The current GP funding model ‘does not sit comfortably’ with NHS England’s plans for primary and community care integration, according to a senior NHS England director.
In a Lords Committee hearing today, NHS England’s national director of primary and community care services Dr Amanda Doyle said a ‘rethink’ was required with regards to the primary care estate, with ICBs tasked to draw up local plans.
Asked whether the GP partnership model was compatible with integration, Dr Doyle told the committee that this was ‘one of the challenges’ they are facing.
She said: ‘One of the challenges that the current predominant ownership model in general practice gives us is that both investment and revenue flows support that model [of] an individual, practice-sized building.
‘And lots of the things we want to do as we move forward into co-located primary care services and scaled-up primary care delivery drive the need for bigger premises with a wider range of capacity, and those two models don’t sit comfortably together.’
She added: ‘There’s also an argument that a younger generation of GPs [are] less keen to jump straight into partnership including building ownership and all the risks that brings.’
She confirmed that each Integrated Care Board (ICB) is currently preparing a strategy for its own estate.
Asked if too much money is being spent on hospitals currently, Dr Doyle also told the Committee that ‘we absolutely need to rebalance’ the capital investment differences between secondary and primary care.
‘There is no doubt that as we expand our thinking about the capacity needed in primary and community services to serve a population who will be much more reliant on preventative but also care for long-term conditions and increasing frailty out of hospital in people’s own homes, as well as the expansion of things like virtual wards, where we’re delivering care in the community rather than in a traditional hospital bed.
‘That is going to drive us to a greater consideration of what the capital, estates and IT infrastructure out of hospital both in primary care and community care services need to be,’ she said.
When it comes to staffing struggles across the country, Dr Doyle also admitted ‘there’s no doubt’ NHS England ‘needs to do more to retain more experienced clinicians’ on top of efforts to attract more GP trainees.
In answer to a question regarding the statistic that 23.2% of general practitioners work full-time, although she highlighted that this could be due to a multitude of reasons – such as parents choosing to work part-time, doctors having portfolio careers or reducing their hours towards the end of their careers – she added that ‘we can’t ignore the fact that alongside all of that, there are people who are finding the job, the workload, overwhelming, the demand is overwhelming, and they are choosing to adjust to that by working less than full-time’.
Dr Doyle acknowledged that it was key when implementing the primary care recovery plan to create ‘a future where general practitioner is a job where people can manage the workload, do what they were trained to do, it’s a satisfying job and they want to stay doing it for 30 years’.
GPs in the UK experience the highest levels of stress and have the lowest job satisfaction compared to doctors in other high-income countries, according to a recently published report, while more than one in five GPs aged under 30 quit the profession last year.
Labour Party leader Keir Starmer has said the GP partnership model is ‘coming to an end of its life’ and that the NHS needs ‘more salaried GPs’.
“ Dr Amanda Doyle said a ‘rethink’ was required with regards to the primary care estate, with ICBs tasked to draw up local plans”
I read this as cost rent will be going elsewhere
These industry-led plans (see Finola ONeill’s comment) are 10-20yrs old and – in the face of the current concoction of NHS and patient mortality catastrophes – the determined inflexibility of government, NHSE, and probably the Labour Party, is astounding and deeply worrying. These plans will do nothing to improve things and are highly likely to make things worse. Deprofessionalisation is an aim, not a by-product, of penning the sheep. Ignore the obvious, deny the neglected basics, keep spinning the sunlit uplands and we’ll let you pretend that GPs are the problem.
Dear All,
I really think the problem here is that they simply cannot understand the value that the entrepreneurial element of the IC model delivers in terms of efficiency. I am a partner, my income is substantial but my hourly “rate”, when counting the actual hours I work, is moderate by other comparators. When I read letters written by salaried doctors who have moved elsewhere I see comments like; “you’ve unblocked sinks, changed lightbulbs, re-written draft responses to complaints” and I think would I have done any of those if I were a salaried employee?
My message is very simple, they know not the value of what they squander.
They think that by getting rid of the 3,500 high earning and thus contract declaring GP partners (their data) they will somehow sort the problem.
Have they not considered that as a salaried employee it is lawfully impossible to deny my right to do what I want outside my contracted hours?
So to the observers, what that means is I give up my partnership, I take a cash lump sum for my equity, become an NHS employed GP, I adhere 100% to their terms and conditions and NHSE/CQC/GMC protocols (read for that I will now refer or test for everything and everything at every contact rather than practice my skill of managing uncertainty, so your costs will go through the roof, longer term I will harbour no feeling of professional identity and will probably do what I can to subvert the system i.e. find something at every consultation to refer into 2ry care) and now outside those absolutely defined and policed NHS employed hours I can do whatever I like in the private world, which of course is being fueled by the lack of those GPs that used to be partners in the NHS because my overall accessibility will be reduced.
So all in all the wrong policy at the wrong time.
Regards
Paul C
They don’t have to put any more holes in an already sunk ship.Another I’ll thought out mess.As Paul C says,work to contract and they will well and truly stuffed with much poorer patient care.
Just a thought the only other places in the nhs that work at scale are hospitals and they are a example of efficiency and workforce contentment at the moment eh NHSE.I’ll thought out mess.Remember the out of hours cost 4 times as much with a poorer service.This direction of travel will make that look like a shrewd move in comparison.
I think Amanda has a case of Darzi syndrome, it’s been well described and often accompanied by the delusional idea that shoving a bunch of clinicians in a building and bringing in some more managers will suddenly make them seamlessly work together in an integrated holistic cost effective evidence based way. I suppose it will be cheap to change the name from Darzi centres to Doyle centres as only 4 letters need changing.
There it is, I’ve expelled my buzzword flatulence.
Back to Lab results
“The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design. To the naive mind that can conceive of order only as the product of deliberate arrangement, it may seem absurd that in complex conditions order, and adaptation to the unknown, can be achieved more effectively by decentralizing decisions and that a division of authority will actually extend the possibility of overall order. Yet that decentralization actually leads to more information being taken into account.”
Friedrich Hayek, The Fatal Conceit 1988.
It’s not that successive generations of NHS central planners are unintelligent, rather it is an impossible task to know every individuals changing wants, needs and preferences in the first place. All this central planning is pointless, with each successive “X year plan” sounding more like a pastiche of the USSR or Chairman Mao.
Current GP funding model is not compatible with good clinical practice
I am aware there are issues with access to General practice (albeit far better than that of secondary care though) however the alternate systems are not working either – look at the first integrated community and GP system which is in freefall.
https://www.hsj.co.uk/dudley-integrated-health-and-care-nhs-trust/pioneering-trust-facing-last-ditch-talks-as-merger-bid-fails/7034995.article
Replacing a partner based system with a 100% salaried is a stupid idea designed to make things easier for administrators. It’ll cost a fortune but that doesn’t seem to matter because thats a different government department. It’ll be much easier to control everything and make meetings easier. That aside what we have today is a complete and utter dog’s dinner of a set up. We do need partnerships, adequately funded independent partnerships. But thats not what we have today. What we have today is a hybrid system of partnerships, partnerships + salaried and salaried alone. We have a obscenely micro managed severely under funded service that is on its knees. Over and over you hear the cliched almost worn out phrase ‘newly qualified GPs today don’t want the stress of taking on partnerships’ ..Why is this? Why the F do you think this is?? A weird a generational thing perhaps?? It’s because the service is micromanaged and under funded FFS! It arises directly from this. Being a partner and doing things the way they aught to be done is now basically impossible. So the people who take on partnerships please stop smugly patting yourself on the back. You guys have and continue to prop up and facilitate a failing system whilst simultaneously failing to adequately defend what you are watching being destroyed. You continue to accept unacceptable contracts. You meekly agree to do whatever you are told. You refuse to go on strike. You abjectly fail to stand up for yourself. Increasingly the only way to make partnerships work is to exploit a subset of your fellow salaried colleagues and you do it, you tell yourself its the only choice you have. No it isn’t. And you moan, oh how you moan. Passivity? self interest? masochism? greed?..who knows why you are personally still at it but you and the professions failure to defend the service whilst simultaneously keeping it running forms a great deal of the cause of the problems were now face. So whilst I certainly agree a primary care system based on partnerships is better than a salaried one…you guys still doing partnerships aren’t the saints you take yourself for. Not in the least.
Dear A Non, I fully aknowledge your distress caused by current partners failing to defend a failing system and accepting unaccepteable contracts while engaging in passive masochism with greedy self- interest. It may reasure you to know that I, for one, and despite multiple evidence based suggestions to the contrary, have never considered myself to be a saint. Hope this knoweldge is useful to you and please don’t hesitate to make your feelings known in the future. Without our views this world will be a much sadder place.
Thanks for your response to my comment and the neat summary some bloke! I’m delighted you are neither passive, masochistic or greedy. Good on you and keep it up.
..oh forgive me, it was the saint bit you were denying. Well we can agree on that bit then. Nice one.
Can we move this talk away from full time/part time. A ‘part time’ GP doing 6 sessions in GP is, on the best day, 31 and a half hours- on a normal day36 hours which is pretty much a full time job in any other career. Also most have other roles outside of clinical work. So we need to change the dialogue about part time/ full time because it’s nonsense and just used as another stick to bash us all with.
Reply to Paul Cindy.
Absolutely spot on. Independent Contractor status is best. Gives ownership and independence.
The independent contractor model is something they hate precisely because we don’t fit into their plans. We have actually proved more resilient and their dream of crashing the nhs and privatising it is being messed up by the bit of the nhs that is private and efficient. Private companies have tried and failed to turn a suitable profit at primary care. We are making their moneyed friends look bad. Sadly they have a combination of power with unconscious incompetence that enables them to really screw things up for everybody.
I do find these articles a bit of admission of failure in their plans so far. We are road runner to their Wil E Coyote. The big problem for them is that primary care is more fleet of foot. We can make a decision and implement change in a matter of hours. This is like the flash to them.
I have been a partner for 38 years and senior partner for 25 of those and I have thoroughly enjoyed all of it until the last couple of years, We have had a feeling of ‘ownership’ and enough independence to run the surgery how we like and it has been a fun place to work and given a good service to patients.
PCNs have been a ‘breaching mechanism’ to force homogeneity on us much as qof and CQC did before that. Our health authority has repeatedly tried to get us to drop personal lists which we have resisted. I am now just retired and rather relieved because I am a traditionalist and not happy with the ‘template, tick box, guideline’ modern approach. To me it seems to have sucked the joy out of the job. I am sure ditching the partnership model will be a mistake and regretted.
Dr Heatley,
I am happy to note there is somebody else like me after 32 years as a GP and last 10 years as senior partner, could not put yup with the clerical work I had to do.Why train and educate you to such levels to do box ticking.
Though personally I think I have a few more years, I dont think I can stomach CQC,PCN amd CCgs any more.
Thank god I am old enough to retire. My heart goes out to middle aged colleagues who will have to go through this madness.
The only bright light in this is partnership model and Amanda thinks this is incompatible with good clinical care.
I am sure Dr Darzi will be happy.
Ageing population, new expensive treatments and healthcare inflation are inescapable realities.
The national debt and tax burden are at levels comparable to the 1940s and there is no spare money.
NHS salaries have fallen behind inflation leading to recruitment and retention problems that threaten to drive up costs. (Not only use of agencies/locums but also significant costs from increasing supply through med school or poaching medical staff from poor developing nations).
The public are getting / will have to get used to “less”. Loss of continuity may be more inefficient and offer lower satisfaction although it may influence public expectation and demand on services. It will also be more palatable to have to travel across town to a go than to wait 60mins for a 999 ambulance. The system has piled additional pressures on practices that has compromised delivery so that the move to volume will be accepted.
I recognise that loss of continuity and excessive ‘skill mix’ may increase the need for 999. However, the direction of travel has been well broadcast for years. GPs who are not able to emigrate/retire early need to consider the implications of holding premises / staff liabilities. It initially affected just smaller practices like mine was years ago – it is now medium sized practices.
It has long passed “how things should be” and it is now “how things are and will be”.
The CCG and ICB were just distractions to keep you over-matched so GPs didn’t notice