What does NHSE’s direction of travel mean for GPs?

Next year’s contract had been seen as the one to revolutionise general practice. But, in an exclusive Q&A with Pulse, NHS England primary care director Dr Amanda Doyle says the 2024/25 contract will be a ‘stepping stone’ but will determine the direction of travel. We analyse what her answers mean for general practice in England.
Questions asked by Anna Colivicchi 

2024/25 contract

Q: Is this year going to be a stop-gap contract (for a year) or are negotiations ongoing for a multiyear contract?

A: As you know this is the final year of the five-year contract framework that started in 2019. The reason that we were able to put a five-year contract in place was that we had a five-year funding settlement from 2019 to 2024. 

We only have a one-year funding settlement for 24/25 and so it is almost certain that we won’t be negotiating another five-year contract. 

We have committed to a public consultation on the future of QOF and incentives in general practice and we will be doing that and that will inform our longer-term approach – there is an opportunity for longer-term contractual reform for 25/26. 

And what we want to do is see what we can do in 2024/25 as a stepping stone to take us in the direction of travel that our strategy directs.

But we are not going to be in a position to commit to a five-year contract.

Q: Will funding for the additional roles reimbursement scheme be rolled forward?

A: ARRS funding will be recurrent, there is absolutely no risk to PCNs. They should recruit using that funding this year. And they will have the money, it will come in future years for them to pay their staff. There’s no concern at all that money will suddenly be withdrawn and that practices will be left with responsibilities.

Pulse analysis: It had been thought that next year’s contract would be the most significant since 2004. However, the political situation – with a general election next year – has put paid to this. That is not to say that these negotiations won’t be important. As Dr Doyle said, it will dictate the ‘direction of travel’, and this will include a review of QOF – with Chancellor Jeremy Hunt on record as opposing the framework. It is likely that the current contract will roll over, but will include announcements around consultations on the future of QOF and enhanced services – and potentially even the whole funding mechanism. But her comments do seem to suggest that NHS England is wedded to PCNs – even if the BMA GP Committee isn’t. 

Access requirements

Q: The new contract states that practices must offer an appropriate response at first patient contact, and that it’s acceptable to signpost to 111 ‘in exceptional circumstances’. Do those circumstances include breaching the BMA’s ‘safe level of contacts’ number of 25 patients a day per GP? If so, what happens if 111 redirect the patient back to the practice? 

A: [The contractual requirement] is not about seeing everybody first time they phone up. But what I consider to be completely unacceptable is patients hanging on the phone for 45 minutes in the morning only to be told they have ring back tomorrow.

So we are saying our ambition is for the future – and we recognise that practices are struggling to deliver it now – but our ambition is that everyone with an urgent clinical need is assessed within the same day that they make contact and routine requests for appointment are offered within two weeks.

I know that lots of practices have huge difficulty doing that now because demand is high and they’re struggling with capacity. And I accept that. What I don’t accept is telling somebody who is repeatedly trying to call to ring back tomorrow.

We don’t want practices routinely diverting patients to 111 when they are open. Part of the reason for that is that 111 is a triage and assessment service – patients go through a clinical algorithm on the phone and the outcome for half of 111 contacts is ‘contact your GP’. 

We’ve said to practices, if you feel you need to divert patients to 111, then you need to inform your commissioner

But in the situation where suddenly there is an issue with the practice, people might go off sick or suddenly there’s a huge demand or something happens and they cannot deliver a same-day service in the way they would normally want to, then it’s perfectly acceptable to contact your ICB. And, in that specific circumstance, to divert patients to 111.

But what we have said to practices, if you are in a position where you feel you need to divert your patients to 111, then you need to let your commissioner know. And that’s completely and utterly separate from any arbitrary number of contacts.

Pulse analysis: This is not what GPs wanted to hear. The ‘exceptional circumstances’ in which GPs are able to divert patients to 111 have never been adequately defined by NHS England. In this vacuum, the BMA provided its definition: 25 contacts a day per GP. The problem is that in this environment, this is not exceptional – a Pulse survey in June revealed that 37 was the average number. However, Dr Doyle did say that ‘huge demand’ would warrant practices contacting their ICB. This might lead to unintended consequences for NHS England.

Funding

Q: You told a House of Lords select committee meeting in June that NHS England’s plans are not compatible with the current GP funding model: what is being done to fix this? 

A: I don’t think we’ve got it right with regard to the funding model for NHS estates. 

If we are going to move more care out into primary and community care, we’re going to work towards integration at neighbourhood level with primary care and community services, if we are going to scale up the offer both at network level, but increase the number of trainees in primary care increase the number of GP, widening our staff mix, there’s a clear need for estates and infrastructure to support that. 

And at the moment, the flow of capital into primary care estates doesn’t allow us to do that.

Q: How will you rebalance the investment differences between primary and secondary care, as you told the Lords committee you would?

A: I appreciate that changes in inflation, which hadn’t been predicted when the five-year contract framework was agreed, have made things tighter for practices, I absolutely accept that. 

But nevertheless, the total quantity of investment in primary care has increased very significantly over the last five years. 

And we’re increasing other services in the community, things like virtual wards, NHS at home services, urgent community response services, acute respiratory hubs – a whole range of services that are in the community in which we have significantly increased investment. And we’re committed to continuing to do that.

Q: Will the future model for GPs be entirely salaried?

A: At the moment, what we’ve got is a huge mismatch in demand and capacity in general practice. We’ve got a largely independent contractor model, the partnership model, which in some places is working very effectively, and in some places is really struggling to manage. 

Partly because of difficulties with recruitment, we haven’t got enough qualified GPs, with some places finding recruitment more difficult than others, some places are finding all the wider challenges more difficult than others. 

So in some places, we are going to have to look at what other ways can we contract for primary care to support the existing partnership model where people are struggling to deliver. 

But I absolutely don’t think that we have to change something where it’s working really well, and in huge parts of the country, the current model is working well. So I think what we’ll probably need is a mixed model.

Pulse analysis: There has been a lot of talk about shifting resources from secondary care into primary care, and NHS England’s plan has been to develop primary care networks and build on Professor Claire Fuller’s 2022 Stocktake report’s proposal to work at a ‘neighbourhood level’. Dr Doyle said that Covid affected their ability to shift resources away from secondary care. But the fact is, NHSE – or maybe more accurately the Government and the Treasury – refused to budge on the 2.1% uplift for 2023/24 negotiated as part of the five-year deal, despite rampant inflation. This has left practices struggling to carry out routine care, and not in a position to think about the moving more services to community in the way Dr Doyle is envisioning. And Pulse’s survey this month, which found a third of the 362 GP partners in England surveyed would be prepared to shut for a week if funding is not significantly increased in 2024/25, should give pause for thought at a time when many NHS workers are striking.

Workforce plan

Q: How is NHS England planning to fulfil the training commitments set out in the workforce plan?

A: [The plans] are ambitious. And I think it’s really positive. Not only is there an overall commitment to increase medical student places, increase nurse training places, but also a disproportionately high increase planned for primary care for general practice training places, and for community and general practice nursing places from within that number. 

So again, it’s part of that direction of travel, to move more of the care that we deliver into primary and community care.

We do need to recognise that increasing our workforce in that way, even over a long period of time, is going to need us to be able to increase the estates and the digital infrastructure to support that workforce. And we’re really conscious of that. 

So we’re looking at how the increasing size of the workforce in primary care is going to drive our strategy for estates, the digital infrastructure. All of the ICBs are looking at their local strategies. 

It’s really important that we plan this properly and that we start now. To have more trainees we need more trainers, we need more rooms to put people in, we need more kit for them to use. And all of that is committed to in the workforce plan and recognised.

Q: How is NHS England planning to address trainers’ shortages and provide increased number of trainers needed to put that plan in place?

A: Of course, it’s all closely related to increasing the number of qualified GPs who are available, because they’re the only people that can become those trainers. 

We’ve been really successful in significantly increasing the number of GP trainees coming in. So we’ve increased the numbers and recruited to those numbers. 

What we need to do now is ensure that further on, we retain qualified GPs. We need to support general practice so that general practice is a sector where people want to work for the whole of their career, where they look at options to almost widen their clinical portfolio, part of which may be to take on training responsibilities. 

Part of it may be to lead at network level, part of it might be to specialise in women’s health or urgent care. But there’s a whole range of options within a GP’s career that can create a portfolio that keeps the job interesting and challenging. And we need to push that. And training is part of that, we need to encourage more people to become trainers.

Pulse analysis: Dr Doyle is correct to say that Health Education England has been successful in increasing the number of trainees. But she is being overly optimistic in claiming that this will eventually lead to an increase in the number of trainers because, right now, they are failing to retain GPs at every level. Despite HEE’s success, the number of full-time-equivalent GPs continues to decrease. Offering flexible careers is the right thing to do, but it is unlikely to lead to the retention necessary to meet training demands. 

Q: GPs have raised concerns about SAS doctors working in general practice as they said this could cause exploitation and inequalities. What is NHS England’s vision for SAS doctors in primary care and how will it help the current staff crisis? 

A: It’s really important to be clear about what we’re trying to do here. This is not about specialty doctors coming in to replace GPs. 

This is about future proofing the regulations, so that doctors who have a degree of expertise in a specialist area can legally be employed in primary care as part of a multidisciplinary team. 

We are not saying that we think we can make up for the shortage of GPs by employing SAS doctors. These doctors have significant expertise in things like geriatrics or diabetology, or working in accident and emergency departments. 

We are not saying that we think we can make up for the shortage of GPs by employing SAS doctors

If you’re offering urgent same-day clinics across a network, it might be great to be able to employ a doctor with years of experience in emergency department work. 

And what we’re doing is asking to change the regulations to allow that to happen. It is not about having SAS substituting for GPs. 

It would only be where primary care teams want to employ those sorts of doctors, in the same way that we’re all happy to employ nurse practitioners, pharmacists, paramedics, physios or dietitians. 

What’s wrong with employing doctors with specialist skills as part of that team? But actually, because there’s been quite a lot of feedback and a lot of questions raised about this. the Government hasn’t put this through with the current regulatory change. We’re giving time for people to feed back further so that we can understand people’s concerns on this.

Pulse analysis: The comments on SAS doctors are enlightening. But this seems to be wrapped up in primary care providing more services, when actually practices need more GPs just to help them provide routine care – something that Dr Doyle suggests here that SAS doctors won’t be able to do. 

Q: The plan doesn’t seem to address GP retention – why? What is being done to reduce burnout and workload pressures in the short term, which is what has been pushing GPs to leave the profession?

A: I recognise the issue, I think we need to be really careful that the answer to the challenge we’ve got with retention is not just schemes to help retain people. 

It’s about creating a future where being a GP is a job where people can manage the workload, they can do what they were trained to do, they can get satisfaction from that job. And they want to keep doing it for 30 years. 

And that’s what we need to tackle. And it’s all those things you’re describing – contributing to people feeling burnt out or overwhelmed or just not wanting to do the job – that we need to address. 

Part of the answer to that, but only the first part, is in what we’re trying to do through the primary care access recovery plan… So patients book their own appointments, refer themselves to a whole range of community services, access information about self-care and how to manage their conditions. 

Pulse analysis: The recovery plan was only announced this year, so it might be unfair to proclaim that it will fail to help retain GPs. But nothing we have seen suggests it is giving GPs second thoughts about leaving the profession.

Recovery plan

Q: Has the recovery plan helped to improve access and the 8 o’clock rush?  

A: Well, quite frankly, it was only published in May, it’s not going to help improve access yet.  

But what’s important to say is this is admittedly very transactional. It’s trying to address the things that are contributing most to the reduction of patient overall satisfaction in general practice, and that overall reduction in satisfaction is largely attributable to reduction in satisfaction with actually getting through to practices. 

And so recognising it for what it is, we’ve had a pretty good reception, an awful lot of interest from GP practices and quite good levels of interest in uptake on key parts of the plan. 

Every single practice that hasn’t yet got a cloud-based telephony system has signed up now to have one installed this year. 

And that’s really positive. We’re now looking at the practices that have digital systems, but they don’t necessarily have the most functional digital system, so they’re not on the highest-quality systems. 

We’re now looking at the size of that, to see how much further we can take this, but we’re really pleased with that. 

We’ve had a huge uptake of the care navigator training, that programme has started and we’ve got almost 3,000 people signed up in the first month alone. We have already kicked off the GP improvement programme, with lots of practices signing up and feeding back really positively about that programme.

Q: We know that almost half of GPs who have already implemented ‘modern’ access measures prescribed by the general practice recovery plan say that it has not helped improve access – how can this be addressed? 

A: New telephone systems are not the answer on their own. And what we’re talking about when we talk about modern general practice access is the combination of cloud-based telephony, high-quality digital triage and flow tools, and high-quality communications platforms. 

That actually changes the operating model. It’s not just about telephones. What we do know about telephones is that being able to properly signpost, queue and call back through phones makes a difference to patients. 

Analogue phone lines are going to be completely phased out in this country in 2025. So nobody had an option to stay on an old-style phone system – what we’re doing is funding and supporting practices to move more quickly. 

And then the other issue is that once you’ve got proper digital telephony system in place, that gives you as a practice a load of data that helps you analyse the demand coming in, how long people are waiting on the phone, how many people are abandoning their calls, how many of them are calling back. 

All of that information helps practices to understand the model of demand. And so having the information more quickly gives practices some of the tools and information to help them make the changes that are going to improve patients’ perception of access. 

And there’s no doubt that the conversation is different if a patient has waited 45 minutes for someone to answer the phone or if they’ve had to keep trying because they’re at work, than if someone rings and gets answered, I guess.

Pulse analysis: There is no doubt that it’s not right patients should be waiting 45 minutes for someone to answer the phone. However, although Dr Doyle spoke about this a few times in the interview, there is no evidence this is a common phenomenon. And it remains true that the problem isn’t the phone lines – it is the shortage of clinical staff.