NHS England’s announcement last week of a new GP contract lays out plans for 20,000 additional staff working to deliver care in general practices within the next five years. It has been widely welcomed. In this blog I ask what the changes will mean for patients and for GP surgeries – and take a look at some of the important unanswered questions.
What will the contract mean for patients?
Mostly, it’s good news. The 2019 GP contract will offer more choice for patients. In the future they will be able to book an appointment directly to see a physiotherapist or a pharmacist without first having to go through a GP.
By freeing up GP time to concentrate on patients who are sickest, surgeries may also be able to offer longer appointments for those with complex illnesses, or more than one long-term health problem – where too often an 8-minute appointment just isn’t long enough.
But the scale of this change may take some getting used to. According to NHS England, within five years non-GP staff are likely to form the majority of the workforce in practices. That will be a historic change. Research shows that patients are not always happy to accept care from a nurse as a substitute for their GP, and that this is associated with lower confidence and trust in health professionals, and poorer patient-rated communication. Practices will need to communicate with patients to build trust and confidence in new working arrangements, and plan for this as they design new services.
What will it mean for General Practices?
Again there is good news: the agreement offers a more secure funding foothold for general practice and, importantly, this extends beyond the short term. The 2% uplift for GP and staff pay and additional funding for primary care networks, coupled with other positive changes including a state-backed indemnity scheme to cover clinical negligence, will go some way to ensuring sustainability.
However, we should remember funding was already starting to rise significantly under the GP Forward View. And with 40% of the new money tied to practices taking part in new networks, it is unclear exactly how they will qualify or who might miss out.
Detail on new initiatives for managing and improving quality is still emerging. Changes to “exception reporting” – rebranded as a “personalised care adjustment” – allow practices to tailor care to individuals without losing out financially by reporting when a quality indictor is, for example, unsuitable for the patient, or the patient declines care.
Financially rewarding practices for how well the local NHS as a whole does on measures like avoiding emergency hospital activity is an interesting new approach, but establishing clear lines of accountability may be difficult. Should we really hold primary care networks responsible for keeping people out of hospital, when there are so many other factors at play?
Success, or failure, in delivering better care for patients depends in good part on how changes to general practice are implemented. It is good to see stronger funding for clinically led quality improvement initiatives, with a focus on prescribing safety and end-of-life care for 2019/20. But evidence on the effectiveness of this approach is very mixed. Time-limited, small-scale projects; projects without the resources or the power to implement change; and a lack of rigorous evaluation and learning are all known problems that need to be addressed.
We need a lot more detail about how teams of different professionals will work in practice – and how they will ensure continuity of care for individual patients. Those who previously have seen just their GP may find their care is now spread across three or more different health professionals all working in the same practice. This may be a good thing. But this change has the potential to work against, not for, better integrated care, and that needs to be carefully thought through.
We should recognize that successfully implementing multidisciplinary team working within general practice means not only new roles, but also a big shift in mindset. This will be particularly the case for the many practices who have never before employed anyone but doctors and nurses to see patients.
Will this solve the challenges facing primary care?
The expectation of more than 20,000 extra physiotherapists, pharmacists, paramedics and link workers in general practice by 2023-24 seems ambitious. As my colleague Nigel Edwards has said, we need to hear more about where these staff are coming from.
And then there remains the serious shortage of doctors in general practice - GPs who are still very much needed to provide clinical care, and leadership for wider multidisciplinary teams. Estimates by the Royal College of GPs suggest England is 6,000 GPs short of what it needs. Despite promises made of 5,000 more GPs by 2020, we now have 400 fewer full time equivalent GPs working than we did three years ago.
In the face of these ongoing issues with recruitment and retention of GPs, have NHS leaders really grasped the underlying problems facing general practice? This GP contract will only work in the long term if it leads to a professional environment that future doctors, physiotherapists and pharmacists are eager to join, and where staff will want to continue working.