The mid-2010s saw some big promises from the Government. Emma Wilkinson and Jaimie Kaffash look back on whether they were fulfilled
A read through the 2016 General Practice Forward View is a disconcerting experience given that both everything and nothing appears to have changed all at once.
Alongside health secretary Jeremy Hunt’s New Deal for general practice announced the previous year, GPs were promised things would be different.
The plans promised that years of underinvestment would be overturned, the GP workforce and wider team would grow dramatically and box-ticking and endless bureaucracy would come to an end as would workload creep from secondary care.
Many GPs feel overwhelmed by demand and undervalued by the system, Hunt said at the time, leading to burnout and early retirement. Effective, strong and expanding general practice was ‘needed now more than ever’. So how successful were his pledges?
What was promised
- A substantial investment of a further £2.4 billion a year by 2020/21 would push general practice from 8.6% of the total NHS budget to more than 10%.
- The Carr-Hill formula would be scrapped, and in its place would be a better way to capture practice workload, deprivation and rurality.
The 2019 contract did, in fact, lead to a £4bn a year increase in investment in general practice (£3bn when excluding the costs of Covid).
However, as our table shows (see below), it didn’t quite reach 10%, although NHS England could point to the effect of Covid here. NHS England data also show there were real-terms increases
So in fact, Mr Hunt did almost stick to his word when it came to increasing funding. But it is important to note that this came after years of real-terms cuts and much of the increased investment came with prescriptive demands, such as having to join primary care networks and having to use funding on approved additional roles.
Meanwhile, the plans to scrap the Carr Hill formula led nowhere, with the RCGP calling for this again just six months ago. Maybe the 2024 contract negotiations will change this, but there is no guarantee. The problem remains that any change will see losers as well as winners.
What was promised
- An extra 5,000 additional doctors working in general practice by 2020, a number that was later revised up to 6,000.
- A minimum of 5,000 other staff working in general practice by 2020/21. This five-year programme was to include investment in an extra 3,000 mental health therapists to work in primary care by 2020, which is an average of a full-time therapist for every two to three typically sized GP practices.
The pledges around GPs have failed miserably. By the end of 2022, the number of fully qualified full-time equivalent GPs had fallen by 1,884 compared with 2015. Even when using NHS England’s preferred definition – doctors in general practice, which incorporates trainees – there has only been an increase of 2,200 since 2015.
Across the wider workforce, there have been decent strides made. A £31m pilot scheme for the deployment of 470 clinical pharmacists outlined in the Forward View proved successful and has now been superseded by the Additional Roles Reimbursement Scheme (ARRS).
In December there were 18,221 additional roles staff working in general practice, including 1,642 pharmacists. Almost two-thirds of the promised 1,000 physician associates are now in post.
Other roles are harder to track. Mental health practitioners are now included in the Network DES but are as yet uncounted. GPs report that as mental health services struggle to cope post-pandemic, they are having to manage patients despite their problems being beyond GPs’ competence.
A long called-for independent workforce strategy for the NHS is now finally set to materialise later this year, but we do have much better data now. One of the point the King’s Fund made in 2016 when looking into the causes of the ‘crisis’ in general practice was there was no way of knowing how many consultations were happening or the nature of those consultations.
The monthly data now published show demand spiralling beyond anyone’s expectations, with 361 million appointments delivered in primary care in 2022.
These pressures, with no break after a gruelling pandemic, are perhaps partly to blame for several proposals designed time to attract and retain experienced GPs back into general practice failing to have the desired impact.
Mental health support
What was promised
- The GP Forward view promised £16m extra investment in specialist mental health services to support GPs suffering with burnout and stress
Chief executive of NHS Practitioner Health Lucy Walker said not only was the funding provided, it has also been extended. The programme for burnt-out GPs and other doctors is funded until 2026 and when clinicians do seek help, it works, she notes: ‘There is a really good recovery rate.’
The programme has had about 9,000 GPs come through the service in total but recently there has been a real spike in those – not just GPs who make up 40% of their caseload – asking for help. By the end of 2021 it was a third more than they have capacity to deal with, Ms Walker said. Those who are seeking help from the service now are some of the ‘most resilient’, who are simply overwhelmed.
What was promised
- A whole chapter of the Forward View was dedicated to addressing bureaucracy and paperwork. The main pledge was to stop ‘workload dump’ from secondary care – especially where hospital doctors would send patients back to GPs for referrals to other departments, but also where GPs were treated as house officers by being asked to do bloods, for example. This was to form part of a new standard contract for trusts.
- To further reduce the burden on practices, the CQC would reduce the workload related to inspection, particularly for those practices rated ‘good’ or ‘outstanding’, and a successor would be found for the QOF, which would be replaced with more ‘holistic team-based funding’.
Cut to a post-pandemic world in which hospitals are under great pressure to clear a growing elective backlog and once again GPs are having to battle against workload dump. Anecdotally, GPs say that it is worse than ever.
Cambridgeshire LMC chief executive Dr Katie Bramall-Stainer said they had issued pushback template letters for GPs amid a ‘tsunami’ of secondary care workload transfer.
Any efforts to simplify the primary-secondary care interface may have been further complicated by the growth of ‘advice and guidance’ schemes, which have meant further workload and duplication for general practice as a third of GPs says the approach is preventing patients who really need a referral from getting one.
Writing in Pulse in November, former BMA council chair Chaand Nagpaul said the ‘dysfunctional’ primary-secondary care interface is ‘time-sapping’ and harming the quality and safety of patient care.
In 2020, the Government published eight priority areas for action on bureaucracy suggesting little progress had been made in the intervening years.
In fairness, the CQC has reduced inspection frequency for ‘good’ and ‘outstanding’ practices, but GPs still find inspections burdensome.
Working at scale
What was promised
- One striking aspect of the 2015 and 2016 plans is the absence of the term ‘PCN’. Yet the Forward View is where the concept of greater working at scale started, particularly in relation to extended access (anyone remember multispecialty community provider contracts?).
- Seven-day access was a key feature of Hunt’s New Deal, with networks of practices offering evening or weekend appointments. Improved in-hours and out-of-hours care, clinical hubs and reformed urgent care are all aspects of the Forward View where progress does seem tangible.
Although we didn’t see much more of the MSC contracts, they certainly delivered on working at scale – although the PCNs that emerged as a result haven’t been universally welcomed.
As part of the PCN contract, there is routine Saturday service from 9-5 at a network level.
What was promised
- Last but not least premises. ‘We will go further faster in supporting the development of the primary care estate’, NHS England said, with £900m over the course of the next five years. On top was funding to improve IT, Wi-Fi services and stimulate uptake of online consultations systems for every practice.
GPC premises lead at the BMA Dr Gaurav Gupta notes the easiest way to see how much has been achieved in improving the infrastructure of GP surgeries is to visit one.
‘The vast majority [of premises] are completely inadequate and directly impacting our ability to provide high-quality patient care,’ he says. That investment has not kept pace with the scale of demand GPs are managing or the extra ARRS staff working in their teams, which was ‘not properly thought through’, Dr Gupta adds.
‘We have had heard endless promises from the Government about plans to improve the GP estate, but solutions are often just sticking plasters and ensnared in endless bureaucratic processes, making it harder for practices to get the help they need.’