Best Laid Plans 2021/22: Sajid Javid’s punitive measures

The former health secretary’s plans in October 2021 caused shockwaves among the profession. Rachel Carter looks at what happened with the more punitive parts of the plan 

Former health secretary Sajid Javid’s plan for improving GP access in October 2021 followed months of the media bashing GPs over face-to-face appointments. As the row rumbled on, there was hope among the profession that the promised rescue package from the Government would at least offer some support, especially given the rise in abuse from patients. But instead, GPs received what many likened to a kick in the teeth. 

While the £250m funding attached to the plan was not to be sniffed at – and did help practices in some ways – it came with strings attached that could at best be described as performance managing and at worst, punitive. Here we take a look at what became of the measures announced.

The ‘worst-performing 20%’

What the plan said

Under a heading of ‘Tackling unacceptable variation’, NHS England set out that Integrated Care Systems should immediately put together a list of practices deemed to be in the bottom 20% on a range of metrics, including those with overall appointment numbers lower than in the equivalent pre-pandemic months, the lowest levels of face-to-face appointments, the most significant levels of 111 calls from patients during GP hours, and the highest rates of A&E attendances. 

This list – which was unlikely to be more than 20% of all local practices – also had to take account of the need to address healthcare inequalities and be submitted to NHSE by 28 October. Subsequent guidance said ICSs shouldn’t name the practices and instead use anonymised codes to identify them. 

The plan also said that the CQC would provide NHS England with any feedback they had received at a regional practice level, including concerns, complaints and whistleblowing allegations. 

What happened

This list was one of the most heavily criticised elements of the plan, with GPs expressing concern that practices struggling the most would be named and shamed and miss out on much-needed funds. There were also fears that practices that had worked hard to boost digital access – which had very much been the national direction of travel pre the media storm around face-to-face appointments – were now about to find themselves penalised for it.

But, in reality, not much actually happened. Pulse heard anecdotally in January 2022 that some – but not all – commissioners had done away with the list and opted for a different approach. A Pulse investigation reveals this was common. Of the 19 ICBs who responded to a Pulse query, 14 had not submitted the list to the NHSE. Five told Pulse they had submitted an anonymised list of practices. 

CQC access inspections

What the plan said

‘CQC will work with NHS England to support systems in this process and to make the required improvements across those practices which are not meeting people’s reasonable needs. CQC is rapidly developing an inspection methodology with a particular focus on access to GP services. Wherever appropriate, it will make unannounced inspections.’

What happened 

The CQC outlined its framework for access-focused inspections in early December 2021. It was based on eight statements – including whether patients were able to make appointments in a way that met their needs, were offered a range of appointment types, and there were enough staff to provide appointments and prevent staff from working excessive hours. The regulator said at the time that all concerns raised about GP access would be followed up, but not all would result in an unannounced practice inspection. The access-focused inspections would also not result in any rating change. 

A week later, the CQC announced all inspections across health services would be cancelled until January 2022 after ‘alarming’ new data on the Omicron variant and GPs were asked to prioritise Covid boosters over routine appointments. This included the access-focused inspections.

Pulse later reported that the CQC had carried out 40 of the access inspections in November and December before pausing them.

At a CQC board meeting on 19 January the then chief inspector for primary medical services Dr Rosie Benneyworth revealed what many GPs could have guessed: ‘None of the reviews of the locations identified any current issues with patient access.’ A month later, the CQC said it was scrapping these inspections. 

Sanctions

What the plan said

‘A wide variety of actions are likely to be required to resolve the issues: for example, to increase resilience, smaller practices offering unacceptable access may be expected to partner with other practices, federations or PCNs, as an alternative to the application of contract sanctions and enforcement. Where practices do not engage with support and are in breach of their contractual obligation to meet the reasonable needs of their registered patients, appropriate contractual action will need to be undertaken by CCGs/ICS.’

What happened

When asked whether any practices were subject to these actions, NHS England said this information was not available nationally as it was subject to local commissioning discretion. 

Of 10 ICBs responding to a Pulse query, all said that no practices in their area had been subject to such actions. One ICB did however comment that in some cases practices did work with PCNs and GP Federations based on local circumstances, where this was needed to ensure resilience. 

The Access Improvement Programme

What the plan said

NHS England said a new intensive form of its ‘Access Improvement Programme’ (AIP) – which was already working with over 900 practices – would support more than a further 200 practices experiencing ‘the greatest access challenges’. The programme offered onsite support from primary care improvement experts to help practices reduce waits and increase appointment numbers. 

It added that the pace and scale of further rollout of the programme would be determined in 2022.

Further NHSE guidance said the intensive AIP would last approximately 24 weeks and would aim for practices to achieve ‘at least’ pre-pandemic appointment levels, excluding Covid vaccinations. It also confirmed that practices identified for the AIP may also be able to access support via the Winter Access Fund. 

What happened 

NHS England told Pulse that in 2022, 540 practices either completed or are currently participating in the ‘Accelerate’ programme, with a further 165 due to have started in January 2023. It added that hundreds more practices are expected to take this up in 2023/24, supported by their ICS.

Community pharmacist consultation service

What the plan said

The plan said that participation in the community pharmacist consultation service (CPCS) – which saw GPs referring to pharmacies for minor illnesses – was a condition of a practice being able to benefit from the Winter Access Fund. Practices were instructed to sign up for the service by December 2021.

What happened

It’s unclear whether any practices were actually penalised for failing to sign up to the GP CPCS. Since April 2022, the Investment and Impact Fund (IIF) has included an indicator on this scheme, which incentivises GPs to increase the number of referrals they are making to the service. 

NHS England told Pulse that the CPCS received 214,830 referrals from practices in the first six months from April 2022. But when asked whether sign up to the CPCS to receive Winter Access Fund funding was enforced, NHS England said it did not hold this information and that arrangements regarding the funding were subject to local commissioning discretion. 

Measuring patient satisfaction

What the plan said 

‘A new real-time measure of patient reported satisfaction with general practice access is to be rolled out nationally and incentivised as early as April 2022. Patients will automatically receive a message following their appointment and asked a series of questions about how they rate their access to care.

‘As part of plans for PCNs, individual practices will be incentivised under the Investment and Impact Fund (IIF) to improve their rates of satisfaction for 2022/23. The scale of the incentives will be increased significantly in 2023/24 within the planned GP contract envelope.’

What happened

Nothing on the first point. This new real-time measure has not come to fruition. NHS England told Pulse that patient experience and satisfaction continue to be measured through the annual GP Patient Survey and GP Friends and Family test. 

Meanwhile, an IIF indicator – ACC-05 – took effect in April 2022 that required practices in a PCN to use GP Patient Survey results to identify patient groups experiencing inequalities in access to general practice. As part of the indicator, they would also be required to develop, publish and implement a plan to improve patient experience and access for these patient groups, taking into account demographic information including levels of deprivation.

The indicator has however since been retired. In September 2022 NHS England announced it was deferring or scrapping four IIF indicators worth £37m, with the money repurposed and provided to PCNs as a monthly payment to support GP workforce and patient access over winter 2022/23.

NHS England told Pulse that QOF instead continues to support improvements to patient satisfaction through the QI module in 2022/23, which was also referenced in the Winter Access Fund plan – which incentivises practices to make quality improvements that optimise patient access.

Practice league tables

What the plan said

To facilitate self-assessment and local conversations about the access offer, we understand that NHS Digital is working to publish activity and waiting time data at individual practice level as soon as possible. This will include the proportions of appointment by different professions and by different appointment modality. As the new data come on stream, patient-reported satisfaction levels will also be published.

Dr Thérèse Coffey – who had a brief tenure as health secretary from September to October 2022 – also reiterated this pledge in her ‘plan for patients’ which said data on how many appointments each GP practice is offering, alongside appointment waiting times, would be published in November. 

What happened 

The data were published for the first time on 24 November – and the profession’s initial fears that it would lead to naming and shaming, and practice league tables, were fully realised. Media outlets had a field day, with headlines such as ‘Leeds GP practices where its hardest to get a face-to-face appointment’, ‘GPs in Trafford: the 10 GP surgeries with the longest waits to see a doctor after booking an appointment, and ‘The areas where more than 80pc of GP appointments are remote’.  

Two days before the data were released – as part of an annexe to the existing GP appointments data publication (GPAD) – the BMA’s GP Committee for England said it had raised concerns about its accuracy and potential use, and NHS Digital had agreed that further work was required. NHS Digital has made clear that the statistics are experimental and continue to be developed. From April 2023 they are expected to be integrated into the GPAD, rather than being released as an annexe.