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This explainer was originally published in February 2020 and was last updated in November 2020.
In January 2019, a five-year GP contract framework was agreed that was intended to stabilise general practice and allow it to be a key vehicle for delivering many of the commitments in the NHS long-term plan and provide a wider range of services to patients.
A voluntary extension to the contract, known as a directed enhanced service (DES), was developed that would be offered to general practices coming together as primary care networks (PCNs), covering populations of around 30,000 to 50,000 people. These networks would eventually be required to deliver a set of seven national service specifications including structured medication reviews, enhanced health in care homes (with community services), anticipatory care (also with community services), personalised care, supporting early cancer diagnosis, cardiovascular disease case-finding, and locally agreed action to tackle health inequalities.
Context
An update to the contract and the contract extension was negotiated between NHS England and the British Medical Association’s general practice committee (GPC) and published in February 2020.
The journey to this agreement has not been an easy one, with the publication of draft service specifications in December 2019. This led to serious concerns about what general practice could reasonably be expected to deliver, calling into question the very future of the primary care network model. This updated contract responded to the significant feedback received from GPs and other stakeholders, along with the need to deliver the new government’s manifesto commitment to 50 million extra appointments in GP surgeries to improve access to general practice.
Covid-19 has also led to a number of challenges in implementing the contract for 2020/21, with certain elements being postponed or amended in light of the immediate pressures faced by general practice in dealing with the pandemic.
This explainer sets out the key elements of the final contract and potential implications for the wider health system based on information available in November 2020.
New roles
A central feature of the 2019 GP contract was the additional roles reimbursement scheme that would support the recruitment of 20,000 additional staff working in general practice by 2023/24. Under this agreement, NHS England and NHS Improvement would reimburse 70 per cent of the ongoing salary costs plus on-costs (for example, pension and employer National Insurance contributions) for four roles: clinical pharmacists, physician associates, first-contact physiotherapists and community paramedics along with full funding for social prescribing link worker roles during the contract period.
The updated contract for 2020/21 sets out a major increase in the scale and ambition of the new roles being brought into general practice to expand the primary care team. It raises the number of additional staff to 26,000 and opens the eligibility for reimbursement to a number of other roles including:
pharmacy technicians
health and wellbeing coaches
care co-ordinators
occupational therapists
dieticians
podiatrists
nursing associates and trainee nursing associates.
NHS England will undertake further evaluation to determine whether mental health practitioner roles and advanced nursing practitioner roles are included in the future. For an average PCN the increase in new roles means around an additional seven full-time equivalent (FTE) staff in 2020/21, rising to 20 additional FTE staff by 2023/24. NHS England and NHS Improvement will now reimburse 100 per cent of salary and on-costs for all new roles.
GP retention and recruitment
Alongside new roles in primary care, the updated contract aims to address the serious shortage of GPs, particularly in more deprived areas with a range of changes to support training, recruitment and retention. The number of GP trainee places will increase from 3,500 to 4,000 a year from 2021 while the time a trainee spends working in general practice will increase to 24 months out of a 36-month training period.
The government has re-stated its commitment to the GP partnership model, with the introduction of a one-off £20,000 payment to GPs or other staff who enter into a practice partnership. £3,000 will also be available to pay for business training to improve the capacity of GPs to successfully manage their practice. A similar premium will also be offered to more trainee GPs willing to work in under-doctored areas as part of the Targeted Enhanced Recruitment Scheme.
To increase retention new GPs and nurses will be offered a new two-year fellowship to support their first steps in a primary care career. Experienced GPs will also reimbursed for mentoring their newly qualified colleagues.
Locum GPS will have better access to continuing professional development, while changes to childcare support and parental leave for returning doctors and salaried GPs aim to add flexibility.
Service specifications
The updated contract sets out detail on the first three service specifications: enhanced care in care homes (to be jointly delivered with community providers); structured medication reviews and medicines optimisation; and early cancer diagnosis.
The enhanced health in care homes service was implemented in July 2020 following a transition from similar services established by PCNs in response Covid-19. Structured medication reviews and early cancer diagnosis services were introduced in October 2020.
Expectations around enhanced care in care homes and structured medication reviews have been altered significantly since plans were originally drawn up, introducing more flexibility to account for local context and capacity, and a premium payment per care home bed has been included to account for variation in the spread of care homes between networks. Sufficiently qualified non-GP members of PCN staff can now also become clinical leads for care homes for the new service after obtaining approval from the clinical commissioning group.
Two specifications – anticipatory care and personalised care – that were to be delivered in April 2020, have been delayed until April 20211 .
Access and data
The new government’s manifesto commitment to improving access by delivering 50 million more appointments in general practice has significantly shaped the updated contract, including the increased funding for additional roles.
Specific interventions include a new national programme to work with PCNs to identify ways of improving access, development of a nationally consistent extended-hours offer, and an expansion of digital services.
Practices will also contribute to a more robust dataset to allow analysis of activity and appointment availability at a national level (this is not currently possible meaning it is difficult to demonstrate the scale of activity and demand in general practice). However, ensuring the data is of sufficient quality to be useful and comparable will be technically and operationally challenging. The British Medical Association and NHS England and NHS Improvement published guidance to support more accurate appointment recording in August 2020.
Requirements around workforce data reporting in general practice have also been tightened up to better track the introduction of new roles.
The updated contract also sets out an intention to develop a new ‘as close to real time as possible’ measure of patient experience nationally from April 2021. While measuring patient experience is essential, collecting meaningful real-time feedback will pose technical and operational challenges.
Overall funding
There are other important contractual changes in the contract update including an increase to the global sum that practices receive per patient, and changes to vaccination and immunisation arrangements. Maternity medical services become an essential service with £12 million of new funding allocated for a universal 6–8-week health check for babies and new mothers.
The Quality and Outcomes Framework was reviewed in 2018, and the new contract outlines further changes, including two new quality improvement modules focused on improving care of people with a learning disability and supporting early cancer diagnosis. As a result of Covid-19, NHS England and NHS Improvement announced measures to protect income from the Quality Outcomes Framework for the first half of 2020/21 and a refocusing in the latter half towards restoring services such as cervical cancer screening or delivering flu vaccination to help mitigate further impacts of Covid-19.
Starting from October 2020, a new Investment and Impact Fund will act as incentive and reward for PCNs delivering objectives set out in the NHS long-term plan and updated GP contract. This will be worth £24.25 million in 2020/211 increasing to £300 million in 2023/24. The first round of indicators for 2020/21 will cover:
uptake of learning disability health checks
uptake of seasonal flu jabs
social prescribing referrals
prescribing.
Conclusion
Overall, the updated contract signifies a clear intention to stabilise general practice so that it is able to deliver both improved access and offer an extended range of services with continuing support for primary care networks and new roles forming key parts of this.
For more information on what primary care networks are, how they’re funded, and what difference they might make, see our explainer here.