How will the NHS 10-year plan affect GP funding?

In the second part of our mini series considering how the 10-year plan will influence a new GMS contract for general practice, Anna Colivicchi looks at what it will mean for GP funding

The Government has promised to shift resources from secondary care into the community, as part of its big ambitions set out in the 10-year plan. With ‘an extra £29bn in investment’ allocated to the Department of Health and Social Care by the spending review earlier this year, it was hoped we might see a big cash injection into general practice – which every GP in the country is crying out for.

Yet it was a bit too good to be true. Ahead of the plan’s publication, GPs’ hopes were immediately dampened with warnings that it would not come with huge investment into primary care straight away. When the plan was published – later than expected – it came as no surprise that it is very light on financial detail, and on how this shift would be delivered.

There was no mention of any new funding for general practice and, for GPs, this seems ominous. ‘I have yet to have a conversation with anyone that sees it as anything other than a threat – massive shift of workload, risk, responsibility and no actual detail on how funding will move, the biggest hurdle to actual change I have seen in the last 25 years,’ says YOR LMC medical secretary Dr Brian McGregor.

But despite the vagueness within the plan, there are indications that general practice funding is set for fundamental change, likely through the next GP contract, which the BMA want implemented by 2028.

Within the plan, there was yet another announcement around a review of the Carr-Hill formula, which determines the global sum received by individual practices in England. There are moves to reform the QOF and enhanced services.

But perhaps the most interesting change is a line buried in the plan – the development of ‘year of care payments’, which will introduce a capitated budget for a patient’s care over a year, including all primary care, community health services, mental health, specialist outpatient care, emergency department attendances and admissions. Such a change would revolutionise general practice in England.

What changes can we expect for the Carr-Hill formula, QOF and local enhanced services?

For GP practices in England, some of the more concrete suggestions are based on reforms to the current contract.

One such suggestion was to review the Carr-Hill formula for GP funding, so that ‘working-class areas’ receive their ‘fair share of resources’. There are many issues with the current formula, which is supposed to ensure resources are directed to practices based on an estimate of their patient workload, taking into account ‘drivers of workload’ and ‘unavoidable costs’ – but this fails to take into account deprivation and is based on old data.

Both the RCGP and the BMA have argued for years that it needs to be replaced to accurately reflect the communities that practices care for, so the review was welcomed – but simply redistributing fixed funding risks creating new pressures in other areas, creating winners and losers.

‘I totally agree that deprived areas need more investment,’ Andy Pow, adviser to the Association of Independent Specialist Medical Accountants, tells Pulse. ‘But the worry is that if all they’re doing is redistributing existing funding from one area to another, we are in danger of creating better investment in deprived areas but then making those areas which are fine at the moment not sustainable, because they’ll have funding taken off them.’

The health secretary has recently told MPs that the Government ‘will consult’ on the Carr-Hill reform, but DHSC has confirmed to Pulse that there won’t be a public consultation, only ‘key stakeholders’ will be asked for their opinion. According to the Government, the review will look at how health needs are reflected in the distribution of funding through the GP contract, ‘drawing on evidence and advice from experts’ such as The Advisory Committee on Resource Allocation (ACRA), and ‘in consultation’ with the BMA GP Committee – but so far, we don’t have any details of how and when this will happen.

The 10-year plan does not mention enhanced services and QOF specifically. However, it does commit to reducing bureaucracy for GPs, so this could potentially mean reducing the number of QOF indicators even further than the Government did this year.

‘QOF could go,’ says Mr Pow. ‘I can’t see neighbourhoods being able to do QOF as it is now but there could be a thinned down neighbourhood QOF I suppose. To me the biggest risk is local enhanced services (LES) funding – you could see cash strapped local areas looking to support neighbourhoods by raising LES money, assuming GP practices were engaged with neighbourhoods this could well be subcontracted back, but if not they could in theory go elsewhere.’

Doctors’ Association GP spokesperson Dr Steve Taylor agrees that some aspects of QOF have lead to improved performance in poorly performing GP practices but the system is ‘over bureaucratic’ and at times ‘leads to unnecessary reviews of patients’. ‘Enhanced services also create incentives but again add to a complex funding structure for GP practices,’ he says. ‘A change is needed but there has to be a way of monitoring poorly performing practices so that they don’t cut patient care, whilst not creating work for the vast majority of well run practices.’

New ‘year of care payments’ and ‘patient power payments’ – what will these mean for general practice funding?

Yet while these reforms will tinker at the edges of the contract, the Government proposed a much more fundamental change – for both GP practices and trusts.

The 10-year plan said that to ‘support the shift of care away from hospital settings towards neighbourhood care’ they will will develop ‘year of care payments’ (YCPs). ‘These allocate a capitated budget for a patient’s care over a year, instead of paying a fee for a service,’ the plan said. The YCP could include all primary care, community health services, mental health, specialist outpatient care, emergency department attendances and admissions, according to the plan, and these ‘will be consolidated into a single payment’.

There is not a huge amount of detail around this so far. But BBO LMCs pointed out that this strongly suggests that budgets between primary and secondary care will be ‘indistinguishably merged’, and also any previous funding specific to GP will be more broadly labelled ‘primary care’. They also point out that this new payment structure is incompatible with the current GMS core funding process and therefore ‘can only mean the end of GMS’ – something that GP leaders have been raising concerns about since the publication of the plan.

The plan also proposed to trial new ‘patient power payments’, which would introduce a new funding flow in which patients are contacted after care and given a say on whether the full payment for the costs of their care should be released to the provider. DHSC has told Pulse they intend to trial the patient power payments in ‘selected trusts’ in ‘a small range of areas of care’ for now and that further details will be confirmed in due course.

The RCGP is concerned how this would work and whether it would apply to general practice too. ‘The plan proposes a trial of “patient power payments”, where patients have a say on whether full payment for their care should be released to the provider, or if a proportion should go to a regional improvement fund,’ the college said. ‘We are concerned about how these proposals would work and whether it would apply to general practice and will be seeking further clarity.’

There is another major change to trust’s funding, that could free up funding for general practice. The plan seems to suggest that early phases of the reforms could be financed through phasing out ‘deficit support funding’, which is used to cover the shortfall in NHS trusts’ budgets.

It said: ‘Our plan to remove deficit support funding (worth £2.2bn in 2025 to 2026) starting from financial year 2026 to 2027 will free up funding to allow us to move resources more quickly to areas of higher health need.’ But LMC leaders have questioned what will happen to that £2.2bn worth of debt for NHS trusts.

How will this affect small practices?

The year of care payments, alongside the introduction of neighbourhood health centres, have led experts and GPs to raise concerns that the proposals could mean that funding will mostly be channelled into large scale providers and that traditional practices will be left with fewer resources.

‘I think there needs to be a lot of clarity on funding flows,’ says Katie Collin, a partner at medical accountancy firm Ramsay Brown. ‘It needs to be more precise than what we have now, which is “you’ll get some money, but it’s kind of down to you how to use it, and we’re not quite sure where it’s going to come in or how it’s going to be divvied out” – I think there needs to be really clear parameters and good financial systems so that people being paid are exactly clear what they’re being paid for, what they’re expected to deliver, and how they’re going to access that money.’

She adds that one of the problems of working at scale is that money ‘tends to go into the biggest institution’, which, although has good systems to a degree, is ‘often really slow at getting the funding out’, with the risk of ‘massive’ cash flow issues.

‘If we’re working at this kind of scale, who’s going to be responsible for the money? And how is that going to flow down? I can just see we don’t have the technical infrastructure to run payments at this scale,’ she tells Pulse.

LLR LMC chief executive Dr Grant Ingrams says that the concept that funding will be based at least in part on patient experience ‘seems superficially attractive’ and that for hospitals covering a large diverse area it may actually work as planned. ‘However, if general practice was included it would result in downward spiralling of practices, particularly affecting those providing services to deprived populations,’ he adds. ‘Practices in more deprived areas received lower levels of funding, and patients from more deprived areas tend to be more negative about their practices. We know from LLR data that there is a direct correlation between the amount of funding a practice receives and patient satisfaction.’

He adds that the plan picks up on the Darzi report’s observation that the pendulum must swing to move funding from secondary to primary care, but that with acute trusts potentially at the helm of neighbourhood services, it is ‘extremely unlikely’ that any of this funding will come to general practice.

What next?

The 10-year plan carried no promises of new funding for general practice in the short term, and very opaque ambitions to move resources out of hospitals and into the community – so all the financial details of how the plan will be put in place are still to come.

Dr Katie Bramall, chair of the BMA’s GP Committee England, says that the additional funding allocated in the spending review back in May ‘is being allocated right now’. ‘It’s crunch time, deciding where that £29bn given to the Department of Health will be spent and when,’ she adds.

At present there are concerns that GPs could go back into dispute with the Government over funding following the plan and a lack of reassurance over the new GMS contract.

The Government has recently told Pulse that it is ‘still committed’ to working with the BMA on GMS ‘contract reforms’ and LMC leaders have also called on the BMA to re-enter formal dispute over the plan – but we are still awaiting the results of a GPC vote which took place last week.

Dr Bramall says she expects that details around delivery and funding will become clearer and the ‘shades of grey will become black and white’ by the start of September. ‘The £29bn sounds like a lot of money, but it’s not,’ she says. ‘In fact it allows for about a 2.8% average spending growth between now and the next general election. That’s just about enough to maintain current service levels, but expecting massive transformation on those terms feels very optimistic.’

Read the first part of our mini series here.