First, we have been arguing for some time that workforce is the most significant challenge facing the NHS. The new contract underlines (in capitals, and in bold), that NHS England has got the message loud and clear. The list of initiatives to overcome the current crisis is long, and includes funding for more staff (as promised in the Conservative Party manifesto), additional support for newly qualified GPs and nurses, a one-off signing bonus for new partners and incentives to support locums provide extra hours. Just as important as getting the numbers of staff up, the deal makes a clear attempt to match any additional asks on general practice to the availability of staff to deliver them. This can be seen most clearly in the changes to the detail of the new service specifications, with some specifications now contingent on the additional staff being recruited. This is important: without ensuring the staff and resources are available, ambitious promises of new services just set the NHS up to fail, a recurrent problem for the NHS as a whole, not just in general practice.
Of course, there may need to be more initiatives (and not just from NHS England – it’s over to the Chancellor to sort out pensions), and not everything will work. The contract paperwork makes clear that should this be the case NHS England will come back with more initiatives – in other words, they are watching. After the years of neglect on the funding and workforce in general practice and primary care more generally, this is a clear statement of intent to maintain the focus on capacity. An intent that we will of course need to see maintained in the coming years.
Second, the contract looks to cement a new operating model for primary care into the English NHS. This includes the strategic shift to greater multi-disciplinary working in general practice with the contract providing the funding for the extra 6,000 staff (added to the 20,000 already planned, with 100 per cent of their salaries funded rather than the original 70 per cent) but also extends the range of professions that are included. Wisely – given the vacancies across the NHS – these new professions are all subject to local availability to prevent general practice and the wider NHS entering a battle for staff. Importantly, this will encompass mental health in due course – the ‘in due course’ again a pragmatic reflection of existing deep shortages in the mental health workforce. It also confirms that PCNs – whose future looked decidedly uncertain a couple of weeks ago – will be an enduring element of the NHS landscape and continues the job of helping them enmesh themselves in local health and care systems with more money and more support.
Third, cynics may sometimes doubt that politicians really mean to carry through their promises. Well, it may be early days but so far in the NHS at least, such cynicism doesn’t look well placed. After the election the government quickly moved to introduce maintenance grants for nurses and many allied health professionals. Now, the documentation behind the GP contract also makes very clear that the objective is to deliver the extra staff and appointments in general practice that the government promised. Extra money has been provided (before the Budget) to make good on this. However, as the ticks begin to go in the boxes against manifesto commitments (or, rather, ticks saying ‘started’), the question arises about what else the government may do in health and care – social care reform, NHS reform and filling out a policy program looking at ‘levelling up’ across England.
Lastly, NHS England do appear to have listened to the (very) negative response it received to its consultation on the GP service specifications. As the long-awaited NHS People Plan will almost certainly say, the NHS does not always have a great track record of listening to staff and, sometimes, a habit of reverting to an unhelpful bullying culture. The last major conflict between the service and its staff (the junior doctors’ dispute) did not end well for anyone. Yet despite all the warning signs, as yet, NHS England and GPs seem to have left the negotiating table with an offer that gives hope to struggling GPs and their teams, while also offering a reformed and expanded primary care service. However, while the outcome looks positive, how we got there was not, with many GPs furious about the original plans. Next time, a little less brinkmanship on behalf of NHS England might help – some quiet road testing of the entire package could have avoided a lot of pain.
Of course, none of this means the future is assured: there is still so much to be done to get real team working across multiple professions in primary care, to make sure PCNs really do deliver on working at scale with other community providers. The workforce challenge remains daunting and the risk of overloading GPs, their teams and PCNs must remain front of mind. Nonetheless, for now this critical and ambitious element of the wider transformation agenda is not just back on the road but motoring at pace.
Still the question why NHSE tabled such a provocative proposal. Was it incompetence or a consultation failure, whereby they didn't didn't do their homework and therefore had little idea of front-line views? Or was it a Machiavellian plan to propose something unacceptable so that any subsequent position was welcome?
The UK should not have to poach qualified medical staff from other countries; it should train its own. Physicians and nurses are grossly underpaid. People who undergo the long, arduous, demanding training to enter these professions feel they are being exploited - and they are right - and that is partly why there is a shortage of qualified medical staff in the NHS.
Pay physicians and nurses a lot more, and pay the fat-cat hospital administrators who have no medical qualifications less.
(By the way, I have no bias - I'm not a medical practitioner, nor am I related to one - I'm just an impartial observer.)