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Is this the way forward for general practice?

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The magnitude of NHS England’s support package for general practice – its General Practice Forward View – caught everyone by surprise. 

In the months leading up to it, there had been fears that the package would contain as little as £110m, and would be a damp squib to rival the so-called ‘new deal’ announced by health secretary Jeremy Hunt last year. 

When it came, however, it proved to be an entirely different beast, with Mr Hunt nowhere in sight. NHS chief executive Simon Stevens fronted a ‘turnaround package’ totalling £508m, with details of immediate measures intended to support practices in crisis. 

But this is dwarfed by a massive £2.4bn of extra funding a year promised by Mr Stevens by 2020 for general practice, translating to a 14% overall real-terms increase. This is almost double the funding increase for the rest of the NHS. 

The 60-page document provides headline after headline: the frequency of CQC inspections is to be reduced to five-yearly for most practices; hospitals will be stopped from sending patients back to GPs for re-referrals; and £40m will be devoted to a fund to support struggling practices. And there is much more besides that. 

At first glance, there would seem to be little for GPs to find fault with. 

The RCGP has been unremittingly positive about the package, hailing it as perhaps the ‘most significant announcement for general practice since the 1960s’ and going as far as to place its badge on the document. Indeed, many of the measures listed in it could have been written by the college itself.

College chair Dr Maureen Baker says it will ‘send a loud and clear message to those about to embark on a career in general practice, and medical students considering it, that their future as a GP will be attractive and secure’.

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The biggest commitment is to increase general practice’s share of the NHS budget to at least 10% – something the GPC and RCGP have been pushing as a priority for years.

But, as GPs had the chance to digest the package, questions began to arise: would struggling practices get to see any of the money, and if so when? Would the funding only be available to those practices willing to provide seven-day access and upscale? Why is it spread over five years?

The GPC, having initially welcomed the document, urged a note of caution after its committee meeting. Chair Dr Chaand Nagpaul has refused to lift the threat of mass resignation, voted on at the Special LMC Conference in January. 

He tells Pulse: ‘The deal is weak in terms of immediate help for practices and that’s something we will be lobbying for and negotiating for in coming months.’

The Forward View also omits many of the demands set out in the GPC’s Urgent Prescription for General Practice campaign, such as a maximum limit for the number of patients a GP can see in a day, a new DES for GPs to dedicate time to care home patients and the effective abolition of CQC inspections. 

LMC leaders have gone further in their criticisms, with Leicestershire LMC chief executive Dr Chris Hewitt warning it ‘could accelerate the demise of general practice as we know it’. 

He adds: ‘General practice needs a clear vision. We need a rescue package that clearly outlines pounds per patient and per-patient contact for core GP work. 

‘Little or none of the money is allocated to core funding of GMS practices.’

Without a direct injection of cash into the core GP contract, Dr Hewitt says, the profession will not know ‘how much of the glossy document is smoke and mirrors from the politicians’. 

There are concrete funding commitments: £112m to give each practice access to a clinical pharmacist; £45m to train reception and clerical staff to ‘navigate’ patients and handle clinical paperwork; and £30m for implementing innovative ways to free up GP time. 

But these funding streams – and many of the others announced – require buy-in to NHS England’s vision. GPs will not have the freedom to use the cash for the areas they see as the most pressing. 

Instead, resources will be given to them in the form of CCG ‘transformational support’ or to implement schemes trialled in the Prime Minister’s seven-day access pilots and IT innovations such as Skype appointments. All of which may be welcome, but might not be what practices actually need. 

And the more long term the investment, the more strings are attached. One-fifth of the £2.4bn funding boost for 2020-21 will be spent on seven-day services, the Forward View says. Around £900m of capital investment over five years will be dependent on CCGs approving plans for premises – which will have to involve upscaling and providing more services, as detailed in the document.

As Hull GP and media lead for GP Survival Dr Zoe Norris puts it, ‘practices will have to jump through a lot of hoops’.

Dr Norris adds: ‘We’re not being trusted to be given core funding. It does give the impression of a more positive future… but who will actually still be  a GP when that time comes around? It’s weighted towards newer models of care.’

Tangible differences

In fairness to Mr Stevens, he acknowledges that the success of the Forward View rests in practices seeing rapid and tangible change on the ground. He says: ‘It is perfectly understandable that practices are cynical. The real test will be how the report is turned into action, so people feel the difference.’ He promises that the investment will be available to ‘all practices’ regardless of size.

Professor Martin Roland, professor of health services research at the University of Cambridge who produced a report on the GP workforce earlier this year, backed by the Forward View, says the package signals a ‘sea change’ in NHS England’s attitude towards primary care: ‘I think they are starting to get it.

‘Realistically, this package exceeds what either the BMA or RCGP could have hoped for, and I think it will be a real watershed for general practice. So let’s see the positive in this. If general practice thrives then we really are on our way to a world-beating healthcare system.’

Not all GPs would agree with this view. And they will have a chance to voice their opposition through their LMCs at their annual conference in May where, no doubt, they will deliver their verdict on the Forward View – and on whether to move forward with their threat of mass resignation. 

But it may be that any action will be irrelevant. Because it looks likely that, within current funding constraints, NHS England has played its whole hand. Whether you believe this is a turning point, or the profession has been sold down the river, this is the future for the profession and GPs will have to work within its boundaries.