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The unanswered questions about NHS England’s GP ‘support’ plan


GP appointments


As GP practices wait to receive their share of the Winter Access Fund, Rachel Carter looks at what we still don’t know about NHS England’s plan to improve GP access.

The deadline for integrated care systems (ICSs) to submit their plans for the Winter Access Fund – the £250m attached to NHS England’s ‘support’ package for GPs – has now passed.

According to NHSE’s supplementary guidance on the fund, the final funding allocations will be confirmed to ICSs from next week. This guidance shed more light on what the plan means for practices deemed to be in the bottom 20% in terms of access, such as face-to-face care – including confirming that those considered the worst performing on access won’t get any cash. But there remain wider questions unanswered about what this latest set of measures will mean for the profession.

Performance

  • What questions will the real-time patient satisfaction survey ask?
  • Will the IIF measure patient satisfaction based on the real-time survey and how much money will be attached to this?
  • Will there be league tables on practice appointment levels?
  • When will unannounced CQC inspections on access start?

Many of the measures set out in NHSE’s plan have been criticised as ‘punitive’ by the BMA and there is widespread concern over how they will be used to performance manage practices in the future. In the short term, ICSs were told to identify and submit a list of the 20% of practices performing worst on a range of metrics, including with the lowest levels of face-to-face appointments, the most significant levels of 111 calls and the highest A&E attendances.

The plan also set out that the 200 practices deemed to be worst performing on access would join the pre-existing Access Improvement Programme, to receive targeted support.

The supplementary guidance from NHSE subsequently revealed more detail on what this intervention entails, and confirmed that those subject to it may also still receive a share of the funding. But others – those in receipt of ‘enhanced support’ – will not be eligible.

Londonwide LMCs chief executive Dr Michelle Drage says practices are in ‘limbo land’ while they wait to hear if ICS plans have been approved, but she adds that what matters to the LMC is whether individual GPs will be performance managed as a result of this. 

‘At that point, we would want to know who they are and we would want to provide individual support – and obviously in doing that we would provide our normal service[…],’ she says.

‘There are all sorts of procedural things that can be done on an individual basis for practices that have been scapegoated unreasonably or targeted for something that is not in their gift to resolve.’

In the longer term, practices are facing unannounced CQC inspections on access, performance data on appointments becoming more widely available, and a new ‘real-time’ measure on patient satisfaction where patients rate their access to care via text message.

NHS England has not yet confirmed what questions will be asked in this text message or whether this survey will form the basis of a new incentive under the Investment and Impact Fund for practices to improve their rates of satisfaction, which was outlined in the plan. Meanwhile, the CQC was unable to comment when asked by Pulse when its inspection methodology ‘with a particular focus on access to GP services’ will be launched. 

The NHSE guidance said systems shouldn’t name the practices deemed to be in the bottom 20% and instead use anonymised codes to identify them – and said it wouldn’t publish any lists of those requiring support.

But Dr Drage says she believes the codes submitted to NHSE will be ‘foilable’.

‘A code will have been submitted, it will be stored on some database somewhere, and it will be public information that will be accessible and therefore [able to be] traced and tracked – to use that analogy – by the media, so I can’t see that being safe,’ she says.

Health secretary Sajid Javid has also since said that there were never any plans for GP ‘league tables’ on levels of face-to-face appointments.

But the original plan says that GP appointments and waiting times data will be published by NHS Digital ‘as soon as possible’ – meaning the public and the media will be able to measure practices against one another.

‘As part of wider work on NHS data transparency overall, NHS England and NHS Digital will then consider how best to create a simple visual tool – learning from the UK Coronavirus Dashboard – to allow anyone to understand the different aspects of general practice performance,’ the document says of the data publication.

Remote v face to face

  • How can the balance of F2F v remote consultations be both ‘clinically warranted’ and ‘taking account of patient preferences’?
  • Will NHS England commit to the conclusions of the RCGP’s guidance on appropriate blends of F2F and remote consultations?
  • When will the ‘big data’ analysis of the impact of remote v F2F be published?
  • Will the plan result in NHSE ditching its strategy for APMS digital practices?
  • Is NHS England speaking to Babylon about its low levels of F2F appointments?

Many would agree that NHS England’s plan can be perceived as a knee-jerk reaction to the media storm around face-to-face appointments. But after more than a year of remote consulting being the norm – and a significant push towards digital providers in the years pre-pandemic – it does also raise questions about what will happen to the ‘digital first’ agenda.

In its supplementary guidance, NHS England said it has not set a ‘specific target’ for the proportion of face-to-face care and that ‘the right answer will depend on the population being served and the operating model of the practice’. It added that ‘digital tools and telephone appointments continue to be an important part of care delivery for the future’.

NHS England has asked the RCGP to consider providing a ‘further update’ to its own guidance on consultations, which it said should include advice ‘on how practices can ensure they are providing the appropriate proportion of in-person GP appointments for their registered population, that is both clinically warranted and takes account of patient preferences’. The RCGP has not confirmed to Pulse if it will issue this update.

The BMA’s analysis says that guidance would be welcome ‘if drawn from best practice and evidence-based’ but that it should not be used by NHSE and the Government as a ‘benchmark’. It adds that each practice must decide what works for them and their patients – allowing for ‘deprivation and social demographic related variation’.

NHS England has also pledged a ‘big data analysis’ on the impact of remote versus face-to-face consultations, carried out with NIHR, but it is not yet clear when this will be published.

Staffing

  • Are there figures for the digital locum pool?
  • How can GPs make progress if one of the main pillars of support [digital locum hubs] won’t be in place by their deadline?
  • Where is the evidence that there are willing retired geriatricians? 

NHS England’s solutions for how practices can improve access centre largely around the employment of additional staff – including the suggestion that practices use retired geriatricians to plug the gaps, which has been met with disbelief by GPs. Among the costs covered by the WAF are extra sessions with existing staff; employing locums, other physicians or administrative staff; and expanding extended access and urgent care capacity.

But the shortage of GPs is already well-documented and as Dr Nick Grundy, a GP in Richmond, points out, other professions such as nurses and paramedics face similar issues.

He says that one way his local area is considering using the funding is increasing the work they do through extended access hubs, ‘but the problem there is there are no staff’.

‘We’ve fed back to [the CCG] that we would like to do it, but actually there are no doctors who want to do extra work right now,’ he says.

He adds: ‘It is welcome that [NHSE] will fund some time, but actually for most practices, I think it will come down to “do you want to do this additional work and take the money home or not”, because I don’t think there are people out there to do it otherwise.’

The NHSE plan also states that all parts of the country should have established a digital locum bank model or equivalent by December and the Winter Access Fund can be used to support ‘optimal use’. But this deadline doesn’t tally with other measures it set out – namely that practices could see their funding cut if they don’t make progress by mid-December.

Following its publication, the BMA’s sessional GPs committee chair Dr Ben Molyneux said the suggestion that practices use locums to boost appointment numbers was ‘baffling’. And the BMA’s own analysis of the plan says the suggestion of ‘directing the way locums engage’ – via the digital locum banks – ‘disrespects the independent nature of their working’.

Meanwhile, chair of the National Association of Sessional GPs Dr Richard Fieldhouse says demand is high – the association’s online system has seen a 60% increase in bookings in the last two months and a 30% month-on-month increase on average over the last year.

‘There aren’t locums to be booked or they’ve already been booked, so practices are sending out lots and lots of availability requests – which means they are going onto the platform and typing in the days and times they need cover, but the locums are just booked,’ he says.

He adds they are also finding there are some locums with capacity but who are ‘really apprehensive’ about taking on work because of the current environment in general practice.

‘When you read the press, look at any Facebook group to do with GPs, when you hear the news, you [they] just think why – I could just stay at home,’ he says.  

Support

  • When will the anti-abuse campaign be launched?
  • Will this be for practices to carry out themselves using communications tools, or will it be done at a national level with national communications?
  • How can practices access the £5m security fund?

Sadly, NHS England’s plan did little to address the anti-GP media rhetoric, or the increasing incidences of abuse towards practice staff it is fuelling. The BMA said the issue of patient abuse should have been ‘front and centre’ of the plan – but instead received ‘minor mention’.

Measures included in the plan were a set of ‘communication tools’ to help the public understand ‘how they can access the care they need’ in general practice. These have not been published yet. There is also a £5m security fund available to facilitate essential upgrades to practice premises, which the health secretary suggested could include ‘panic buttons’ or CCTV. The funding is non-recurrent, and practices will have to sign a ‘project agreement’ with NHS England and their CCG for any one-off enhancements they wish to make. ICSs must submit initial expressions of interest to regions by 30 November.

NHS England and the Government also pledged to launch a zero-tolerance campaign on abuse towards NHS staff. But a Department of Health and Social Care Spokesperson told Pulse last week that there is no update on the timings for this.

Chair of Greater Manchester LMCs Dr Amir Hannan says any funding to support staff is welcome, but zero-tolerance messaging alone is ‘not enough’ and it’s ‘not really new’.

‘It’s important that we stick to that and make it very clear that we will not tolerate any kind of abuse for our staff and that we expect the police and the courts to deal with things,’ he says.

‘But at the same time, we’ve got to think about why people are becoming more angry and upset. The NHS needs to do better, and we need the resources to enable that to happen.’

Dr Hannan concludes that it feels ‘very much like the Government vs GP practices’ at the moment, and the most important thing is ‘to try and take the heat out of the system’.

He says he would like to see ‘a recognition of the pressures that we are all under’ and ‘more people talking up and supporting what general practice is doing – and looking at how we can try and put our differences aside with the Government and have a new conversation’.