In this feature Thoreya Swage, Healthcare Consultant, highlights the key changes to the GP contract published in January 2019.

Background

In January of this year, the Long-term Plan for the NHS was published which highlighted that primary and community services would receive a greater share of the total NHS funding over five years (from 2019/20 to 2023/24) reaching £4.5 billion by the end of this period — with core funding for general practice increasing by £978 million a year during this time.

The aim of this funding is to enhance the local services that patients receive outside of hospital.

The GP Contract 2019

The 2019 GP contract, which was agreed between NHS England and the BMA General Practitioners Committee (GPC) in England, sets out a number of major changes to General Medical Services for a decade and underpins the ambitions of the NHS Long-term Plan to strengthen the delivery of primary care. This agreement only applies to practices in England. The main principles on which the contract was negotiated includes, among others, seeking a means to address the workforce shortage in general practice, improving the Quality and Outcomes Framework, joining up services providing urgent care and enhancing the use of digital technologies.

What are the key changes?

Primary Care Networks

The main change will be the development of Primary Care Networks (PCNs) across the country.

What is a Primary Care Network (PCN)?

A PCN consists of a group of GP practices serving natural communities typically between 30,000–50,000 registered population in size.

Within PCNs practices work together and with other services such as community and mental health, community pharmacy, hospitals and the social and voluntary care sector in their localities to provide proactive, co-ordinated integrated health and social care.

All practices are expected to become part of a PCN which will be supported by a Network Contract.

The Network Contract is a large Directed Enhanced Service (DES) commissioned by the local Clinical Commissioning Groups (CCGs) and all types of general practices services are eligible, including General Medical Services, Personal Medical Services and Alternative Provider Medical Services. This contract will set the basis on which practices will work together and ensure that PCNs are the basis of the Integrated Care System.

The Network Contract requires all member practices to be signed up to the DES, and defines the area covered by the prospective network and the named accountable Clinical Director. CCGs will not be permitted to host PCNs. The Network Contract goes live from 1 July 2019.

The Network Contract includes the introduction of seven national service specifications which reflect the goals of the NHS Long-term Plan, which are:

  • review and optimisation of medicines

  • enhanced health in care homes

  • anticipatory care requirements — for people with multiple long-term conditions

  • personalised care

  • earlier cancer diagnosis

  • cardiovascular disease prevention and diagnosis

  • addressing neighbourhood inequalities.

PCN Clinical Directors will not only have an essential role in ensuring the full engagement of the constituent practices, but also will have a key part in leading the implementation of local system plans to meet the requirements of the NHS Long-term Plan. These roles will be funded as part of the Network Contract.

Network Clinical Director — key roles and responsibilities

Each network will have a Network Clinical Director who will provide the leadership for the network strategic plans working with the constituent practices and the wider partners in the Integrated Care System to develop and enhance the network services.

Key responsibilities include the following.

  • Leading quality improvement (including that of the Quality and Outcomes Framework) and performance across the member practices of the network.

  • Enhancing relationships across the network in order to improve outcomes for patients.

  • Providing leadership for the development of the clinical workforce in the network.

  • Leading and supporting pathway and service changes across the network in collaboration with system partners.

  • Developing relationships with the clinical leaders of other PCNs, health and social care providers, commissioners and Local Medical Committees.

  • Facilitating the involvement of practices to participate in research within primary care and other research institutions.

  • Representing the network at CCG and Integrated Care level meetings and contributing to the wider strategy and work of the local health and social care system.

Each network will receive funding equivalent to 0.25 WTE per 50,000 population size towards the costs of the Network Clinical Director.

PCNs will be expected to invest in more health professionals, around 20,000 in total, including extra clinical pharmacists, physician associates, physiotherapists, paramedics working in the community and link workers specialising in social prescribing. Through expanding the teams of different professionals in a PCN, patients will receive tailored care and this releases GPs to concentrate on people with more complex needs.

In addition to the Network DES, all PCNs will be required to sign a Network Agreement which sets out the obligations of the network as well as how it will work with the other community-based organisations to secure the integration of primary, secondary and mental healthcare and social care.

A national template for the Network Agreement will be used and every GP practice is expected to sign this. A key component of this agreement will be a requirement of the sharing of patient data to support the safe and effective delivery of patient care.

Support for the development of PCNs will be provided in the form of a national programme established by NHS England. In addition, the new NHS Chief People Officer will ensure that the Clinical Directors themselves will be offered development opportunities as part of the national NHS Leadership development programmes.

Improving the use and infrastructure of IT

The NHS Long-term Plan highlights the development of a “digital-first” primary care in which patients will benefit from the latest digital technologies. There will be funding to enhance GP IT infrastructure.

A new national support programme will be established to enable practices to provide a “digital-first” primary care service. This includes different ways of working such as video and online consultations reflecting the preferred way of contact of many patients. Through the use of better data, more accurate diagnosis and providing support tools for patients, it is envisaged that access, quality and outcomes will be enhanced. There will be a focus on developing digital primary care for students, concentrating on mental health working in conjunction with Universities UK.

Eight specific changes have been agreed including the following.

  1. All patients to be able to access video and web consultations by April 2021.

  2. From April 2020, all patients will be able to have online access to their full record including the ability to add their own information.

  3. From April 2019, all practices should be offering repeat prescriptions and repeat dispensing electronically.

  4. By July 2019 at least 25% of appointments should be available for booking online by all practices, with NHS 111 having the ability to use this process if appropriate, following a contact with a patient (rather than the latter having to make a separate phone call).

  5. By April 2020, all practices to have up-to-date information online.

  6. All patients to have access to online correspondence by April 2020 (with patients opting-out rather than opting-in as the default position).

  7. The use of fax machines will cease by April 2020.

  8. Emails will be used for alerts sent by the Medicines and Healthcare Products Regulatory Agency (MHRA).

Practices will be expected to share digital data for services such as the NHS App and Local Health and Care Records to facilitate information sharing across a system.

Joining up emergency and urgent care in a system

In order to make the provision of urgent and emergency care more cohesive the following changes will be made.

  • The funding for the Extended Hours Access DES and the CCG commissioned extended access services will be combined as part of the Network Contract DES by April 2021. It is expected that this new single service will be delivered through digital services such as the NHS App.

  • NHS England will be leading a review of how PCNs can offer physical and digital access services that reduce duplication, provide better and more convenient “in-hours” appointments, as well as improved integration between NHS 111, urgent treatment centres and general practice. Full implementation is anticipated to be by 2021–2022 although many Integrated Care Systems and their PCNs will be expected to go faster. PCNs will also be able to play an enhanced role in running urgent care in the community through a Supplementary Network Services additional to the new Network Contract.

Improvements to the quality and outcomes framework

A major review of the Quality and Outcomes Framework led by NHS England was published in July 2018. A number of improvements will be implemented which are designed to support the clinical priorities in NHS Long-term Plan. The five key improvements include clinically appropriate indicators such as improving outcomes in people with diabetes, managing blood pressure in line with NICE guidance, cervical cancer screening, pulmonary rehabilitation for people with Chronic Obstructive Pulmonary Disease (COPD) and weight management in people with mental health conditions.

Two quality improvement modules will be introduced as part of a new quality improvement domain. The topics will change each year with safe prescribing and end-of-life care being the focus for 2019–2020. There is an intention to prioritise the development of further Quality Improvement topics to support the seven specifications set out in the Network Contract DES.

There will also be a continuing programme of review of indicators in priority areas starting with heart failure, asthma and COPD in 2019–2020 and mental health in 2020–2021.

General practice workforce

The workforce shortage in general practice continues to be a high priority and this is an area that requires a great focus if the requirements of the NHS Long-term Plan are to be realised.

The NHS Long-term Plan recommends that the numbers of GPs are to increase by 5000 “as soon as possible”. To support this aim NHS England is extending a number of general practice programmes for the whole five-year period from 2019–2020 to 2023–2024 including international recruitment, retained doctors, GP retention programmes, practice resilience programmes and a specialist mental health service for GPs.

For nurses, a number of initiatives which started with the GP Forward View are being accelerated including guaranteed placements for student nurses and an increase in apprenticeships as well as nurse practitioners. Experienced nurses will be encouraged to broaden their role to cover nurse education, mentoring, supervision and leadership.

For newly qualified nurses and doctors entering general practice a new voluntary two-year primary care fellowship programme will be offered. This is not only provides a secure contract of employment but also professional support and development to the individual as well as meeting the needs of the service.

Primary Care Training Hubs will be established in conjunction with Health Education England to provide more consistent training for primary care staff.

To enhance the provision of mental health services in primary care, community mental health professionals will become aligned to PCNs.

Investment and impact fund

In 2020 a new national network Investment and Impact Fund will commence to support Integrated Care Systems to deliver the NHS Long-term Plan. The funding will be £75 million in 2020–2021 increasing to £300 million by 2023–2024. The main aim of the funding is to help PCNs enhance their performance within an Integrated Care System through greater investment in workforce and services.

Part of this funding will be directed towards the principle of “shared savings” identified in the NHS Long-term Plan covering the following areas.

  • Reducing avoidable attendances at A&E (through the changes described above in joining up the urgent and emergency care system such as direct booking through NHS 111).

  • Reducing avoidable emergency admissions.

  • More effective hospital discharge.

  • Redesign of outpatients through greater use of electronic bookings.

  • Review of over medication through pharmacy reviews.

References

  • Investment and Evolution: A Five-year Framework for GP Contract Reform to Implement the NHS Long-term Plan (January 2019), Department of Health and Social Care, available at www.england.nhs.uk

  • NHS Long-term Plan (January 2019), NHS England, available at www.longtermplan.nhs.uk

Last reviewed 23 April 2019