Written evidence submitted by The Department of Health and Social Care (FGP0392)

 

Section 1: Accessing general practice today

 

1         General practice is the bedrock of the NHS, which is why improving access to general practice services continues to be a priority for the government. We set clear ambitions through the Long Term Plan and the five year contract framework, focussing on support for practices to improve access through the NHS England and NHS Improvement-led Access Improvement Programme, incentives to drive improvements in patient experience of access, digital first provision of general practice, and simplifying extended access provision. This has been backed by additional funding, a £1.5 billion uplift up to 2024, and our commitment to provide an additional 50 million appointments in general practice per year by 2024.

 

2         Demand for general practice is increasing and we have seen appointment numbers rise; in November 2021 there were on average 1.39 million general practice appointments per working day, excluding Covid-19 vaccinations which is a 6.0% increase compared to 1.31 million in November 2019.  When vaccination appointments are included this figure rises to 1.57m appointments per working day in November 2021, 20.3% higher than 2 years before.

 

3         GPs and their teams have worked tirelessly during the Covid-19 pandemic to continue to provide care for all of us when we have health concerns, at the same time as playing a key role in the Covid-19 vaccination programme. Accessing general practice services during Covid-19 changed, with practices offering triage and remote consultations alongside face-to face appointments, in order to see as many patients as possible while protecting staff and patients from infection risks.

 

4         To help expand general practice capacity throughout the pandemic, the government made available an additional £270 million funding from November 2020 until September 2021 to support practices to provide vital services to patients.

 

5         We know that some patients have struggled to gain access to general practice. Practices have faced high levels of demand, including from people who may have postponed seeking care earlier in the pandemic. At the same time infection, prevention and control (IPC) measures which are rightly in place to protect patients and staff can often slow the flow of patients that can be seen in person. These issues have been compounded by the impact of covid-19 on the workforce, with reported high levels of staff sickness due to covid-19 infection and isolation.

 

6         Recognising these difficulties, on 14 October 2021 NHS England/Improvement (NHSEI) published “Our plan for improving access for patients and supporting general practice”. This plan outlines steps for recovery and reform for general practice to overcome the difficulties of the pandemic. At its heart was a £250m Winter Access Fund to improve access in the immediate term over winter. The fund is being used across the system to support a wide variety of activities. This includes but is not limited to:

 

7         One of the challenges patients report is getting through to their practice on the telephone and confusion over other ways to access servicesWe are aware of the frustration this can cause patients, and the knock-on impact this can have on treatment of GPs and their staff.

 

8         The plan announced on 14 October included a strategic ambition to move all practices to adopt cloud-based telephony, that would support practices to improve call handling from benefits such as more phone lines and automated queuing. Recognising that this could not be done quickly, to support practices in the short term the Government has supported NHSEI and NHSX to develop a time limited solution with Microsoft for practices to use MS Teams telephony functionality to make outbound calls independently of their existing telephone solutions. This will free up existing lines for incoming calls.

 

9         The department has also committed to working with professional bodies to develop communications tools to help people to understand how they can access the care they need.

10    Remote triage and consultations have been important for practices to reduce the Covid-19 infection risk for patients and staff and manage demand as practices prioritise the most urgent care needs and direct patients to the right service, with the right healthcare professional. For many patients, remote consultations are more convenient, and patients should receive the same high quality of care regardless of how they access their GP services. They are an important element of good access to General Practice. However, there is more to do to build confidence in and familiarity with different modes of appointment. Patients’ input into choices about appointment mode should be sought and practices should respect preferences for face-to- face care, unless there are good clinical reasons to the contrary.

11    We recognise that the issues created by the pandemic have affected some practices more than others. The access improvement programme (AIP) is an NHSEI led programme to support practices experiencing the greatest access challenges to reduce waiting times, optimise workflow, improve patient experience, and ultimately improve the working lives of general practice teams. The programme builds on lessons learnt from the Time for Care Programme. The AIP is supporting over 900 practices, and through the package of measures announced in October 2021, the AIP is being expanded to allow 200 more practices to take part in an accelerated form of the programme, using interventions that have already shown the most impact.

Acceleration of the Covid-19 booster campaign

12    Following the emergence of the Omicron variant, rapidly expanding the COVID-19 vaccine programme became a national priority. In December 2021, measures were announced to increase general practice capacity and financial support to deliver an expanded vaccine programme including part-suspending the Quality and Outcomes Framework (QOF) and Investment and Impact Fund (IIF) and extending self-certification for sickness from 7 to 28 days for statutory sick pay.

 

13    These changes are unprecedented, time limited, and are being taken in recognition of the extraordinary challenge general practice is facing to deliver the accelerated Covid-19 booster campaign. 

 

Expanding the workforce

14    In the longer term, the department is working with NHSEI and Health Education England (HEE) and the profession to increase the general practice workforce in England. This includes measures to boost recruitment, address the reasons why doctors leave the profession, and encourage them to return to practice and increasing the number of GP training places. In 2020 we committed at least an additional £1.5 billion in cash terms for general practice until 2023/24 for additional staff to deliver our manifesto commitments. This is in addition to the £4.5 billion real terms annual increase announced for primary and community care in the Long Term Plan by 2023/24. We remain committed to growing the GP workforce and number of doctors in general practice - the Government is determined to deliver this as soon as possible. There were 1,841 more FTE doctors in general practice in September 2021 compared to September 2019. The highest ever number of doctors accepted a place on GP training this year - a record 4,000 trainees, up from 2,671 in 2014.

 

15    We are also working to strengthen existing plans to increase the number of primary care professionals, over 10,000 of which have been recruited into PCNs and practices between March 2019 and September 2021 as part of a transformation to the general practice clinical workforce. This will help patients to be seen by those who are more expert at dealing with their particular needs, improve the use of medicines, and also help to free up capacity for GPs to focus on what only GPs can do.

Indemnity costs

16    For a number of years rising indemnity costs have been an increasing source of concern for general practitioners and for those working in general practice more widely.[1] This negatively affected the GP workforce. As part of the Government’s commitment to ensure general practice remained an attractive long-term career option, the Clinical Negligence Scheme for General Practice (CNSGP) was launched on 1 April 2019 to deliver a more affordable and sustainable system in England.

 

17    The scheme, which is operated by NHS Resolution, covers clinical negligence liabilities arising in general practice in relation to incidents that occurred on or after 1 April 2019.[2] The scheme is centrally funded, meaning those working in general practice do not need to make any payments to benefit from indemnity. There is no formal membership or other registration requirements for either individuals or practices/organisations. The volume of claims taken on by NHS Resolution in respect of the general practice indemnity schemes increased from 401 in 2019/20 to 1,813 in 2020/21, 840 of which relate to historical claims.[3] As CNSGP is relatively new, the number of claims reported in each year is projected to increase.

 

18    As of 31 March 2020, the end of first year of the new general practice indemnity arrangements, the provision for liabilities for reported and unreported claims was £1.3bn.[4] In 2020/21 the value of payments (damages and claimant/NHS legal costs) for general practice indemnity schemes was £62m.[5] As the scheme matures, the provision and annual payments are expected to increase.

 

Bureaucracy and Burnout

19    GPs time is very precious, and we are committed to ensuring that their clinical time is protected. As part of the 2020/21 GP contract update, to help boost workforce morale and maximise the time available for clinical tasks, the Government committed to a review of bureaucracy in general practice. This work is currently underway and DHSC is continuing to work across government and with the NHS to implement the solutions that emerge. A number of initiatives have been pursued to date, including:

 

 

20    GPs deal with high workloads of complex cases, which can lead to burnout - the provision of mental health services, such as NHSEI and RCGP’s #LookingAfterYouToo and the #LookingAfterYourTeam, is important for building resilience and reducing burnout in general practice.

 

21    General practice staff are dedicated to delivering care for patients, and have the right to work free from fear of assault or abuse in a safe and secure environment. This Government takes a zero-tolerance approach to dealing with violence and abuse  a £5m fund for practice security was announced in October 2021 and we are working on longer-term solutions.

Regional Variation

22    There are many reasons why general practices across England may face different challenges. For example, a typical rural practice has fewer registered patients than an urban practice (median values are 7,240 for rural and 8,220 for urban practices), meaning the fixed costs of running the practice (e.g. utilities, wages of non-clinical staff) are spread among fewer patients. Additionally, rural practices tend to have older patients, who may have more complex health needs (average weighted mean age is 44.6 years for rural practices, versus 39.6 for urban practices). According to the Department for Environment, Food & Rural Affairs[6], “overall rural areas tend to be less deprived than urban ones. 12% of people living in urban areas are in areas that are within the most deprived 10% of the Index of Multiple Deprivation, compared to just 1% of people living in rural areas”. It is important to note that the level of relative deprivation also varies within rural areas.

 

23    General practice funding takes into account variation between practices through the global sum allocation formula (which underpins capitation payments to general practices). The global sum includes various components, but the main payment is based on the GP-registered patient list size, adjusted (weighted) through the Carr-Hill Formula to reflect differences in the age and sex composition of the practice’s registered patient list, together with a range of factors that take into account the additional pressures generated by differential rates of patient turnover, morbidity, mortality and the impact of geographical location, such as rurality. Under this formula, practices whose registered patients have greater healthcare needs are paid more per patient than practices whose registered patients have fewer healthcare needs. The amount of global sum funding received per weighted patient is agreed in the annual GP contract negotiations with the British Medical Association and has been uplifted every year since 2013.

 

24    To limit additional costs due to rurality at a Primary Care Network (PCN) level, NHSEI has explicitly allowed commissioners to waive the 30,000 minimum PCN patient list size requirement where a PCN serves a community with a low population density across a large rural and remote area.

Section 2: The future of general practice

 

25    General practice has seen significant investment and reform in recent years, including the establishment and development of Primary Care Networks (PCNs), and has adapted to deliver services differently during the pandemic.  The challenges of increasing demand for general practice services, advances in medicines and technology, and increasing complexity of health needs are likely to continue to put pressure on general practice as the population ages and a larger proportion live with multiple long-term conditions. The general practice workforce reported high workload levels before the pandemic

Five-year contract framework

26    The five-year contract framework agreed in 2019 was designed to respond to these challenges, by providing investment in general practice, tackling the challenges of expanding the workforce and reducing workload, and supporting the delivery of the Long Term Plan goals to expand and improve care quality and outcomes.  These goals remain as important as ever following the pandemic.

 

27    Through this plan the Government committed to a record level of investment in general practice, providing an extra £4.5 billion in primary and community care by 2023/24In addition, the Government committed £1.5 billion in cash terms for general practice until 2023/24 for additional staff to deliver our manifesto commitmentsEnsuring we have enough GPs by retaining existing expertise and building the future pipeline of trainees is key to reducing overall GP workload, and supporting the Government’s commitment to deliver 50 million more appointments in general practice by 2024. We are also committed to increasing non-GP staff to diversify the workforce and ensure that patients can see the right professional at the right time.

 

28    Alongside this investment, the five-year framework introduced PCNs which built on the core of primary care services with the goal of delivering greater provision of proactive, personalised, coordinated and more integrated health and social care for our communities. The introduction of PCNs was also intended to help deliver economies of scale, boost capacity, and improve access.  

 

29    Through PCNs, a number of new services have now been introducedThe Enhanced Health in Care Homes service specification, introduced in full in October 2020, puts personal and proactive care at the heart of the model. It requires PCNs, working with multidisciplinary teams, to develop a personalised care plan with care home patients to strengthen support for care home residents, their families and staff, and move away from traditional models of care delivery towards proactive care, better meeting patients' needs and reducing inappropriate emergency admissions from care homes. To help improve rates of early cancer diagnosis in line with NHS Long Term Plan ambitions, the Early Cancer Diagnosis service specification (introduced in 2020) ensures that practices have the support of their PCNs to review their existing referral practices for suspected cancers, work with local system partners to improve local uptake of National Cancer Screening Programmes, and establish a community of practice across the PCN to support this work. Under the Cardiovascular Disease Prevention and Diagnosis service specification, introduced in October 2021, PCNs must improve diagnosis of patients with hypertension (in line with NICE guidelines) and undertake activity to improve coverage of blood pressure checks. The Tackling Neighbourhood Health Inequalities service specification, introduced in October 2021, requires PCNs to take a number of steps to identify and tackle health inequalities in their area, including identifying a local population experiencing inequality in health provision and/or outcomes, and developing and delivering a plan to tackle that population’s unmet needs.

 

30    Primary care is the gateway to the NHS for most patients. This unique position potentially gives general practice a crucial role in ‘levelling up’ and wider health inequalities. Changes have been made to improve data gathering that can help identify and address health inequalities. Recent improvements include regulations which came into effect in January 2021 obliging GPs to record ethnicity data when in receipt of such data. Improvements to data recording are crucial in determining how to target action on health inequalities.

 

31    We know that there are fewer GPs per weighted patient in more deprived areas and the Targeted Enhanced Recruitment Scheme (TERS) aims to address the issue of under-doctoring. TERS has been in place since 2016 and to date has attracted hundreds of doctors to train in hard to recruit areas by providing a one-off financial incentive of £20,000. 500 places are available in 2021 and through manifesto investment the GP contract has set out plans to grow this to at least 800 by 2022.

 

32    Further to work already carried out by GPs to provide integrated and personalised care, from April 2022, two service specifications will be introduced to develop anticipatory and personalised care, with PCNs focusing on a population cohort within the local area that they identify as having a particular need for this support.

 

33    PCNs have also helped to diversify the Health Care professionals in General Practice. The Additional Roles Reimbursement Scheme has enabled PCNs to recruit additional roles that will provide multi-disciplinary support according to local needs. Since 2019 we have recruited over 10,000 additional staff into general practice, covering a range of roles, for example clinical pharmacists. As of September 2021, there were 14,353 FTE direct patient care staff, 2,374 more than September 2019. These roles have immediately made an impact. Primary care professionals have delivered COVID vaccinations and a wider range of services through PCNs, as well as advanced practitioners and professionals in more senior roles anecdotally taking on some GP workload.

 

34    In additional to the integration encouraged by PCNs, a range of services have been commissioned from community pharmacy to help take the pressure off GPs. This includes the ability for GP practices to refer people with minor illnesses to community pharmacy for a clinical consultation. We continue to promote and incentivise the use of this service. From October 2021, opportunistic testing of blood pressure and referral was introduced as a service in community pharmacy supporting the PCN Cardiovascular Disease Prevention and Diagnosis service. In addition, the Department and NHSEI are exploring how we can expand the role of pharmacists in the supply of medication so they can provide treatment for specific conditions without patients having to go to their GP.

 

35    To help improve the quality of care across general practice, the Quality and Outcomes Framework (QOF), a voluntary reward and incentive scheme, was introduced in 2004. This incentivises practices to undertake specific activities in order to improve prevention and long-term condition management. In 2017/18 NHS England undertook a review of QOF, which concluded that ‘there are aspects of QOF which are both valued and valuable’, but that improvements were necessary to deliver better patient care. The GP contract 5 year framework published in 2019 implements the findings of this review, including via the creation of a new Quality Improvement domain.

 

36    At PCN level, the Investment and Impact Fund (IIF) builds on this work by incentivising PCNs to deliver high-quality care and activity to help achieve the primary care objectives of the NHS Long Term Plan.

Models of General Practice

37    General practice is the face of the NHS, and is where the majority of the public have the bulk of their interactions with the health service throughout their lives. The NHS was established with family doctors and generalists remaining external members. This has resulted in the current model, where general practices technically sit outside the NHS. GP partnerships, individually and through PCNs, deliver high quality care to patients all over the country.

 

38    The inquiry specifically is looking to explore the current partnership model of general practice. It is important to ensure that the business models of general practices are sustainable and fit for the future.  We recognise some GPs are less interested in going into partnership. Following recommendations of the independent review of the GP Partnership model, a number of schemes including the GP New to Partnership scheme and GP Fellowships schemes were launched to encourage GPs into partnerships. This was on top of record numbers of doctors entering GP training this year.

 

39    The partnership model is how the majority of practices are structured, but is not the only model currently delivering general practice. GP practices can and do choose to organise themselves in different ways. Some are limited companies rather than partnerships, while many practices choose to form super-partnerships, federations, clusters and networks. Many of these cite evidence of good outcomes in terms of staff engagement and patient experience.

 

40    While partnerships holding a GP contract continue to be in the majority, it is important that sustainable alternative models are available where the difficulties of recruitment and retention may mean that a partnership model cannot thrive. In February 2021 NHSE/I updated guidance on alternative organisational forms, including a toolkit and key considerations, to make it easier for GP practices and commissioners to decide if a different approach is right for them.

Prevention

41    As we recover, effective prevention will be central to delivering a sustainable NHS, and tackling the disparities in health outcomes faced by certain groups. This means fixing the underlying causes of ill-health that are contributing to health spending increases and worsening outcomes. Improving the health of communities equitably is vital to resilience against future health threats. Our ambition is to enable individuals in communities with particular health challenges to proactively improve their own health, more easily access lifesaving treatments and more resiliently recover from the pandemic. It will reduce pressure on the NHS by empowering individuals everywhere to change their behaviour and negate ill health, whether by quitting smoking, taking up more exercise or changing diets, so that everyone can lead long, healthy and productive lives.

 

42    Good prevention will require robust population health management in communities, and therefore GPs, working with other primary care health professionals, have an ever-important role. General Practice maintains health of patients in the community through the prevention and the proactive management of conditions.

 

43    To achieve the prevention ambitions set out in the Long Term Plan, GP contract arrangements promote delivery of numerous preventative interventions, including diagnosis and management of hypertension to reduce the risk of cardiovascular disease; requirements  to contribute to improving local uptake of National Cancer Screening Programmes; and support and treatment for cessation of smoking. Though some incentives in these areas have been suspended and income protected to support the COVID-19 Vaccination Booster Programme, they will return in April 2022, and in the meantime, care of the highest-risk patients continues to be prioritised.

 

44    General practice has also played a major role in the COVID-19 vaccination programme, helping prevent the spread of the virus and improving the outcomes of those who do contract the virus. Similarly, GPs provide routine childhood and adult vaccinations, and for seasonal flu.

Integration and Integrated Care Systems (ICSs)

45    The NHS Long Term Plan is clear that the health service should involve more closely integrated systems, with health and care organisations working together seamlessly for patients, care users and their families.  The Health and Social Care Bill which is currently in Parliament will put Integrated Care Systems (ICSs) on a statutory basis, but we will need to go further to ensure that people using health and social care services experience well-coordinated care.

 

46    Primary care is an integral part of delivering the vision for Integrated Care Systems and will continue to be at the core of delivering joined-up care to local communities, in partnership with wider health and care services in the area. The Health and Care Bill will enable the direct commissioning functions of NHSE/I to be jointly commissioned, delegated or transferred at an appropriate time to Integrated Care Boards (ICBs).

 

47    The delegated commissioning of general practice services to local Clinical Commissioning Groups (CCGs) has been a successful NHSE/I policy since 2015, with all CCGs delegated responsibility since April 2021. The transfer of primary medical care commissioning to ICBs therefore aims to build on existing collaborative commissioning arrangements. ICBs will also take on primary dental services and general ophthalmic services

 

48    NHSE/I will continue to develop national policy and guidance to support ICBs to discharge their primary care commissioning functions effectively, supporting primary care providers and Primary Care Networks (PCNs) to deliver high quality services for patients. Guidance will also be published on how primary care will have a clear voice in ICBs and at place level.

 

49    NHSE/I has an independent evaluation underway to understand the implications for staff and patients of using digital tools in primary care, including the effectiveness of online consultation systems that support triage in general practice. Findings from this evaluation will support improvements to the services practices provide.

 

50    On 11 November 2021, NHSE/I announced a new national stocktake led by Dr Claire Fuller, SRO of Surrey Heartlands Integrated Care System and chief executive designate of Surrey Heartland integrated care board. The stocktake will report by March 2022 and will provide specific and practical advice to all ICSs, as they assume new statutory form, on how in their own geographies they can accelerate implementation of the primary care, out of hospital care and prevention ambitions in the NHS Long Term Plan and how, in doing this they drive more integrated primary, community and social care services at a local level.

Section 3: Conclusion

 

51    Over the course of the pandemic, general practice has faced many challenges. General practice teams have worked tirelessly to adapt their ways of working, to ensure that patients can safely access the care they need. This has been alongside delivering over 50 million Covid-19 vaccinations across England. The Government is incredibly thankful for the hard work and resilience of general practice throughout this period.

 

52    General practice is the bedrock of the NHS, and it is important that we ensure its sustainability as we look to the future. Key to this is expanding the workforce so that patients can see the right professional at the right time. The Government has committed considerable investment in the general practice workforce, and this has resulted in a record increase in additional staff.

 

53    We are committed to furthering integrated, collaborative care through ICSs, and across primary care through the development of PCNs and schemes such as the Community Pharmacy GP Consultation Service. Ensuring that general practice is collaborating effectively with the rest of the NHS is key to not only improving the nation’s health, but also the long term sustainability of the health care system.

Feb 2022

 

 

 

 

 

 

 

 


[1] Clinical Negligence Scheme for General Practice - NHS Resolution.

[2] Clinical Negligence Scheme for General Practice - NHS Resolution.

[3] Annual Report and Accounts 2020/21 – NHS Resolution pages 16 and 18. NHS Resolution has taken on historical claims responsibility under an Existing Liabilities Scheme for General Practice (ELSGP). This covers the Medical and Dental Defence Union of Scotland from 1 April 2020 and the Medical Protection Society from 1 April 2021.

[4] Annual Report and Accounts 2019/20 – NHS Resolution page 22.

[5] Annual Report and Accounts 2020/21 – NHS Resolution page 17. This figure includes payments for CNSGP, ELSGP and payments made by Medical Defence Organisations for historical General Practice claims for which NHS Resolution has governance oversight (ELGP).

[6] Deprivation_2019.pdf (publishing.service.gov.uk)