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There’s a lot going on at the moment in the world of general practice.
NHS England is working on the negotiations for the 2019/20 GP contract, the first time that it has taken over responsibility for this from NHS Employers. A recent NHS England Board paper states that ‘2019 could herald the most substantial changes to the GP contract since 2004’. The contract negotiations will include reviews of GP premises and the Quality and Outcomes Framework. The Department of Health and Social Care has commissioned a review of the partnership model that will report by the end of the year and NHS Digital is working on a project to overhaul the GP Systems of Choice contractual framework for IT.
The Royal College of General Practitioners is also working on ‘shaping the future’ of general practice.1
General practice needs attention – two years ago we published our assessment of the pressures facing general practice, revealing a service at risk of falling apart. Things haven’t got much better since. The latest GP Patient Survey shows clearly that patients have problems accessing general practice, with more than a third of patients struggling to get an appointment when they need one. The number of full-time equivalent GPs has fallen in the past year. GPs are choosing to cut down on the number of clinical sessions they work because of the intensity of their working day and partners are retiring early or taking pay cuts to fund locums when they can’t recruit. The King’s Fund recently caused some media excitement with the findings of our research which asked doctors currently training to be GPs about their future working patterns. It found that the intensity of their working day was a key factor in driving them away from a full-time career in clinical general practice. Whatever the solutions, it will require a collaborative approach to find them, but what has struck me about the current debates is a lack of trust and openness on all sides.
Ever since the 2004 contract (or maybe even since Bevan’s days) it seems there has been a suspicion among NHS leaders about GPs’ motives. Their very status as independent contractors means there is an ambivalence about investing public money in what are seen as ‘private businesses’ from which partners can extract a profit. From NHS leaders I’ve heard ‘it’s just that they want more pay’, ‘it’s female GPs wanting to work part time’ or ‘millennials not wanting to work full time’. There is a danger that those on the government side inflame tensions by talking tough and wanting to show that they got a good deal. And certainly not to repeat the bruising experience of the 2004 negotiations where, to their surprise, GPs negotiated losing responsibility for out-of-hours provision in return for a 6 per cent pay cut.
GPs are equally mistrustful of NHS leadership. I followed a Twitter thread recently, prompted by an article in the HSJ about primary care data. Now for me, as a researcher, it seems entirely uncontroversial that standardised data should be available at a national level for a whole range of reasons, not least so we can know whether or not resources match demand. But the responses from GPs showed otherwise: ‘they’ll misuse it’, ‘it’ll be a stick to beat us with’, ‘it can’t represent what we do’.
In calling for general practice to innovate, to scale up, to merge and to change, NHS leaders (including NHS England and those leading integrated care systems) will need to think about how they can demonstrate trust in general practice so that it can change, for example, by offering easy access to funding for general practices to invest in the activities required to undertake that transformation, including leadership and organisational development support, project management expertise and capital funding. While NHS England is keen to promote practices coming together at scale in ‘networks’ there needs to be investment in the infrastructure to support such work and there has not been the same investment in general management in primary care as there has in secondary care.
GPs will need to think about how they can work alongside NHS leaders, in particular how to record and share the data that is desperately needed to support national decision-making about workforce planning and resources. And they will need to continue to change the way in which they work to meet the needs of a changing population.
Despite the stresses, general practice is delivering some amazing things – from email consultations, innovative leadership programmes, advanced data analytics, community asset-based models and micro-team working. Some of this has been supported by specific funding, but much has been down to the tenacity and dedication of GPs.
If innovative working is really going to succeed, building a collaborative partnership between the profession and NHS leaders will be key. The King’s Fund has published a great deal of work on how to improve care in the NHS and a common theme has been the need for collective leadership – the NHS needs managers, clinicians and patients to work together to reinforce the values that should underpin the NHS – high-quality care, transparency, supportiveness, learning, listening, co-operation and compassion. NHS England and the leaders of the GP profession now have a great opportunity to demonstrate this in practice to deliver the changes to general practice that are so desperately needed.