Source · Select Committees · Health and Social Care Committee
Fourth Report - The future of general practice
Health and Social Care Committee
HC 113
Published 20 October 2022
Recommendations
3
Deferred
Para 34
Commission a review into short-term problems constraining primary care, including IT and administrative tasks.
Recommendation
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 …
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Government Response Summary
The government partially accepts the recommendation but shifts focus entirely from commissioning a review into short-term operational problems to discussing increases in GP speciality training places and changes to training duration (from 18 to 24 months in general practice).
Department of Health and Social Care
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5
Deferred
Para 39
Provide funding for 1,000 additional GP training places and extend the scheme to four years.
Recommendation
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 …
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Government Response Summary
The government partially accepts but redirects the focus from increasing GP training places and extending training duration to the Additional Roles Reimbursement Scheme (ARRS). It commits to increasing ARRS flexibility by adding new reimbursable roles, increasing caps on Advanced Practitioners, and removing caps on Mental Health Practitioners as part of the March 2023 GP contract changes.
Department of Health and Social Care
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6
Deferred
Identify mechanisms to distribute GP trainees equitably and incentivise settlement in under-doctored areas.
Recommendation
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 …
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Government Response Summary
The government accepts the recommendation but deflects by addressing the role of receptionists and care navigation training instead of GP trainee distribution and incentives. It commits to investing in a new National Care Navigation Training programme for up to 6,500 staff rolling out from summer 2023, and introducing a Quality and Outcomes Framework module focused on optimising demand in general practice.
Department of Health and Social Care
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8
Deferred
Para 47
Set out plans to increase flexibility of ARRS for diverse local hiring.
Recommendation
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 …
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Government Response Summary
The government partially accepts but deflects by focusing on e-prescribing in hospitals and the interface between general practice and hospitals. It rejects a national mandate for a standardised reporting tool, stating that Integrated Care Boards should decide their own approaches to improving communication and local pathways.
Department of Health and Social Care
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9
Deferred
Para 48
Provide standardised national training for primary care receptionists to enhance patient navigation.
Recommendation
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 …
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Government Response Summary
The government partially accepts the recommendation but deflects by focusing on exploring opportunities for automating processes in general practice to free up clinical capacity. It highlights ongoing support for two pilots testing automated coding of bowel screening results and other administrative processes in London.
Department of Health and Social Care
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13
Deferred
Para 59
Fund research into machine learning for automating general practice clinical administration.
Recommendation
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.
Government Response Summary
The government's response outlines changes to pension arrangements, including increasing the annual allowance, abolishing the lifetime allowance, and introducing retirement flexibilities, which is entirely unrelated to the recommendation about funding machine learning research for admin reduction.
Department of Health and Social Care
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14
Deferred
Para 60
Undertake full review of primary care IT systems to improve clinician user interface.
Recommendation
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 …
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Government Response Summary
The government's response discusses the importance of continuity of care, the named GP policy, the Fuller Stocktake, and the role of multi-disciplinary teams, which bears no relation to the recommendation for a review of primary care IT systems.
Department of Health and Social Care
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19
Deferred
Adopt recommendations on NHS pensions, accounting for GP partners and supporting practices.
Recommendation
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 …
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Government Response Summary
The government rejects the recommendation by referring to its response to recommendation 17 (which concerned continuity of care models) and reiterates plans to promote the RCGP’s Continuity of Care toolkit, thereby failing to address the substance of NHS pensions for GP partners.
Department of Health and Social Care
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29
Rejected
Para 102
Examine limiting patient list sizes to 2500, reducing to 1850 over five years.
Recommendation
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. …
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Government Response Summary
The government rejects the recommendation to limit GP patient list sizes, stating that general practices determine their own workforce size and mix, patient care is delivered by a range of health professionals, and significant numbers of additional primary care professionals have already been recruited.
Department of Health and Social Care
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30
Rejected
Necessity for re-implementing personal lists in the NHS GP contract from 2030.
Recommendation
NHS England should re-implement personal lists in the GP contract from 2030 onwards. (Paragraph 103) General practice and new NHS organisations
Government Response Summary
The government rejects the recommendation to re-implement personal lists. It will instead promote continuity of care through the 2023/24 GP contract and the Quality and Outcomes Framework Quality Improvement module.
Department of Health and Social Care
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32
Accepted
Para 111
Need for Integrated Care Systems to simplify patient interface and improve first-contact access.
Recommendation
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.
Government Response Summary
The government accepts, stating it is a priority for ICSs and outlining initiatives like the Modern General Practice Access approach to improve patient navigation, triage, and access, alongside work on digital services and communication standardization.
Department of Health and Social Care
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33
Accepted in Part
Current general practice targets and incentives are overly bureaucratic, failing to improve outcomes.
Recommendation
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 …
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Government Response Summary
The government partially accepts, committing to a 25% reduction in QOF indicators and a reduction of IIF indicators from 36 to 5 for 2023/24. It will formally consult on the future of QOF and engage on IIF reform during 2023/24.
Department of Health and Social Care
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34
Accepted in Part
Para 117
Imperative for NHS England to abolish QOF/IIF, reinvesting funds into core contract.
Recommendation
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.
Government Response Summary
The government partially accepts, stating that for 2023/24 there will be a 25% reduction in QOF indicators and the IIF will be reduced from 36 to 5. It will formally consult on the future of QOF during 2023/24 and engage with stakeholders on IIF reform.
Department of Health and Social Care
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35
Accepted in Part
Para 118
Need for NHS England to improve GP outcomes data, focusing on key measures.
Recommendation
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.
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Government Response Summary
The government partially accepts, committing to explore ways to strengthen outcomes data collection and monitoring during a 2023/24 consultation on the Quality and Outcomes Framework, while also stating the importance of process data.
Department of Health and Social Care
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36
Accepted in Part
Para 119
NHS England's role supporting ICSs to implement gain sharing for reduced secondary care.
Recommendation
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 …
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Government Response Summary
The government partially accepts, committing to provide "light touch support" like sharing case studies for gain sharing, but notes difficulties in proving causality for direct financial transfers. They also state work is ongoing to explore additional opportunities to reward primary care.
Department of Health and Social Care
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38
Rejected
Para 125
Revise Carr-Hill formula and PCN funding to better account for deprivation and high need.
Recommendation
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 …
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Government Response Summary
The government partially accepts but rejects immediate revision of the Carr-Hill formula, stating it will not change during the current five-year contract. They note that NHS England keeps funding mechanisms, including PCN funding, under general review.
Department of Health and Social Care
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40
Accepted
Increase organisational support for GPs focusing on crucial back-office functions like HR and data.
Recommendation
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
Government Response Summary
The government accepts and outlines several initiatives, including ICS implementation of Fuller stocktake recommendations, digital tools, care navigation training, and the new National General Practice Improvement Programme, to increase organisational support for GPs.
Department of Health and Social Care
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42
Accepted in Part
Reaffirm Government commitment to GP partnership model and detail support for its future.
Recommendation
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 …
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Government Response Summary
The government partially accepts the recommendation, reaffirming no policy to abolish the GP partnership model and highlighting existing investments to support general practice, while also expressing a desire to support a range of primary care provision models.
Department of Health and Social Care
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44
Accepted in Part
Para 141
Consider adopting Scottish GP premises model and increase investment in general practice estate.
Recommendation
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 …
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Government Response Summary
The government partially accepts, declining to adopt the Scottish approach due to stakeholder views, but commits to undertaking analysis of the GP estate and considering alternative models. They will also update planning guidance to support primary care infrastructure in new developments.
Department of Health and Social Care
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45
Deferred
Accelerate plans for GP partners to operate as LLPs to limit financial risk exposure.
Recommendation
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
Government Response Summary
The government partially accepts but defers action, stating further exploration is needed regarding the impact on NHS England and government before committing to accelerate plans for Limited Liability Partnerships.
Department of Health and Social Care
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Conclusions (25)
1
Conclusion
Accepted
Para 32
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 …
Government Response Summary
The government partially accepts, acknowledging access challenges but not a 'crisis'. It details ongoing efforts and specific actions from its Delivery Plan for Recovering Access to Primary Care, including a retargeted investment of over £1bn (up to £645m in community pharmacy, £240m for a new access approach), recruitment of over 29,000 primary care professionals since 2019, and measures to reduce GP bureaucracy.
2
Conclusion
Accepted
Para 33
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 …
Government Response Summary
The government partially accepts, agreeing to explore solutions for primary care constraints but states it does not want to duplicate ongoing work. It points to existing efforts like the Academy of Medical Royal Colleges review, the Delivery Plan for Recovering Access to Primary Care, the 'Bureaucracy busting concordat', and pilots for automating administrative processes.
4
Conclusion
Accepted
Para 38
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 …
Government Response Summary
The government accepts and is adapting GP specialty training distribution to better reflect population needs as part of NHS England’s trainee redistribution programme. It also highlights ongoing efforts like new medical schools and the Targeted Enhanced Recruitment Scheme, which provided £20,000 incentives for training in hard-to-recruit areas, with 800 places available in 2022.
7
Conclusion
Accepted
Para 46
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 …
Government Response Summary
The government partially accepts, acknowledging that ARRS doesn't explicitly cover supervision for all roles but states support creates supervisory capacity for Advanced Practitioners. It commits to reimbursing Primary Care Networks (PCNs) for First Contact Practitioners' training time and has increased the cap on Advanced Practitioners. It also states that inner and outer London weightings are reflected within current ARRS allocations to PCNs.
10
Conclusion
Deferred
Para 49
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 …
Government Response Summary
The government's response discusses ongoing work and future plans for improving primary care IT systems, digital consultation tools, and cloud-based telephony, which bears no relation to the recommendation regarding Additional Roles Reimbursement Scheme (ARRS) uplift or Agenda for Change terms.
11
Conclusion
Accepted
Para 57
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 …
Government Response Summary
The government partially accepts, focusing on existing GP retention schemes (National GP Retention Scheme, Fellowship Programme) and exploring flexible working to support retention, while noting that GP partnerships are responsible for reviewing working conditions.
12
Conclusion
Rejected
Para 58
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.
Government Response Summary
The government rejects the recommendation, stating it cannot establish requirements for a minimum fair share of administrative duties due to individual contractual arrangements between locums and practices.
15
Conclusion
Deferred
Para 61
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 …
Government Response Summary
The government partially accepts, stating they will introduce methods to promote continuity of care and consider how best to measure it, but will not commit to a specific measure by 2024, which is unrelated to the committee's recommendation on locum work and staff competition.
16
Conclusion
Rejected
Para 62
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.
Government Response Summary
The government rejects the recommendation, stating that continuity should be balanced with other PCN expectations, and PCNs should be empowered to make their own workforce decisions rather than having top-down requirements.
17
Conclusion
Rejected
Para 63
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.
Government Response Summary
The government rejects the recommendation, arguing that a return to the personal list model is not the correct approach, and reiterates efforts to promote continuity of care through the named GP policy and the RCGP's Continuity of Care toolkit.
18
Conclusion
Deferred
Para 64
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 Response Summary
The government rejects the recommendation, stating that it does not accept it because the size and skills mix of the workforce are matters for individual general practices to determine, which is unrelated to the recommendation on GP pension tax bills.
20
Conclusion
Accepted
Para 73
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 …
Government Response Summary
The government accepts the recommendation and states that continuity of care is a priority for Integrated Care Systems, citing existing initiatives like the Modern General Practice Access approach, issued frameworks, and ongoing work to improve digital services and patient communication.
21
Conclusion
Accepted
Para 79
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 …
Government Response Summary
The government partially accepts the recommendation, stating it will reduce QOF and IIF indicators for 2023/24 to address micro-incentives. It also commits to formally consulting on the future of QOF during 2023/24 and engaging with stakeholders on IIF reform.
22
Conclusion
Acknowledged
Para 86
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 …
Government Response Summary
The government partially accepts, agreeing on the importance of collecting outcomes data. It commits to look at ways to strengthen data collection and monitoring of outcomes as part of the planned Quality and Outcomes Framework consultation during 2023/24.
23
Conclusion
Deferred
Para 89
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.
Government Response Summary
The government partially accepts the recommendation but discusses current and ongoing work to explore gain sharing agreements and financial incentives to reward primary care for reducing secondary care expenditure, rather than making continuity of care an explicit national priority.
24
Conclusion
Deferred
Para 92
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 …
Government Response Summary
The government partially accepts but deflects the recommendation, discussing existing funding mechanisms like the Carr-Hill formula, which it states will not be changed until the end of 2023/24, instead of addressing the routine measurement of continuity of care.
25
Conclusion
Deferred
Para 93
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 …
Government Response Summary
The government accepts the recommendation but discusses existing and upcoming organisational support initiatives for Primary Care Networks and practices, including digital tools, care navigation training, and the National General Practice Improvement Programme, rather than committing to a national measure of continuity of care by 2024.
26
Conclusion
Deferred
Para 96
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 …
Government Response Summary
The government partially accepts the recommendation but discusses its commitment to the partnership model and existing investments in general practice funding through various schemes, without addressing the specific request for additional funding for PCN 'continuity leads'.
27
Conclusion
Deferred
Para 100
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 …
Government Response Summary
The government partially accepts but deflects the recommendation, discussing challenges related to GP premises, property ownership, and how primary care infrastructure can be supported through the planning system, including updating relevant guidance.
28
Conclusion
Deferred
Para 101
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 …
Government Response Summary
The government partially accepts but deflects the recommendation, stating it needs further exploration before committing to accelerate plans to allow GP partners to operate as Limited Liability Partnerships (LLPs), citing concerns about legal and financial risks and low take-up in Scotland.
31
Conclusion
Accepted
Para 110
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 …
Government Response Summary
The government accepts the recommendation for better integrated care, stating NHS England has issued a framework to support access, implemented the Modern General Practice Access approach, begun commercial work to rationalise digital services, and started standardising patient communications.
37
Conclusion
Acknowledged
Para 124
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 …
Government Response Summary
The government partially accepts, acknowledging that NHS England keeps funding mechanisms like the Carr-Hill formula under review for appropriate weighting, but clarifies it will not be changed during the current five-year contract.
39
Conclusion
Accepted
Para 128
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 …
Government Response Summary
The government accepts the importance of giving GPs headspace and back-office support, detailing plans for Integrated Care Systems to implement Fuller stocktake recommendations, providing digital tools and funding through a new delivery plan, and launching a National General Practice Improvement Programme.
41
Conclusion
Acknowledged
Para 134
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 …
Government Response Summary
The government partially accepts by reaffirming there is no policy to abolish the GP partnership model, noting past investments, and expressing support for diverse primary care provision models.
43
Conclusion
Accepted in Part
Para 140
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 …
Government Response Summary
The government partially accepts, agreeing to undertake analysis of the GP estate and consider alternative models. They will also update planning guidance to ensure primary care infrastructure is referenced and considered in new developments.