First announced in the NHS’s Long Term Plan, and for the first time in the NHS history, funding for primary care is guaranteed to grow more quickly than overall NHS funding.
The LTP is not quiet on why this funding is needed: “Community health services and general practice face multiple challenges – with insufficient staff and capacity to meet rising patient need and complexity.”
The LTP outlined some of the initiatives that this primary care funding will be used for – ranging from increasing access to digital GP appointments, to helping practices group together to form networks and supporting workforce growth. But now that the framework for the new GP contract has been published, we know more about how these initiatives will be implemented in practice.
Here are the three of the big changes in the new contract:
1. Networks: Networks are groups of practices covering roughly 30,000-50,000 patients. Standard GP contracts are now being extended to include an add-on network-level contract. This means that practices can receive funding at the network level, to help them implement the LTP commitments. Support will also be given for extended hours. In addition to earmarked funding for LTP commitments and extended hours, practices will receive an additional £1.50 per head of cash support per year. For a typical network, the sum of these funding streams will amount to additional network-level funding of roughly £1.5 million by 2022/23.
After a consultation process and negotiations with General Practitioners Committee England, specific requirements around seven areas from the LTP will be formally introduced in network contracts:
Structured medicine reviews
Delivery of enhanced support to care homes
Proactive care for patients at greatest risk of hospitalisation
Personalised care, including shared decision-making and personal budgets
Support in early diagnosis of cancer, including increased screening
CVD detection and case finding
Tackling health inequalities
The overarching aim of these initiatives is to place primary care at the frontline of anticipatory and proactive population health management. As always, the devil will be in the detail: how can practices, or health systems, risk stratify their population to ensure that the funding is well-targeted? And how effectively can the opportunities and pressures be shared and managed across the health system, encompassing social, community and secondary care as well as general practice?
2. Quality and Outcomes Framework (QOF): The structure of QOF, the primary reward and incentive mechanism for general practice, is changing substantially. 28 metrics have been retired, for a range of technical and clinical reasons, and replaced by just 15 new indicators. Significantly, modules on end-of-life care and prescribing safety have been introduced using the points left-over from the cut metrics. These modules are designed to encourage continuous learning in a peer-to-peer setting, with QOF points dependent on demonstrating that practices have discussed quality improvement at network meetings.
These two modules, which will be updated each year, represent a shift in the direction of the contract. Practices will increasingly be rewarded not just for the care they deliver in their own surgeries, but also the role they play in driving proactive care more widely for their Network population. This appears to cement the more substantial, more collaborative role for GPs set out in principle in the Long Term Plan.
3. Staff: The data on GP workforce makes for grim reading:
In 2008 fewer than 2 in 10 retiring GPs took early retirement. By 2016 this had risen to more than 6 in 10.
39% of GPs are likely to leave patient care in the next five years. This rate has nearly doubled in just 7 years (see image below, from a report by the Guardian).
Figure: Considerable/high intention to leave direct patient care within five years
As a result, there are significant staff shortages in primary care, with incoming GPs not replacing outgoing ones.
As part of the new contract agreement, NHS England has committed to funding a new two-year fellowship in general medicine to encourage newly qualified nurses and doctors to choose general practice. At the network level, schemes will be available to help hire health professionals (such as clinical pharmacists, first contact physiotherapists, physician associates, first contact paramedics), providing a recurrent 70% of their funding. The scheme will also fund 100% of the costs of social prescribers for networks.
Sharing specialist staff, such as clinical pharmacists, across multiple practices has the potential to be a highly cost-effective way of easing workforce pressures across practices, particularly with the new funding support. Again, the challenge will be how effectively, and how quickly, practices can come together to make the most of this opportunity.