If you work in Primary Care you will no doubt have seen information about the Long Term Plan, and about Primary Care Networks, which are being touted as the “building blocks” of the NHS by NHS England. Inevitably, much of the comment online, including in GP Survival, has been quite negative, perhaps best summed up by the idea that this is more of the same, and will change nothing.
Of course, there are reasons for healthcare workers to be cynical given the track record of previous plans:
- The Five Year Forward View, which promised 5000 more doctors in primary care by next year, and has seen that number fall every year of its existence despite the bluster on the NHSE website about improvements in recruitment numbers. The best thing I can say about the 5YFV is that we are now in the process of replacing it in its fourth year of existence.
- The Primary Care Infrastructure Fund, which changed into the Primary Care Transformation Fund, and then the Estates Technology and Transformation Fund, all of which served to produce endless ‘feasibility studies’ which benefitted precisely no one apart from the authors, and which were so habitually raided to plug funding gaps elsewhere that less than 5% had been spent on premises halfway through its lifespan.
While there have been small-scale successes in previous plans, generally they have presided over declining recruitment, increasing workload, and reduced GP retention. Despite this, I believe the Long Term Plan should work, and perhaps more importantly seems to signal a change of direction from NHS England.
Indemnity
First, indemnity. In some ways, I should hate this, given that a large chunk of the increased GMS funding has been clawed back in the first year, effectively meaning that as a GP partner I’m paying towards everyone’s indemnity this financial year. However, removing the burden of indemnity costs will encourage doctors to work more, and takes away the spectre of spiralling costs in the future. Whatever type of GP work you do, this will save you money immediately, and is something that the GPC and NHSE both deserve praise for agreeing.
Staffing
Second, and more controversially, staffing. Lots of the comments on Nikki Kanani’s pulse article were critical that Primary Care Networks will be funded to employ allied healthcare professionals rather than doctors. However, this to me is having-your-cake-and-eating-it criticism – having repeatedly pointed out how long it takes to train a doctor when that 5000 figure was floated, I can’t sit here now and grumble that the long-term plan hasn’t promised me more GPs by 2022 – that’s not possible to do. While I have no particular insights into what the pipeline is or isn’t for pharmacists etc, they can be trained quicker than doctors, and the fact that the LTP has looked at this rather than making blithe promises it can’t possibly keep is a positive thing.
Personally, I know how useful pharmacists can be – my practice has employed one for more than a decade. Yes, they can’t replace GPs, but they can lessen your workload right now, you control what they work they do for you (so it’s not all CCG-mandated cutting of prescribing costs), and that – hopefully – makes the job of a GP day-to-day that bit better. That, in turn, helps retention until we can train up more GPs – and it’s realistic in a way that past promises haven’t been.
Funding
The Long Term Plan also provides funding directly to practices and networks. There’s no bidding for short-term pots of money, as with the soul-destroying process of bidding for Prime Minister’s Challenge Fund, or PCIF, or PCTF, or ETTF monies which you invariably then didn’t get. Jacqui Appleby commented on the GPFV: “while initiatives had been set up at scale, cash had not found its way to individual practices[…]No one really knew how much money they were entitled to or whether it had all been spent on initiatives that benefited practices.” Unlike previous efforts, here if you form a network, you get the money.
These are significant amounts of money, too. Where in the past we’ve had meaningless talk of “the highest proportion” here or “a 3.2% national uplift” there, these are numbers which can be understood at a practice and a network level.
Looking at funding per weighted head of population, practices lose £1.45/head in the Extended Hours DES funding, but gain £1.76/head in ‘Network Engagement Funding’, for a net gain of £0.31/head. The network then gets the £1.45/head DES money, along with £1.50/head from the CCG as the ‘Network Financial Entitlement’, and £0.69/head in Clinical Director funding (less in the first partial year). That’s a total of £3.64/head in direct funding to the network, or £182k to a network of 50,000.
Practices get a net 31p/head just for being part of a network – on top of the GMS uplifts in the contract, that’s a £1.23/head increase.
The networks themselves get £3.64/head, or £182,000 across a network of 50k per year (less in the first year as it is pro-rated to cover 9 months rather than 12). That is a direct entitlement. If you choose to employ a pharmacist and a social prescriber, the network pays £16,204 of that per year, and claims an extra £71,923/year from NHSE – so they pay your network about a quarter of a million a year, and after paying for the two extra staff your network has about £166k left to spend. Some of that needs to pay for the extended hours, so it could go back to practices if they want to do the work. Ultimately there is money there, and although it’s not earth-shattering, it’s a start and it just needs spent towards meeting the aspirations in the contract,all of which I suspect practices are doing already to some degree.
Local
I know, this risks sounding a bit League of Gentlemen – but the money is a financial entitlement if you sign up, and it can only be accessed by local GPs. As Ockham Healthcare have pointed out, “there is almost no other way they could have phrased this without allowing a way-in for out-of-area and private company poaching of work” – this stops new funding getting leached away to shysters and flatterers in favour of entrusting it to the people actually doing the work in GP practices. Up to us, then, not to screw it up…
QOF
I don’t propose to go into the detail here, except to say that the treatment of QOF, as with that on additional staff, reflects a refreshing honesty in the wording of the documents. If you haven’t read it, do: section 3.5 says “QOF also has three notable weaknesses”, listing these as “excessively like ‘tick-box medicine’”, “arrangements for exception reporting are too crude”, and “the scheme has been much slower than it should have been in adapting to the changing evidence base”. This is not the see-no-evil approach of the past.
Conclusion
I’d argue there are two key pillars of NHS primary care – practice numbers and staff numbers. Over the six years of NHS England’s existence, we’ve lost 1,100 GP practices around the country, affecting 4.2m patients, and most of those practices have been small, with an average list size of 3,838. Although it’s good that NHSE have now distanced themselves from Arvind Madan’s desire to see smaller practices “rationalised” out of existence, the decline in practice numbers must change. If we reach 2022 and find that the BMA’s projection of a further 618-777 more practices closing is correct, more than 10m patients will have been affected, or about 18% of the population, and the LTP will likely be struggling.
Similarly, while Primary Care Networks do address the overall workforce, the LTP needs to increase the GP workforce, dramatically. There are green shoots here, but there is still a large historical decline to address. We can’t control national workforce issues at a local level, but for the first time we don’t have to bid to have money to spend to improve patients’ experience of the NHS, and our experience of looking after them. For me, that’s a huge step in the right direction.