Exclusive Practices will be expected to merge or federate to offer routine opening on Saturdays and offer flexible appointment lengths as part of London local area team’s £810m a year bid to reshape general practice in the capital.
The NHS England (London) ‘transformation framework’ – led by former RCGP chair Professor Clare Gerada, who is now chair of the Primary Care Clinical Board at the local area team – encourages practices in London to begin to move towards a range of new services from April, in the first indication about how local area teams will be implementing NHS England’s recently published Five Year Forward View document.
It will incentivise practices to merge or federate as ‘Multispecialty Community Providers’ (MCPs), which will provide a range of enhanced services, and could lead to some providers voluntarily opting out of the national GMS contract for a hybrid of APMS and the NHS Standard Contract.
The new services will include widening access, actively seeking out patients who are not visiting the practice and holding team meetings with social services, housing and finance advisors on a regular basis.
The document says that offering this new ‘specification’ for general practice in London will cost up to £810m a year, representing a 5.36% shift in the overall health care budget – plus an unspecified amount of ‘transition’ funding.
In addition, the report said London practices would also require the £1bn investment for premises recommended in the Better Health for London report.
The plans, which represent the first detailed proposal for how GPs may work within the planned new models of practice in England, would see the groups of practices:
- provide routine opening from 8am-noon on Saturdays;
- provide extended access seven days a week, typically from 8am to 8pm, to be delivered via a network of practices, with a larger practice ‘in most cases’ providing the service on behalf of other practices;
- use a telephone triage system;
- provide flexible appointment lengths to patients;
- provide add-on services such as citizen’s advice and probation services;
- liaise with schools and workplaces to improve health literacy within their patient population;
- have staff reach out to patients not currently seeking healthcare, such as ‘gypsies, travellers, sex workers, homeless people, vulnerable migrants, people in care homes, and people with learning disabilities or severe mental illness’;
- working to joint contracts with other GP practices, primary care, social care and hospital providers;
- identify all patients that need ‘coordinated care’ and manage their care through multidisciplinary teams.
The report emphasised widening access to GP services.
It said: ‘There is… evidence that some patients go to A&E with minor issues because they can’t get a same day appointment with a GP – especially at weekends when many practices are closed. So we’ve proposed that all patients should be able to access a consultation with a GP or senior nurse from their own practice on the same day in routine opening hours and on Saturday mornings. We’ve also suggested that patients should be able to access a primary care health professional seven days a week, 12 hours a day in their local area.’
It also promotes continuity of care, by suggesting that patients should be able to book appointments of ‘flexible duration’ with the GP of their choice in advance.
The report said: ‘Patients, such as those with long term conditions, tend to need more frequent consultation and value continuity and familiarity – but are willing to wait a little longer to be able to do so. So this specification outlines that patients should be able to book at least four weeks ahead if they wish and see their GP of choice in an appointment with a flexible duration.’
The report said the new patient offering ‘can only’ be delivered by GPs working in federation and with other primary, secondary and social care providers, which could be contracted via the NHS Standard Contract, alongside the core GMS contract.
It added that some practices may volunteer to give up their GMS contracts to become APMS-contracted ‘super partnerships’ or take on a new APMS/standard contract hybrid model.
Londonwide LMCs chief executive Dr Michelle Drage reacted to the plans with cautious optimism, saying: ‘For the first time in over a decade there appears to be an appetite from the NHS in London to shift resource into primary care, and to support GPs with better community services. The commissioning specifications are ambitious and will need to be implemented in a way that supports GPs and practice teams doing tough jobs, day in day out.’
Dr Brian Fisher, a GP in south east London and patient and public involvement lead for NHS Alliance, said: ‘I am delighted that it is absolutely clear that it demands a significant investment into primary care. It is less clear where that investment should come from. In my opinion it is unacceptable for this to come from hospital bed cuts.
‘The main limitation is as usual there is no way of delivering the programme. There is no mechanism across London to make this happen. So it now goes down to localities who may or may not be committed to this process.’
But Dr Louise Irvine, a GP in south London and the National Health Action (NHA) party parliamentary candidate for South West Surrey, said Saturday opening would be ‘fine’ if resourced with funding and GPs, adding that this ‘will be a challenge as both GP funding and GP numbers are falling’.
She also warned it could lead to privatisation and inequalities, saying: ‘For me the most worrying aspect of these proposals is the idea of GP practices being subsumed into Accountable Care Organisations run by a “lead provider” who could be a private provider.
‘I would urge extreme caution with the direction of travel of these proposals and do not feel that GPs should support them.’
The plans echoes the five-year vision set out by NHS England last month, which proposed primary care should receive more funding in return for reorganising into multidisciplinary care organisations doing both traditional GP work and services usually provided in hospitals, either via GP practices employing hospital specialists or hospitals employing GPs.
Writing in the introduction to the London report, which is being discussed at a large-scale meeting of commissioners in the capital today, Professor Gerada said: ‘General practice has served patients, the public and the NHS well for over 60 years. It has delivered accessible, high quality, value for money care.
‘However our patients are changing, both in the complexity of their conditions and in their expectations. This means that if the NHS is going to continue to provide the excellent standard of care to which we all aspire, we will have to be more innovative.
‘Tweaking at the edges is not an option. London needs solutions that will sustain primary care for the next 60 years.’