The future of General Practice

The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has snapped after many years of pressure. Patients are facing unacceptably poor access to, and experiences of, general practice and patient safety is at risk from unsustainable pressures. Patient access is at the heart of NHS general practice and we are very concerned about this decline in standards. Given their reluctance to acknowledge the crisis in general practice we are not convinced that the Government or NHS England are prepared to address the problems in the service with sufficient urgency. The Government’s Plan for Patients places a welcome emphasis on improving access to general practice but the measures set out so far will not be sufficient to make a meaningful difference to patient access and do not deal sufficiently with how to improve outcomes.

In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in the short term, to protect patient safety, strengthen continuity, improve access and reduce GP workloads.

The Government should commission a review into short-term problems that constrain primary care including, but not limited to: the interface between primary and secondary care, prescribing from signing to dispensing, administrative tasks e.g. reports and sick notes, day-to-day usability of IT hardware and software, and reviewing of bloods, pathology and imaging reports.

GP recruitment is essential to resolving the crisis in general practice, and while it is disappointing that the Government remains off track to meet its target to recruit 6,000 additional GPs by 2024, the growth in the number of GP trainees over recent years is encouraging. Nonetheless, there are further steps the Government can take both to increase GP recruitment and improve the outcomes of GP training.

The Government should provide the funding necessary to create 1,000 additional GP training places per year and consider extending the GP training scheme to four years, to allow GP trainees more time to develop their skills in practice as well as learn the skills required to enter a GP partnership.

The Government and NHS England should identify mechanisms to distribute GP trainees more equitably across the country so that under-doctored areas receive a balanced proportion of domestic and international GP trainees. The Government should explore schemes that incentivise GP trainees to settle in the areas they train; this could come in the form of improving opportunities to become GPs with Special Interests, incentivising GPs to join partnerships in understaffed areas, and look to create easier ways for GPs to set up their own practices in primary care “black spots”. (Paragraph 40) 40 The future of general practice

We welcome the progress made in recruiting additional professionals to general practice and recognise the potential they have to improve the range of services on offer in general practice and to ensure patients are able to see the right professional at the right time. We are also pleased the Government has committed to increasing the flexibility of staff recruited under the Additional Roles Reimbursement Scheme. However, we are concerned about some gaps within the scheme, particularly the lack of funding for supervision and the absence of any uplift for areas of high need. At present it appears that some staff are not regularly being effectively integrated into general practice and do not receive adequate supervision.

NHS England should set out how it plans to increase the flexibility of the Additional Roles Reimbursement Scheme to allow Primary Care Networks to hire both clinical and non-clinical professionals other than those set out in the current guidance, according to local need.

Receptionists play an incredibly important role in primary care that often goes unrecognised. Given they are often the first point of contact with primary care for most patients, NHS England should review and consider providing standardised national training to drive up standards and equip receptionists with the skills required to navigate and signpost in a 21st century NHS.

The Government and NHS England should explore the possibility of providing an uplift to the Additional Roles Reimbursement Scheme to support non-staff costs such as supervision and training or to provide weighted salaries in areas where the cost of living is high or it is hard to recruit. Consideration should also be given to allowing staff to be employed on Agenda for Change terms and conditions as soon as resourcing allows.

The Government and NHS England have made a start on reducing the administrative workload in general practice, and it is also encouraging to see some Integrated Care Systems agreeing to try to reduce the amount of work that is inappropriately transferred from secondary care to primary care. However, it is clear that there is still a long way to go to make GP workloads more sustainable.

NHS England should take further steps to address the administrative workload in general practice, including by introducing e-prescribing in hospitals and focusing on the primary-secondary care interface by encouraging ICSs to provide a reporting tool for GPs to report inappropriate workload transfer.

The Government should also fund research into the specific role that machine learning can play in the automation of reporting and coding test results to reduce clinical admin in general practice.

The Government should undertake a full review of primary care IT systems from the perspective of the clinicians with an emphasis on improving the end user interface. Making the working life of each clinician that bit easier will drastically improve morale and efficiency.

As we said in our recent Report on the NHS workforce, no NHS employee should be forced to choose to locum or work for an agency to regain control over their working The future of general practice 41 life. This is equally true in NHS general practice. As well as this, GP practices should not be forced to outcompete each other to be able to ensure adequate staffing cover to provide care for their patients.

As part of ongoing efforts to improve the retention of GPs, NHS England should include a specific focus on encouraging locum GPs back into regular employment by supporting GP practices to offer more flexible working patterns.

Urgent work needs to be done to stop a bidding war for the serrvices of locums and establish requirements for a minimum fair share of administrative duties.

Older GPs continue to face prohibitively expensive pensions tax bills which act as a significant disincentive to them staying in practice. Efforts taken to date to reduce the impact on GPs have not been sufficient to prevent experienced GPs from leaving the profession in significant numbers, however we note the Government’s recent consultation on extending ‘retire and return’ arrangements into next year. Experienced GPs are also likely to be employers which may make their pensions arrangements more complicated.

The Government and NHS England should adopt the recommendations related to NHS pensions in our recent Report on Workforce: recruitment, training and retention in health and social care. In developing short and long-term solutions to the NHS pensions issue the Government and NHS England must specifically account for the status of GP partners as employers, for example by providing specific guidance and support for GP practices to help them adopt pension recycling and retire and return approaches. We welcome the focus on this issue in the Government’s Plan for Patients but the Government must provide further detail on what changes it will introduce. (Paragraph 65) Continuity of care

We are extremely concerned about declining provision of continuity of care in general practice. We recognise the enormous pressure that GP services are under but it is unacceptable that one of the defining standards of general practice has been allowed to erode in this way. While we recognise the importance of continuity of information and accountability, and the important role that other professionals can play in providing continuity, we believe the ongoing relationship between a GP and their patients is uniquely important. The Government and NHS leaders have not paid sufficient attention to continuity of care or prioritised it effectively in national policy, which has hastened its decline.

We believe that continuity of care is one of the most important goals for NHS general practice. There is a wealth of evidence that higher levels of continuity of care in general practice are better for both patients and GPs themselves. Continuity of care is more efficient for GPs, improves their shared decision making with patients, and provides them with greater professional satisfaction and development. More importantly, it improves patients’ experience of their care and leads to significantly improved outcomes including reduced hospital and A&E attendances. And rather than being impossible given current pressures there is also evidence to suggest 42 The future of general practice that high continuity is also a more efficient use of resources. One way to improve continuity would be to cap individual GP list sizes, which we believe is a pragmatic solution that should be explored as outlined later in this report.

We recognise that continuity of care is valued differently by different patients. However, just because a patient does not necessarily express a preference for continuity of care, it does not mean that they will not benefit from receiving it. It is clearly the case that even a patient who is young and generally healthy would be better served, in the event that they did develop a serious condition, by receiving care from a GP with whom they have an ongoing relationship. Patients should always be given the choice to receive quicker access if they feel they need it, but we believe the ambition should be to provide continuity to all patients as much as possible.

The Government and NHS England must acknowledge the decline in continuity of care in recent years and make it an explicit national priority to reverse this decline.

Unless continuity of care is routinely measured GP practices and Primary Care Networks will be unable to identify where to focus improvement efforts. NHS England will also be unable to effectively target support without establishing a baseline for the provision of continuity of care. Measuring the proportion of appointments delivered by a named GP is simple and easily understood and could potentially allow for some international comparisons to be made. While this would introduce an additional reporting requirement on GPs, we believe this is proportionate to the importance of continuity of care and would be accounted for by implementing our other recommendations on the GP workload. This could initially be rolled out at primary care network level to allow support and then be phased into individual practices by 2024.

NHS England should introduce a national measure of continuity of care to be reported by all GP practices by 2024. The new measure should be based on existing models such as the Usual Provider Continuity Index and the St Leonard’s Index of Continuity of Care and in the short term should be based on measuring either continuity delivered by a named GP (in pooled list practices) or by a personal GP (in personal list practices). The measure should be reported quarterly at practice, Primary Care Network and Integrated Care System level as well as nationally.

NHS England should provide Primary Care Networks with additional funding to appoint a ‘continuity lead’ for at least one session per week, and additional admin staff funding to support the lead in the role. The role of the continuity lead GP would be to support practices within their network to increase the proportion of patients consulting with their named or regular GP, learning from best practice around the country. There should be a specific uplift for areas of high deprivation.

Personal lists are the best way to deliver continuity of care and are therefore an essential component of improving the levels of continuity provided in NHS general practice. We recognise the pressures in general practice but we believe that delivering high levels of continuity will reduce pressure on GPs rather than increase it by enabling them to be more efficient. Moreover, as patients are already The future of general practice 43 assigned a named GP, implementing personal lists in the short term can be a matter of changing consultation habits and patterns rather than requiring a contractual change.

As part of wider efforts to improve continuity of care NHS England should champion the personal list model rather than dismissing it as unachievable. NHS England should set a stretching ambition that by 2027 80% of practices have returned to personal list continuity and provide support for practices to do so.

The Government should examine the possibility of limiting the list size of patients to, for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over five years as more GPs are recruited as planned. These numbers should reflect varying levels of need in local populations. This would draw us closer in line with our European counterparts, and help improve access and continuity. It should only be implemented in a way that does not undermine the fundamental rights of patients to access a GP.

NHS England should re-implement personal lists in the GP contract from 2030 onwards. (Paragraph 103) General practice and new NHS organisations

Primary Care Networks and Integrated Care Systems offer an opportunity to better integrate care around people. It should not be the case that patients face so much uncertainty about where to turn to if they have a new or urgent care need and it is particularly unacceptable if the number of different organisations involved in providing first-contact services to patients makes it harder to patients to access the care they need. It is welcome that Dr Claire Fuller’s review for NHS England has made this a priority.

Integrated Care Systems should prioritise simplifying the patient interface with the NHS by improving access, triage and referral across first-contact NHS organisations including general practice.

Accountability and quality improvement are both extremely important in the NHS but it is clear that the current system of targets and incentives in general practice is overly bureaucratic, is not having the desired effect on outcomes, and will not enable GPs to change the way care is delivered. In particular, the current system of incentives does not encourage GPs to deliver high levels of continuity and also does not fund GPs for the additional work that will be required to manage more care in the community and reduce hospital admissions. Moreover, the Government’s decision to introduce an additional two-week wait target for GP appointments, while well-intentioned, does not address the fundamental capacity problem causing poor GP access. The Government and NHS England need to be bolder and empower GPs to exercise their professional judgement in the best interests of their patients. (Paragraph 116) 44 The future of general practice

NHS England should abolish the Quality and Outcomes Framework and Impact and Investment Framework and re-invest the funding in the core contract, weighted to account for patient demographics including deprivation, to incentivise continuity of care.

In particular, NHS England should focus on significantly improving the outcomes data provided to GPs by focusing data collection and analytical resource on outcomes measures rather than the process data and reporting required by these micro- incentives.

NHS England should support Integrated Care Systems to implement gain sharing so that Primary Care Networks and individual practices that support the reduction of secondary care expenditure, such as through reducing unplanned admissions, are able to share in the financial gains.

It is unacceptable that areas already under significant pressure due to high levels of deprivation, ill health and under-doctoring have these pressures compounded by unfair funding mechanisms which fail to take account of deprivation. It is particularly concerning that new funding mechanisms in the Primary Care Network contract repeat this failing and risk entrenching regional variation in the establishment of PCNs.

NHS England should revise the Carr-Hill formula to ensure that core funding given to GP practices is better weighted for deprivation. NHS England must also review new PCN funding mechanisms to ensure that they do not inadvertently restrict funding for areas which already have high levels of need.

With general practice currently in crisis it is important that GPs are given the headspace that they need to work differently and improve services, or the potential advantages of new Primary Care Networks will not be realised. Giving GPs time to focus on improvement projects is an important component of this, but so too are important back-office functions like HR support and data analytics.

The Government and NHS England should increase the level of organisational support provided to GPs with a particular focus on important back-office functions such as HR, data and estates management. (Paragraph 129) The GP partnership

It is regrettable that during a time of intense pressure for GPs, following a massive effort by GPs to lead the vital covid-19 vaccination programme, that GP partners were subjected to such open speculation and uncertainty about their futures. It is welcome that the Government and NHS England have confirmed that there is no policy to end the partnership model, which is a positive first step to reassuring GP partners.

In response to this Report the Government should reaffirm its commitment to maintaining the GP partnership model and explain how it will take forward our recommendations to better support the partnership model, alongside ongoing work to enable other models of primary care provision. (Paragraph 135) The future of general practice 45

Despite the risk associated with GP premises continuing to be a significant burden on existing GP partners and a barrier to entry for potential new partners, little progress appears to have been made on this issue. Until the Government grips this issue properly it will continue to seriously undermine GP retention as well as patient care.

The Government should consider adopting the approach to GP premises taken in Scotland and conduct its own analysis of whether this would be viable for general practice in England. More widely the Government must make additional investment available for the general practice estate to enable integrated care to be effectively delivered.

The Government should accelerate plans to allow GP partners to operate as Limited Liability Partnerships or other similar models which limit the amount of risk to which GP partners are exposed. (Paragraph 144) 46 The future of general practice