Substantial investment, but with strings attached
This is significant new investment, and the contract has a number of measures to make sure the investment is channelled directly to improving services. One of the criticisms of the General practice forward view investment was that it wasn’t very visible on the front line. By channelling this new money directly to general practice, via the new primary care network (PCN) contract, rather than through allocations to clinical commissioning groups (CCGs) or national programmes which practices have to bid for access to, this new money should really make a difference to front-line general practice.
There are specific requirements linked to the new money, including changes to the quality and outcomes framework (QOF) and seven new national service specifications to be released reflecting the priorities in the NHS long-term plan. Some of the new money comes in the form of a major new national network investment and impact fund which will start in 2020, rising from £75 million in 2020/21 to £300 million in 2023/24. Part of this money will be tied to shared savings on avoidable accident and emergency attendances, emergency admissions, timely hospital discharge, outpatient redesign and prescribing costs. It will be important to make sure that any such indicators clearly demonstrate a direct link between actions in primary care and the desired outcomes, otherwise general practice may risk being penalised for issues beyond its influence.
Changing the core offer and experience of general practice
The contract contains major new investment in staffing. The ambition to recruit more GPs and nurses remains, but the contract recognises the difficulties of achieving this given the ongoing challenge of retaining existing staff. It therefore focuses attention on recruiting staff where there will be more supply. Just as changes to the GP contract in the 1960s and 1990s saw significant investment in practice nurses who became a core part of the service, this investment will mean patients attending their general practice in years to come may also see a pharmacist, paramedic or physiotherapist, with advanced training in diagnosis and treatment in their specialist areas. This signals a fundamental change in how patients will experience general practice, expanding general practice to much more of a ‘team sport’ that is better suited to meeting patient needs. Research into innovative models of general practice shows that this move towards a team approach will be very important in meeting patient needs in the future. However, implementing team working is not straightforward and support will be needed if these new roles are to have the desired impact.
The contract also puts a great deal of emphasis on digital channels for access to general practice, including email and video consultation, improved access to records and electronic prescribing. This reflects the realities of a changing world but, again, evidence shows that implementation isn’t straightforward.
The development of networks is both more radical and more complex than it may first appear
As in the NHS long-term plan, there is a prominent role for primary care networks. All practices will be required to come together in geographical networks covering populations of approximately 30-50,000 patients to share staff and services. There are grand ambitions regarding their role, and expectations that they will be a vehicle for delivering many of the commitments in the long-term plan and providing a wider range of services to patients.
The timelines attached to their development are extremely ambitious and the scale and complexity of the implementation challenge should not be underestimated. The development of networks has implications that reach far beyond primary care as community health and community mental health services will be expected to ‘align’ around networks. To be successful, network development will need to be seen through a broader lens than just general practice, involving other providers of community-based services as well. The King’s Fund will be exploring these questions in greater detail over the coming weeks.
As someone who worked in the NHS for 27 years through three major structural changes, I recognize similar jargon being used in this one. Leadership is key to success and I fear that this will be an impossible task for most GPs. Leadership cannot be picked up or read up. Those GPs who aspire to lead the proposed changes and manage these larger organized units need to be carefully chosen and trained. Leadership is a skill that few people have and the armed forces go to great lengths to select those who possess this ability. Possessing caring attributes is laudable and essential in medicine but this is not enough to drive the changes