The Government has rejected a recommendation made by MPs to examine the possibility of a maximum GP practice list size.
The House of Commons Health and Social Care Committee had called for the Government to examine the possibility of limiting the list size of patients to 2,500 which it said should ‘slowly reduce to a figure of around 1,850 over five years as more GPs are recruited as planned’.
The committee of MPs said that these numbers should reflect varying levels of need in local populations and that this would draw the country closer in line with European counterparts, and help improve access and continuity.
Its report last year into the ‘future of general practice’ also issued stark warnings of a demoralised profession, with GPs facing burnout from working in a ‘systemically toxic environment’, unsustainable workloads, and managing intensely complex cases at speed with fear over reprisals.
But in its response to the report today, the Government rejected the list size recommendation, saying there is ‘no Government recommendation for how many patients a GP should have assigned, or the ratio of GPs or other practice staff to patients’.
It added that it is for each GP practice to determine the size and ‘skills mix’ of their workforce ‘to meet the reasonable needs of their patients’.
‘The demands each patient places on their GP are different and can be affected by many different factors, including rurality and patient demographics,’ the Government said.
‘Patient care is not only delivered by GPs but also by the range of health professionals available within a practice or Primary Care Network who are able to respond to the needs of their patients.’
The Government also rejected a number of measures set out by MPs that ‘were intended to restore the doctor-patient relationship’. This included the call by the committee for NHS England to champion a model whereby each GP has an individual list of patients.
Meanwhile, recommendations accepted by the Government included:
- the need to ensure that trainee GPs are distributed across the country to support areas facing the greatest challenges in ensuring access to a GP;
- the need to simplify how patients interact with the NHS with improved access;
- increased organisational support for GPs with a focus on back-office functions.
Health and Social Care Committee chair Steve Brine said: ‘We welcome the Government’s very positive response to many of our recommendations on general practice.
‘It should help relieve the burden on GPs and improve access for patients. A number of issues that our inquiry examined have been addressed by the Government in its plan to recover access to primary care.
‘What’s disappointing is that ministers have rejected a series of measures intended to restore the doctor-patient relationship to the heart of general practice.
‘The inquiry heard strong evidence to support continuity of care and we hoped to see NHS England championing the personal-list model as one way to help achieve that.’
The recommendations in full
In response to this Report the Government and NHS England should be clear in
acknowledging that there is a crisis in general practice and set out in more detail the
steps they are taking in response to this crisis in the short term, to protect patient safety,
strengthen continuity, improve access and reduce GP workloads.
The Government should commission a review into short-term problems that constrain
primary care including, but not limited to: the interface between primary and secondary
care, prescribing from signing to dispensing, administrative tasks e.g. reports and sick
notes, day-to-day usability of IT hardware and software, and reviewing of bloods,
pathology and imaging reports.
The Government should provide the funding necessary to create 1,000 additional GP
training places per year and consider extending the GP training scheme to four years, to
allow GP trainees more time to develop their skills in practice as well as learn the skills
required to enter a GP partnership.
The Government and NHS England should identify mechanisms to distribute GP trainees
more equitably across the country so that under-doctored areas receive a balanced
proportion of domestic and international GP trainees. The Government should explore
schemes that incentivise GP trainees to settle in the areas they train; this could come in
the form of improving opportunities to become GPs with Special Interests, incentivising
GPs to join partnerships in understaffed areas, and look to create easier ways for GPs to
set up their own practices in primary care “black spots”.
NHS England should set out how it plans to increase the flexibility of the Additional
Roles Reimbursement Scheme to allow Primary Care Networks to hire both clinical and
non-clinical professionals other than those set out in the current guidance, according to
local need. (Paragraph 47)
Receptionists play an incredibly important role in primary care that often goes
unrecognised. Given they are often the first point of contact with primary care for most
patients, NHS England should review and consider providing standardised national
training to drive up standards and equip receptionists with the skills required to navigate
and signpost in a 21st century NHS. (Paragraph 48)
The Government and NHS England should explore the possibility of providing an
uplift to the Additional Roles Reimbursement Scheme to support non-staff costs such as
supervision and training or to provide weighted salaries in areas where the cost of living
is high or it is hard to recruit. Consideration should also be given to allowing staff to
be employed on Agenda for Change terms and conditions as soon as resourcing allows.
NHS England should take further steps to address the administrative workload in
general practice, including by introducing e-prescribing in hospitals and focusing on
the primary-secondary care interface by encouraging ICSs to provide a reporting tool
for GPs to report inappropriate workload transfer.
The Government should also fund research into the specific role that machine learning
can play in the automation of reporting and coding test results to reduce clinical admin
in general practice.
The Government should undertake a full review of primary care IT systems from the
perspective of the clinicians with an emphasis on improving the end user interface.
Making the working life of each clinician that bit easier will drastically improve morale
As part of ongoing efforts to improve the retention of GPs, NHS England should include
a specific focus on encouraging locum GPs back into regular employment by supporting
GP practices to offer more flexible working patterns.
Urgent work needs to be done to stop a bidding war for the services of locums and
establish requirements for a minimum fair share of administrative duties.
Do not accept.
The Government and NHS England should adopt the recommendations related to NHS
pensions in our recent Report on Workforce: recruitment, training and retention in
health and social care. In developing short and long-term solutions to the NHS pensions
issue the Government and NHS England must specifically account for the status of GP
partners as employers, for example by providing specific guidance and support for GP
practices to help them adopt pension recycling and retire and return approaches. We
welcome the focus on this issue in the Government’s Plan for Patients but the Government
must provide further detail on what changes it will introduce.
The Government and NHS England must acknowledge the decline in continuity of care
in recent years and make it an explicit national priority to reverse this decline.
NHS England should introduce a national measure of continuity of care to be reported
by all GP practices by 2024. The new measure should be based on existing models such
as the Usual Provider Continuity Index and the St Leonard’s Index of Continuity of
Care and in the short term should be based on measuring either continuity delivered
by a named GP (in pooled list practices) or by a personal GP (in personal list practices).
The measure should be reported quarterly at practice, Primary Care Network and
Integrated Care System level as well as nationally.
NHS England should provide Primary Care Networks with additional funding to
appoint a ‘continuity lead’ for at least one session per week, and additional admin staff
funding to support the lead in the role. The role of the continuity lead GP would be to
support practices within their network to increase the proportion of patients consulting
with their named or regular GP, learning from best practice around the country. There
should be a specific uplift for areas of high deprivation. (Paragraph 96)
Do not accept
As part of wider efforts to improve continuity of care NHS England should champion
the personal list model rather than dismissing it as unachievable. NHS England should
set a stretching ambition that by 2027 80% of practices have returned to personal list
continuity and provide support for practices to do so.
Do not accept.
The Government should examine the possibility of limiting the list size of patients to,
for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over
five years as more GPs are recruited as planned. These numbers should reflect varying
levels of need in local populations. This would draw us closer in line with our European
counterparts, and help improve access and continuity. It should only be implemented in
a way that does not undermine the fundamental rights of patients to access a GP.
Do not accept.
NHS England should re-implement personal lists in the GP contract from 2030 onwards.
Do not accept.
Integrated Care Systems should prioritise simplifying the patient interface with the
NHS by improving access, triage and referral across first-contact NHS organisations
including general practice.
NHS England should abolish the Quality and Outcomes Framework (QOF) and Impact
and Investment Fund (IIF) and re-invest the funding in the core contract, weighted to
account for patient demographics including deprivation, to incentivise continuity of
In particular, NHS England should focus on significantly improving the outcomes
data provided to GPs by focusing data collection and analytical resource on outcomes
measures rather than the process data and reporting required by these micro-incentives.
NHS England should support Integrated Care Systems to implement gain sharing so
that Primary Care Networks and individual practices that support the reduction of
secondary care expenditure, such as through reducing unplanned admissions, are able
to share in the financial gains.
NHS England should revise the Carr-Hill formula to ensure that core funding given to
GP practices is better weighted for deprivation. NHS England must also review new
PCN funding mechanisms to ensure that they do not inadvertently restrict funding for
areas which already have high levels of need.
The Government and NHS England should increase the level of organisational support
provided to GPs with a particular focus on important back-office functions such as HR,
data and estates management.
In response to this Report the Government should reaffirm its commitment to maintaining
the GP partnership model and explain how it will take forward our recommendations
to better support the partnership model, alongside ongoing work to enable other models
of primary care provision.
The Government should consider adopting the approach to GP premises taken in Scotland
and conduct its own analysis of whether this would be viable for general practice in
England. More widely the Government must make additional investment available for
the general practice estate to enable integrated care to be effectively delivered.
The Government should accelerate plans to allow GP partners to operate as Limited
Liability Partnerships or other similar models which limit the amount of risk to which
GP partners are exposed.