NHS England yesterday announced the 2022/23 update to the GP contract, which was met with dismay across the profession.
The stand-out line of the imposed GP contract changes was that PCNs in England would need to offer routine services between 9am and 5pm on Saturdays from October as part of a new access offer within the network DES.
The BMA has declined to provide any clarifications, saying that all queries about the contract should be directed to NHS England. But NHS England has also refused to respond to any of Pulse’s queries.
So, what do we know so far?
In the letter sent to practices yesterday, NHS England confirmed that the new ‘enhanced’ access offer will bring together the current £1.44 per head Network Contract DES extended hours funding and the current £6 per head CCG-commissioned extended access services into the PCN DES.
While the work for the CCG service will be brought into the PCN DES, NHS England’s letter is vague about whether the money that backed it will also be moved into DES.
The £1.44 is already part of the PCN DES, so if the £6 is brought in, PCNs would receive a total of £7.44 per head for delivering the service. If not, this would mean a significant drop in funding – perhaps meaning practices would be offering the service at a loss.
The funding has dropped before. When extended hours was brought into the network DES, it dropped by 46p – from £1.90 to £1.44.
At the same time, the requirements have become more onerous. NHS England has said that PCNs will need to provide a ‘minimum of 60 minutes of appointments per 1,000 PCN adjusted patients per week’. Until now, the Network DES – like the extended hours DES before it – specified 30 minutes per 1,000 patients. It added that this new offer is ‘based on PCNs providing bookable appointments outside core hours within the Enhanced Access period of 6.30pm-8pm weekday evenings and 9am-5pm on Saturdays’.
But it’s unclear whether the service needs to cover the whole time period, or whether the contractual extra hours can be offered at any time during the ‘Enhanced Access period’ – ie 6.30pm-8pm on weekdays and 9am-5pm on Saturdays, referred to by NHS England as the ‘network standard hours’.
PCNs can also provide a ‘proportion’ of the required Enhanced Access minutes outside of these ‘network standard hours’ if this has been agreed with the commissioner – where it is ‘evidenced by the PCN that such appointments would better meet the needs of the PCN’s patients’.
NHS England said this could be through the provision of a morning clinic between 7am and 8am, or ‘by exception’ a proportion of capacity could be used to ‘support management of demand during core hours where this is regularly high’.
PCNs have been told they must offer ‘a range of general practice services, including “routine” services such as screening, vaccinations and health checks, in line with patient preference and need’. They have also been told they must provide bookable appointments for ‘any general practice services’.
This too is vague, and seems to allow GPs some flexibility in interpretation. It is unclear whether NHS England will be issuing guidance on how PCNs should decide which services to offer. And Pulse has sought to clarify whether there is indeed flexibility with this ‘range’ of services, or whether PCNs are in fact being asked to offer the full range of routine services during the Enhanced Access hours.
NHS England’s letter seems to suggest that all appointments offered as part of the service must be ‘bookable’ – both in advance or on the same day – but it is unclear what is meant by this.
It also says that ‘all appointments that do not require triage are able to be booked online, as well as in person or via the telephone’. With many practices still doing total triage, it is unclear whether NHS England is saying they shouldn’t. And it has not clarified which appointments are classed as those that ‘do not require triage’.
Meanwhile, NHS England has stipulated that the service must include a ‘reasonable number’ of face-to-face appointments, without defining what this means in practice.
And the appointments must be delivered from premises that are ‘as a minimum equivalent to the number of sites within the PCN’s geographical area from which the CCG Extended Access Service was delivered’.
While the service must ‘[utilise] the full multi-disciplinary team, PCNs have been asked to ‘ensure GP cover’ during the network standard hours – ie 6.30pm-8pm on weekdays and 9am-5pm on Saturdays. This ‘GP cover’ must include ‘providing in-person face-to-face consultations, remote consultations, leadership, clinical oversight and supervision of the MDT. This seems to suggest a GP needs to be onsite at all times while the service is being offered.
NHS England said PCNs must make any ‘unused on the day slots’ during the extra access hours available to NHS 111. It said this was ‘in line’ with previous guidance, but it remains unclear what guidance it is referring to. And it is unclear whether this means unused slots from any time of day should be made available to 111 during the ‘enhanced access’ hours, or unused slots from during the ‘enhanced access’ hours should be made available to 111 during the same hours. In any case, the letter added that PCNs may not have to open the slots to 111 if they have ‘agreed with the commissioner that the timing for when these unused slots are made available is outside of these hours’.
What was the situation before?
Under the Network Contract DES extended hours service, PCNs are required to provide a minimum of 30 minutes per 1,000 registered patients per week. These appointments must be held outside of ‘core’ hours, which are 8am to 6.30pm for GMS practices, and are funded at £1.44 per head.
Under the CCG-commissioned extended access services, GP practices are required to provide a minimum of 30 minutes per 1,000 population backed by £6 per head. On weekdays, this includes pre-bookable and same-day appointments in the evenings (after 6:30pm) to provide an additional 1.5 hours a day. On weekends, this includes pre-bookable and same-day appointments on both Saturdays and Sundays to ‘meet local population needs’.
However, the CCG service was very variable due to differing levels of funding for the scheme across the country. While the scheme was funded at £6 per patient, this wasn’t spent in each site. And while it was originally suggested that the service would be offered form 8am-8pm seven days a week, there has been lots of variability on that too. What’s more, NHS England has been very vague in sharing the service specification publicly.
There was also less focus on routine services under previous schemes.
Delivery of the service is due to start from October 2022, but NHS England has said that ‘preparatory work’ will begin ‘from next month’. There is no detail so far on what is meant by this.
PCNs have been told to ‘work with their commissioner to produce and agree an Enhanced Access Plan‘ to ‘prepare for delivery’ of the service from 1 October. Plans must be submitted by 31 July with a ‘final iteration’ agreed by 31 August.