationary rise. And an even bigger problem is that, despite the GPC’s (and Pulse’s) call for GPs to be included in the ARRS, they have not done this.
DATA AND CONTINUITY
Despite the contract letter lauding the cutting of red tape, NHS England can’t help itself, with more data collection requirements.
Practices will be required to provide data on eight metrics through a national data extraction, for use by PCN clinical directors, ICBs and NHS England: call volumes; calls abandoned; call times to answer; missed call volumes; wait time before call abandoned; call backs requested; call backs made; average call length time. This shouldn’t lead to greater workload, but this continues NHS England’s focus on access and could lead to practices facing more awkward questions.
Alongside this, there are new requirements around workforce and vaccinations data, while practices will be expected to produce a digital copy of their practice boundaries.
At the NHS Confederation conference yesterday before the contract was announced, NHS England primary care director Dr Amanda Doyle said that continuity of care will form part of the contract in future years. Later that day, it transpired she meant 2024/25. The letter says: ‘GP contract regulations will be amended to explicitly require continuity of care to be considered when determining the appropriate response when a patient contacts their practice.’
We will have to wait for the upcoming contract documents to see how they will measure and enforce this.
PCN DES
One of the ‘carrots’ given by NHS England has been simplifying the PCN DES by merging eight of the service specifications – medicines optimisation; enhanced health in care homes; early cancer diagnosis; social prescribing service; CVD prevention and diagnosis; tacking neighbourhood inequalities; anticipatory care; and personalised care – into one ‘simple overarching specification with a greater outcomes-focus’. The only separate service specification will be enhanced access.
It is not clear why this has been done, or what the agenda is behind this. The ‘greater outcomes-focus’ looms large. Until we receive the NHS England guidance, we will be none the wiser.
There have also been major changes to the Investment and Impact Fund (IIF) indicators (ie, the PCN equivalent of the QOF). They have been reduced from five to two – with those relating to flu and access being ditched, and those relating to learning disabilities and cancer remaining.
The funding from these retired indicators has been put into the Capacity and Access Payment, which requires PCNs to provide digital telephony, simpler online requests and faster care navigation.
There are changes to the clinical director role: funding will be rolled into core PCN funding, and there responsibilities are defined as ‘co-ordination of service delivery, allocation of resources, supporting transformation towards Modern General Practice and supporting the PCN role in Integrated Neighbourhood Teams’.
PERFORMANCE LIST CHANGES
The performance list flexibilities that were brought in during Covid. The letter says: ‘Supporting guidance will also be issued to clarify that non-GP doctors should not see undifferentiated patients, and that they continue to be required to operate within their sphere of competence.’
It adds that these changes will ‘permit GP practices and PCNs to employ doctors who are already employed, for example, by an NHS trust, NHS foundation trust or health board without the requirement for the doctor to also be registered on the medical practitioners list’.
This seems to open up the path for staff and associate specialist doctors to be employed by practices and PCNs (although they are not – as yet – part of the ARRS).
Yet the requirement that they should not see undifferentiated patients seems to prevent them from working in traditional general practice. And GPs might be forgiven for questioning why SAS doctors are not allowed to see undifferentiated patients, yet physician associates are…
WHAT IS NEXT
The BMA will put the contract to the profession next week. As it has been imposed, they will recommend that GPs vote against it (and it will be a huge surprise if ‘Yes to the contract’ polls 1% or above).
This won’t be news to NHS England, and with such a poor offer – especially in terms of funding – they are unlikely to negotiate to anything near what would be acceptable to the GPC negotiating team. GPC chair Dr Bramall-Stainer has said she expects the process to lead up to a general election in autumn, and the GPC leadership is not afraid to call for industrial action.
We have a long summer ahead.
