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What the future holds for GPs under NHS England’s contract reforms

1 Digital-first general practice

Why the focus on ‘digital first’?

NHS England’s consultation document on proposed changes to the contract is clear on how it sees general practice developing: ‘By the end of the next decade digital technology is likely to have transformed general practice.’

The term ‘digital-first primary care’ refers to ways in which a patient can receive advice and treatment outside the surgery, via online symptom checking and remote consultation.

The document says: ‘This means that a patient’s first point of contact with a GP is through a digital channel, not a face-to-face consultation, although the latter remains an option if required.’ It adds these models are ‘increasingly common’, and will result in ‘greater convenience for patients’, as well as help to manage ‘increasing demand’.

What changes can we expect to the contract?

We know how much stock NHS England is putting in digital first, and it already has several funding streams in place for practices that want to make greater use of technology, including the £45m fund to support the implementation of online consultation systems, introduced in the GP Forward View in 2016, and the £1bn Estates and Technology Transformation Fund.

NHS England suggests the contract will change to take account of technological developments: ‘Over the coming years we are likely to see further innovation in digital delivery and across primary care, and will remain alert and responsive to where the contract framework may need updating.’

The BMA appears to be on board with harnessing the use of technology via the contract – and has its own priorities. Its GP Committee chair Dr Richard Vautrey says: ‘We believe NHS England and CCGs should enable all practices to be provided with the technology to offer smartphone and digital consultations.’


Why the focus on the QOF?

NHS England has said it  is reviewing the QOF in a bid to create stability for general practice and to ensure GPs aren’t overburdened by the scheme’s demands.

It follows a review of the payment system earlier this year by an advisory group including the BMA’s GP Committee, the RCGP and the Department of Health and Social Care.

What changes can we expect to the contract?

The consultation document proposes:

Scrapping up to a quarter of indicators.

Introducing a ‘quality improvement domain’, focusing on three priority areas each year (practices will be able to choose from a list of ‘quality improvement’ options that will be agreed nationally and locally).

Modifying indicators to target population segments (for instance, because different age groups or people with varying disease severity require different targets).

Rebranding exception reporting as ‘personalised care adjustment’ (which will allow GPs to make a clinical judgement over whether a patient needs, for example, to have a blood pressure check if other factors suggest otherwise).

Trialling an approach allowing QOF targets to be met at a GP practice network level.

NHS England says its proposed changes would be likely to ‘take a number of years’ to bring in ‘and are subject to negotiation’. But the advisory group agreed ‘this was the likely direction of travel’.

3 Global sum

Why the focus on the global sum?

This stems in part from the growing emergence of digital models, which means patients are more likely to register with practices further away from home.

The obvious example is the ‘GP at Hand’ service, run by Babylon from a practice in west London. The practice has been using the ‘out of area’ scheme to sign up patients from across London, who receive an online consultation ‘usually within two hours’ and a face-to-face consultation the following day. 

This has dismayed other practices in London, which say they are losing younger, healthier patients who are more likely to use such services. Babylon wants to expand across England.

The ongoing row over the Carr- Hill formula – which determines practice funding – is also likely to be revisited as part of the new contract negotiations.

What changes can we expect to the contract?

So far, NHS England has proposed changes to three elements of the contract:

Out-of-area patients – As part of the 2014/15 contract, practices were able to register patients from outside their practice boundaries, receiving the same payment for in- and out-of-area patients, even though they have no requirement to provide home visits or out-of-hours care for the latter. NHS England now says this ‘does not reflect’ the lesser workload from out- of-area patients and wants to reduce the payments and redistribute the money to practices with more in-area patients.

The ‘rurality index’ – This is an additional payment to practices with a higher average distance between patients’ homes and the practice location. But the growth of online consultations skews this, as Babylon – for example – has a high average distance without the associated costs. As a result, NHS England is proposing to base the index on average distance between the practice and its in-area patients rather than all patients – meaning genuinely rural practices will retain their extra funding.

London weighting – This is an additional flat payment of £2.18 per patient to all practices within a defined London boundary. However, NHS England says patients who don’t live in London but register there may be ‘less likely’ to present ‘London-specific complexities’. It proposes to offer payments based on where patients live, not the practice location.

NHS England says the ‘cumulative impact’ of its three proposals could mean digital-first practices – such as that hosting GP at Hand – see their funding reduced by approximately 19.5%.

Other proposals include scrapping the additional payment for newly registered patients (currently 46% more in the first year) because digital-first practices show signs of a higher turnover of patients.

4 Premises

Why the focus on premises?

GPs in England have been calling for increased investment in premises. Those in rented buildings have seen costs skyrocket and, as of July, the Government said it was owed £202m in unpaid premises fees. In Scotland the new contract sees GP partners reimbursed for premises fees, and it is expected that no GPs will own their premises by 2043.

What changes can we expect to the contract?

NHS England, the Department of Health and Social Care and the GPC are carrying out a six-month review of GP premises. They are coy about what the review entails but NHS Employers has said it will look to ensure ‘premises used for primary medical care are fit for purpose into the future’, and ‘promote the recruitment and retention of GP contractors as well as representing value for money’.

5 Partnership review

Why the focus on partnerships?

There has been a rise in the number of GPs taking on sessional and portfolio roles rather than partnerships.

What changes can we expect to the contract?

The Government has launched a review to ‘reinvigorate’ the GP partnership model, led by Wessex LMCs chief executive Dr Nigel Watson and an interim report is due in the autumn.

There is unlikely to be any move to the type of model being introduced in Scotland, whereby GPs retain their partnerships but hand over responsibility for premises ownership and employment of wider clinical teams to health boards.

NHS England director of commissioning Dan Hardy says Scotland is ‘fundamentally different’.

Pay rise contingent on reforms

The Government has said GPs will receive a 2% ‘pay rise’ in 2018/19. This means the 3.4% uplift in practice funding now becomes 4.2%, with the difference backdated to April.

This has not been received well by the BMA GP Committee, which pointed out that the 2% so-called rise was below the 4% recommended by the independent pay review body, saying the 4% was needed ‘simply to keep services for patients running’.

Chair Dr Richard Vautrey was scathing: ‘For the new secretary of state to commit, only last week, to addressing the workforce crisis in general practice and raise hopes of investment in primary care, to now dash those hopes, will signal to dedicated GPs and their staff that they are not valued.’

Buried in the announcement from new health secretary Matt Hancock was a statement that made clear the importance the Government is placing on contract reform.

He said there would be a deferred extra 1% increase in pay to begin in April 2019, plus any further award the Government decides to make for 2019/20 – but this will be conditional on GPs accepting ‘contract reforms’. Whether this 1% extra incentive will mean much for GPs is another matter.