This short paper provides an overview and brief analysis of the Rt. Hon. Jeremy Hunt's 'New deal for general practice', set out in a speech delivered on 19 June 2015.
Ostensibly the Health Secretary's speech was intended to set out 'the first steps in a new deal for general practice', though many elements of the package announced are already underway and he also used the speech as a platform to describe additional responsibilities which the Government would like GPs to take on over the coming years.
The Secretary of State described commitments to general practice on:
- reducing bureaucracy
- helping to support struggling practices
He also outlined plans to review the way quality of care is assessed in general practice.
In return he is asking GPs to work towards:
- offering appointments seven days a week
- assuming social prescribing responsibilities
- playing a more prominent role in public health
- taking 'real clinical responsibility' for patients
Acknowledging the pressures facing general practice
The Health Secretary's speech began with welcome praise for the world-leading quality of UK general practice, which he described as 'the jewel in the crown of our NHS'.
In what was probably the most high-profile political acknowledgement to date of the challenges facing general practice, the Secretary of State went on to acknowledge that "successive governments have undervalued, under invested and undermined the vital role [general practice] has to play."
Highlighting the increasing demographic demands facing the NHS he said "we need effective, strong and expanding general practice more than ever before in the history of the NHS".
During the election, the Conservatives committed to increasing the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice, as well as more practice nurses, district nurses, physicians associates and pharmacists.
The new deal sets out plans to address recruitment and retention problems by:
- marketing general practice to medical students
- increasing GP training places
- improving the general practice experience gained during training
- offering a returner scheme for those coming back to the profession
- exploring 'new flexibilities' to retain GPs nearing retirement
- promoting innovation in skill mix, including a commitment to ensure 1,000 physicians' associates are available to work in general practice by September 2020
- focusing efforts on the most under-doctored areas.
Many of these workforce commitments are already under discussion or in the early stages of implementation through the workforce.
The '10 point plan' is a joint initiative between NHS England, Health Education England (HEE), the General Practitioners Committee (GPC) and the Royal College of General Practitioners (RCGP) launched in January 2015.
As part of this workstream a new Induction and Refresher Scheme was announced in March 2015.
The Health Secretary's workforce commitments are unlikely to be deliverable in isolation from broader changes in general practice.
While the GPC is committed to supporting the work around the 10 point plan, the Health Secretary's workforce commitments are unlikely to be deliverable in isolation from broader changes in general practice. Unmanageable workloads in the face of increasing patient demand are acting as catalysts for early departure from general practice, and deterring new graduates from entering.
The GPC had a huge response to the BMA GP survey carried out earlier this year, with over 15,000 GPs responding; unmanageable workload was one of the biggest negative factors for them. Nine out of 10 GPs believe high levels of workload are damaging the quality of patient care and that the 10-minute consultation is inadequate to meet patient needs. We have an understaffed GP workforce trying to cope with unmanageable workloads, and we need several thousand more GPs just to stand still.
The workforce crisis can only be turned around by addressing the pressures in general practice, creating a more manageable and rewarding workload.
The workforce crisis can only be turned around by addressing the pressures in general practice, creating a more manageable and rewarding workload that will attract medical students and junior doctors to general practice and retain the current workforce.
GP training takes a total of 10 years, and the Government's target of 5,000 extra GPs does not fit the harsh reality that recruitment remains bleak.
Our survey signaled an alarming early retirement bulge, with one in three GPs intending to leave the profession within the next five years, and worryingly one in five GP trainees intending to work abroad rather than in the NHS. Since the Secretary of State's speech he has admitted that 5,000 GPs is actually only the maximum number he could hope to recruit during this parliament, rather than a firm commitment.
The BMA has long campaigned on the need for investment in GP premises. The Your GP Cares campaign raised the profile of the premises funding shortfall with the public and policy makers, and GPC made premises a key element of last year's GP contract negotiation agreement.
The Health Secretary's speech referred to the £1 billion Primary Care Infrastructure Fund announced last year. He said that over 1,000 GP practice bids equating to £190 million in investment have been provisionally approved for 2015-2016. The remaining portion of the fund will be allocated over the next three years to be used for both primary care facilities and supporting digital innovation, including helping practices link their patient records to NHS secondary and community care providers and the social care sector.
The GPC has produced guidance on the outcome of the 2015-2016 round of the infrastructure funding and is discussing the use of the next three years' tranches of funding with NHS England.
...there is still a long way to go before all GP facilities are fit to provide patients with the level of services they need...
We are pleased that Government has finally listened to BMA lobbying on the declining, inadequate state of GP premises, which has damaged the ability of practices to meet the needs of patients, but there is still a long way to go before all GP facilities are fit to provide patients with the level of services they need.
The BMA's premises survey last year revealed that seven in 10 practices felt their facilities left them unable to provide additional services to patients, and four in 10 struggled to provide even basic GP services because of problems with their premises.
A key question for the GPC is whether there will be recurrent funding attached to these projects.
The Secretary of State's new deal speech committed to reducing bureaucracy, paperwork and inappropriate workload in general practice. NHS England is to examine ways to cut the burden of reporting bureaucracy and paperwork, and equip GPs with practical tools to better manage the additional workload they generate. The outcome of the NHS England review is due this autumn.
Red tape and over regulation were among the biggest negative factors for GPs.
The GPC welcomes moves to lighten the workload of GPs. Red tape and over regulation were among the biggest negative factors for GPs highlighted in the BMA GP survey from earlier this year.
GPC has published its own guidance for GPs struggling to manage workload, which includes recommendations for managing bureaucracy and inappropriate work shift.
Support for struggling practices
The new deal speech referred to a new £10 million programme of support for struggling practices to be developed between NHS England and NHS Clinical Commissioners. It has since emerged that this funding will be taken from the infrastructure investment so is not new money.
...more funding will be needed to make a meaningful difference to practices in difficulty...
GPC welcomes the commitment to help support struggling practices but will want to be involved in the proposals and would anticipate that more funding will be needed to make a meaningful difference to practices in difficulty.
There are in fact a number of relatively easy changes that could be implemented to make life easier for struggling practices and we will be discussing these with NHS England over the coming months.
Assessing quality of care
Changes are envisaged to the way performance metrics are collated and published. The Health Foundation has been asked to work with NHS England to review, by the autumn, all current metrics used to assess quality of care in general practice.
The Health Secretary wants outcomes-based measures to be published for different patient groups and hopes for new data sets to be published next spring. He said he wants to move from a naming and shaming culture to learning and peer review but as yet we have very little information on what the implications of these changes will be for general practice.
Seven day access
The Secretary of State's reference to seven day access to primary care has received more attention than any part of his speech. In line with Conservative election pledges, the Health Secretary asked GPs to work with him to improve access to routine appointments. This has angered many who feel that it is becoming increasingly difficult to deliver good quality care to patients in core hours and that this should be the primary focus for Government until current problems have been resolved.
The BMA has responded robustly to this part of the speech, highlighting the impossibility of meeting demands for routine seven day services while the profession remains overwhelmed and under-resourced.
If access to routine care is to be extended wihout damaging other services, new ways of working will need to be underpinned by significant additional, recurrent resources and an expanded workforce.
The GPC will continue to make the point that GPs already offer 24-hour care seven days a week, with thousands providing out-of-hours care daily throughout the night and weekends. Forcing practices to provide routine services over seven days would come at the expense of quality and reduce GP availability for older and vulnerable patients, many of whom need to be visited at home. The Prime Minister's Challenge Fund pilot sites indicate that there is not even particularly high patient demand to see GPs for routine appointments throughout the weekend.
It should be noted that the Health Secretary did not suggest that individual practices will need to provide routine seven day services and the proposals do not suggest that all GPs will be required to work weekends. The speech referred to finding a 'flexible and balanced approach' based on local solutions, multi-disciplinary working (particularly with pharmacists) and imaginative use of technology.
The Secretary of State referred to GP networks and federations as one possible way to increase access. Seven day working has already been tested in some parts of the country through the Prime Ministers Challenge Fund and this programme will be rolled out this year. If access to routine care is to be extended without damaging other services, new ways of working will need to be underpinned by significant additional, recurrent resources and an expanded workforce. New models of care are evolving and must be considered as part of the solution and future of general practice.
The GPC has published a discussion document on new models of care proposed by the Five Year Forward View and has guidance for GP networks. It has also been consulting GPs, the public and other stakeholders about the future of general practice.
Other demands from general practice
In addition to the seven day service commitment, the Secretary of State's speech referred, very briefly, to other new responsibilities for GPs to 'deliver a profound change in the quality of care we offer to patients'. He asked that social prescribing becomes a normal part of GPs' work, that GPs play an even bigger role in public health and that general practice takes 'real clinical responsibility' so that patients know 'where the buck stops for their NHS care'.
No real detail is given about how these changes will be implemented. The GPC will keep GPs and LMCs informed as further details emerge and will resist any attempt to increase the existing responsibilities of GPs without commensurate resources and support.