Despite his prominent position as head of primary care commissioning at NHS England, Dr David Geddes is readily available. The York GP still answers his own emails and readily picks up his mobile phone. We set up our interview via email, but run into difficulty when the press office decides it wants control over the questions asked.
After a lot of to-ing and fro-ing, it is agreed that we can ask pre-submitted questions, although one about further GP involvement in persuading patients of the value of care.data is nixed – that is not Dr Geddes’ territory.
We meet at NHS England’s Kremlin-like Leeds headquarters, against a backdrop of further NHS turmoil and funding uncertainty for GPs. The seven-year phase out of the minimum practice income guarantee (MPIG) for GMS practices has just begun, NHS England’s area teams are poised to conduct a review of £260m of PMS practice funding, and new NHS England chief executive Simon Stevens has announced CCGs will join area teams in commissioning GP services.
Using a combination of lifts and hidden staircases, we reach a remote meeting room on the otherwise deserted seventh floor. Dr Geddes arrives, blissfully unaware of all the background manoeuvring by the press office, and happily poses for our photographer. He is calm and collected, speaking with knowledgeable air.
Right from the start, he refuses to beat around the bush or sugar-coat hard truths – tactics so common among high-level managers in public institutions. He will not guarantee NHS England will prevent ‘outlier’ practices, heavily affected by MPIG, QOF changes or the impending national PMS review, from closing.
‘Well, I can’t say that,’ he says. ‘Because obviously what you are implying is that we will be focusing on all practices and saying none of them will ever close.
‘I think what we aren’t expecting is for the cheque books to come out to create another small MPIG – in other words, provide some backfill with no purpose.’
The same goes for the PMS reviews. ‘I don’t think staying open will be a guarantee that anyone can make,’ Dr Geddes says.
‘This is not about saving practices, but ensuring that patients get good primary care services. As such, some things will just have to change.
‘[But] if you have a practice which is providing a fundamentally important service for that population, [then] it can’t go anywhere.’
Amid the anxiety of the PMS review, some GPs have taken matters into their own hands to ensure future stability. In Essex and East Anglia, hundreds of practices have been offered deals from the area team to switch to GMS, supported by a seven-year phase-out of the PMS ‘premium’ they are paid on top of core contractual funding.
Does moving away from PMS contracting fit in with the wider strategy? He says simply: ‘No.
‘It is not like there has to be that fundamental shift from PMS to GMS, that is not what it is about. PMS practices… still have the right to go and become GMS practices. But I don’t think we are into trying to encourage that.’
Working with CCGs
Dr Geddes is open to the idea of PMS practices keeping their ‘premium’ payments, but only those that are prepared to offer additional services aligned to the local primary care strategy. These are currently being worked out by area teams as part of NHS England’s Call to Action consultation on the future of general practice, and also within CCGs’ five-year commissioning plans for their local health services, the final versions of which are due imminently.
Dr Geddes says: ‘It is really important that the PMS review takes into account the strategic direction for primary care and how it is going to be developed. Again, it comes back down to making sure this is done jointly with CCGs.
‘The outcome at the end needs to be that for practices, of whatever type, if they are offering the same service – the same core service – then they should be getting the same funding.’
To get this right, plans for CCGs to co-commission general practice alongside area teams will be critical, says Dr Geddes.
He says: ‘Commissioning of primary care should be clinically informed [and] CCGs are where decisions are made for the community.’
Despite enthusiasm from NHS England – and indeed some CCGs – LMC leaders have rejected co-commissioning, due to the risk of undermining the national GP contract and concerns the move makes GPs vulnerable to accusations of conflicts of interest.
Dr Geddes is not perturbed. ‘Whenever we develop a new service, or we take that process forward with CCGs and NHS England co-commissioning, we need to manage the conflict of interest,’ he says.
‘It is perhaps inevitable, following the Health and Social Care Act, that stability hasn’t felt like it has been there for the last year.’
Dr David Geddes
‘That is really important… but I think that it is eminently doable, and is not therefore going to be an impediment.’
The importance of stability
Dr Geddes is a jobbing GP – he still sees patients on Fridays – and this may explain his ability to transcend the usual NHS England technocrat language and speak directly to GPs. He accepts that, after several years of upheaval and reform, GPs just want some stability. He says: ‘It is perhaps inevitable, following the Health and Social Care Act, that stability hasn’t felt like it has been there for the last year.’
But he insists the latest changes are about transferring funding into the system and even easing workload for GPs.
‘I think there are more discussions to have with CCGs, regarding how we can co-commission and how we would work that through in order for CCGs to be able to look at shifting some of the funding from where it currently sits in secondary care into more of a community and primary care service,’ he says.
‘There is a really important message that we want to be able to create some stability, create some confidence in the system. We want to create headroom for people to be able to think differently and innovate in a way that will help us provide primary care at scale, which would be our long-term ambition.’
The ambition to create headroom for busy GPs may be laudable, but what about the fundamentals – why can’t NHS England pay GPs on time? Dr Geddes gave a ‘cast-iron guarantee’ last year that the payment delays and mis-payments plaguing GP practices across the country would be fixed by April. Has this happened?
He says: ‘I don’t think it’s completely smooth and I think that some of the consequences of having three different commissioners mean it is inevitably going to be a little more complicated than under PCTs. But the endemic problems that arose from the shift to a new system, I think have been sorted.’
And after that nugget of good news, he is whisked away by the NHS spin doctors.