The National Health Service (NHS) in England celebrated 70 years of service in 2018, and in early January 2019, NHS England published the NHS Long Term Plan to set out the direction for the next decade. In parallel, NHS England also negotiated a five-year contract framework for general practitioners with the British Medical Association’s General Practitioners Committee to translate the Plan’s commitments into reality.
The new general practice contract framework marks some of the most significant changes in over a decade, and has the potential to act as a lever to increase the sustainability of general practice and community services over the next five years and beyond. Key aspects of the contract framework are summarised below.
Contract commits historic levels of funding to create new ‘primary care networks’
The contract framework commits £1 billion to the capitated contracts held by individual general practices over the next five years. An additional £1.8bn is planned to flow through a new ‘network contract’ for geographically-mandated networks of practices across England covering 30,000-50,000 registered patients called ‘primary care networks’ (PCNs). PCNs are meant to be sufficiently large to gain economies of scale, but small enough to still provide the personal care valued by patients and practices. The network contract aims to encourage the 80 per cent of practices that are already collaborating to formalise their membership, nominate a clinical director, and jointly with community services, deliver new services specified by NHS England and local commissioners.
While the introduction of primary care networks has been positively received by the general practice community, there are worries that the expectations for primary care networks might be too high – in part because there is little evidence supporting the abilities of collaborations to impact economies of scale or quality.
Expanding the workforce and tackling workload pressures
One of the many workforce solutions offered by the contract framework is to rapidly develop expanded teams of community-based health professionals attached to PCNs by 2023/24 – which builds on the integrated working principles outlined in the 2014 Five Year Forward View.
In the first year, PCNs will be 100% reimbursed for at least one social prescribing link worker and one clinical pharmacist, at a 70% recurrent reimbursement rate. In subsequent years, PCNs will receive funding to introduce physician associates, practice-based physiotherapists and paramedics into their community-based teams. New community-based teams have a lot of potential to improve services, but GP leaders will need to ensure that they think carefully about team structures and processes to ensure effective team working.
An eagerly awaited step-change from the status quo is the introduction of a state-backed indemnity scheme beginning in April 2019, meaning GP partners will no longer need to personally fund clinical negligence cover for themselves and their practice-based staff – another historic first and a recommendation in the recent GP partnership review.
New quality improvement approaches
The contract promises to modernise the pay-for-performance ‘quality and outcomes framework’ introduced in 2004, by retiring many indicators (which has been advised for many years) and creating a new quality improvement domain.
In addition, seven new national network-level service specifications (e.g. structured medication reviews, anticipatory care with community-based teams) have been added to the contract. Performance on service specifications will be measured on a new national ‘network dashboard’, and the networks that manage to decrease pinch points in the service (e.g. emergency hospital activity or over-prescribing) will be financially rewarded from a new national ‘investment and impact fund’. This loosely scales up local initiatives that have demonstrated success.
Digitalisation of primary care services
The most visible patient-facing change will be increased access to primary care via digital technology (either provided by their practice or sub-contracted to an online GP provider). Practices will also need to make 25 per cent of appointments bookable online, improve their online presence and give new patients access to their digital records as standard. Patients will also have a right to request an online and video consultation by 2021. When in full effect, the new digital offer has the potential to substantially change the way the public interacts with their neighbourhood practice, but there is a lot about these services that we don’t yet understand that could lead to misuse of services and increase workload.
Where could the future lead?
Many across the health and care sector heralded the GP contract framework as the most significant policy change in primary care in over a decade. However, as mentioned above, the evidence for some aspects of the policy is not strong, so a successful delivery of the NHS Long Term Plan through the contract framework is not guaranteed. It feels like very exciting, but unknown times – the good news is that iterative evaluations promised by NHS England should provide a sense of progress over time.