In this feature, Thoreya Swage, Healthcare Consultant, examines in detail the five-year investment plan for general practice called General Practice Forward View published in April 2016 which is part of the wider strategic plan for the NHS.
In October 2014, NHS England published a strategy for the next five years called, Five Year Forward View, for the Health Service in England. This document described the transformational change necessary to meet a widening health and wellbeing gap, the care and quality gap, and funding and efficiency gap. The document acknowledged that primary care required support and development to respond to the increasing demands it has been experiencing in recent years.
In April 2016, General Practice Forward View published by NHS England in conjunction with the Royal College of General Practitioners (RCGP) and Health Education England (HEE), describes how this growing demand will be managed through an investment of an extra £2.4 billion each year to support primary care by 2020/21. In other words, the spending on general practice services will increase from £9.6 billion a year in 2015/16 to over £12 billion by 2020/21. This funding comes from the increased investment in the NHS that the Government has promised over the next five years of £8 billion each year recurrently, representing around 30% going to primary care by the end of this parliament.
General Practice Forward View contains further detail on developing the workforce, managing the workload, improving the primary care estate and information technology, and redesigning care.
It is recognised that the workforce in primary care is under strain despite the increase in the number of doctors (whole time equivalents) rising by 5000 over the past 10 years. Practices are increasingly reliant on temporary staff, while many older GPs are signalling that they wish to retire early.
The plan outlines an increase of a further 5000 doctors working in primary care by 2020. This includes the following actions led by NHS England and HEE by:
increasing the numbers of GPs in training to 3250 a year
running a major campaign of recruitment to attract doctors (specifically foundation year 2 doctors) to become GPs in England supported by 35 national ambassadors and advocates who will be promoting the primary care doctor role
running a major recruitment campaign overseas to attract up to an extra 500 doctors who are appropriately qualified and trained
awarding £20,000 bursaries for 109 GP trainees in areas that have found it challenging to recruit doctors
establishing an extra 250 post-certificate of completion training (CCT) fellowships to boost the training opportunities in the areas where family doctor recruitment is challenging
attracting and retaining 500 or more extra doctors back into English general practice by simplifying the routes for return to work and financial incentives in areas where recruitment is greatly challenged.
This increase in the medical workforce needs to be mirrored by a similar increase in the non-medical workforce. Over the five years, the plan details the following developments:
setting out a practice nurse development strategy (including at least an extra £15 million investment nationally) to increase the number of pre-registration nurse placements, initiatives to enhance nurse retention, support for practice nurse return to work schemes and improving practice nurse training
recognising the contribution of administrative and clerical staff in primary care by enhancing their role in the navigation of patients and handling clinical paperwork to free up doctor time. This will be supported by a national investment of £45 million
training up 1000 primary care physician associates as recommended by the RCGP to support general practice
investing £6 million in the development of practice managers
investing in an extra 3000 primary care mental health therapists by 2020 providing approximately a full-time therapist for every 2–3 average sized GP practices
increasing the number of pharmacists working in general practice by 1500 by 2020
establishing 13 new multi-disciplinary training hubs (Community Education Provider Networks) across England to support the development of the wider primary care workforce through the investment of £3.5 million
dealing with the challenging issue of locums through the systematic gathering of data from practices about the rates charged by locums in order to target the workforce to the areas that have the greatest need.
In 2015, a survey conducted by the BMA revealed that workload was the biggest concern in general practice. The main aim of the General Practice Forward View is to reduce the administrative burden, have better management of the demand experienced by primary care and greater integration across hospital and GP services.
Key actions include:
changes in the NHS standard contract to reduce the shift of work transferring from hospital to primary care, for example:
preventing unilateral implementation of local access policies such as discharging patients back to primary care if they do not attend their outpatient appointment and requiring another referral
simplifying onward non-emergency referral from one secondary care professional to another without requiring a new referral from the GP (unless the Clinical Commissioning Group (CCG) requests otherwise)
standardising hospital discharge summaries using a format agreed by the Academy of Medical Royal Colleges, so that key information can be found more easily and discharge summaries sent electronically to the practice for inpatient, day case or A&E within 24 hours
sending outpatient letters within 14 days following the appointment — the intention for 2017/18 is for electronic transmission of these letters within 24 hours
providing medication on discharge for at least 7 days (or shorter if clinically indicated) according to agreed protocols.
supporting the 800 practices that have been identified by NHS Clinical Commissioners as vulnerable through an injection of £40 million for a practice resilience programme beginning with £16 million in 2016/17. This is to build resilience in these practices and to facilitate the development of new models of care
changing Care Quality Commission (CQC) inspections for practices rated as good or outstanding (the majority) to five-year intervals and developing a streamlined approach to the inspection of federations, super partnership practices and new models of care
a review of the Quality and Outcomes Framework (QOF) and simplifying the processes of payment for practices.
Primary care estate
The programme to develop the primary care estate began in 2015/16 and will continue over the next five years up to a total of £900 million.
The aim of the capital programme is not only to improve existing buildings, but also to develop facilities that support the new models of care and different ways of working such as accommodating multi-disciplinary teams, innovations in care, greater use of technology as well as new premises to meet growing population demand. To facilitate this, various measures are proposed to speed up the delivery of capital projects and new rules on premises costs will be introduced to enable NHS England to fund up 100% of the costs of development starting in September 2016.
There are also changes for practices that are tenants of NHS Property Services to ease the burden of stamp duty land tax and compensation for VAT charging by landlords. In addition, there will be transitional funding support for practices that will be experiencing significant increases in the costs of facilities management in leases held by NHS Property Services and Community Health Partnerships over the next 18 months.
Information technology (IT)
The document signals a big drive to enhance the use of information technology to improve communication and access, for example:
a national programme (£45 million) to encourage the uptake of online consultations
using IT to:
support patient self-care such as online self-care and self-management services
develop online access to accredited clinical triage systems for patients
reduce workload and achieve a paper-free NHS by 2020
establish wi-fi services in practices for patients and staff
improve interoperability between practices and other systems.
ensuring that community pharmacy has access to the summary care record by March 2017 and increasing the uptake of the electronic prescribing system.
Developing new models of care
The Five Year Forward View recognised that general practice is evolving and this required working in different ways such as in federations, networks or multispecialty community providers (MCPs). General Practice Forward View takes this further by identifying initiatives to strengthen primary care in support of these new ways of working.
One of the key areas is access to care; specifically the number of appointments available at a convenient time is becoming increasingly difficult for general practice to provide. To improve this situation, NHS England will be funding over £500 million recurrently by 2020/21 to enable CCGs to commission extra capacity to enhance access to primary care to include appointments in the evenings and at weekends.
This £500 million is over and above the extra £2.4 billion promised each year to support primary care by 2020/21.
This increase in primary care access will be supported by further integration with out-of-hours and urgent access services including a relaunched 111 service and Primary Care Access Hubs which are designed to increase clinical capacity across a number of practices (running in a similar way to current GP out-of-hours care).
The 14 Vanguard MCPs have now been running since April 2015 across the country. MCPs comprise a number of practices joining together into single entities where GPs and other primary care professionals proactively manage patients with complex and continuing needs utilising digital technologies as well as developing new skills. MCPs may also have a delegated healthcare budget for their registered patients which could include the funding for social care.
NHS England will be publishing a new voluntary MCP contract to start in April 2017 to facilitate the integration of primary and community services with wider health services. Six health systems have been involved in developing the new contract with NHS England. Key features are likely to include:
integrated provider — ie the scope will be the services the MCP itself can provide
different organisational forms such as LLP, community interest company or joint venture with a local trust
new payment structure which encompasses all the existing relevant budgets of the MCP services
a single quality and performance scheme which replaces commissioning for quality and innovation (CQUIN) and QOF at the level of the MCP
some services to be performed at MCP level rather than practice level
new options for employment and independent contractor status.
In addition, general practice federations are seen as the most effective way forward for primary care to grow. These will be supported by the initiatives outlined in the document, eg better access and expansion of services, and funded by a one-off investment for this transitional development of £171 million by CCGs in 2017/18.
On a national level, £30 million has been identified to facilitate change in practices called “Releasing Time for Patients” over three years. Such changes include the dissemination of innovation (such as the 10 high impact actions to release capacity), redesigning services and enhancing capability within general practice to lead change.
10 high impact actions
Implementation of the programme
Implementation of the programme will be overseen by a national group which will include not only NHS England but also partners such as the RCGP and General Practice Committee and patients.
The extra £2.4 billion each year represents a positive investment for primary care and reverses the decline this sector has experienced in recent years. This has the potential to be augmented as CCGs begin to shift services from secondary to primary care.