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. This explainer sets out the key elements of the final contract and potential implications for the wider health system.
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 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
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.
The updated contract contains more 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. Expectations around enhanced care in care homes and structured medication reviews have been radically altered, 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. All three finalised specifications are now radically shorter, with the proposed metrics replaced by an overall network dashboard.
Two specifications – anticipatory care and personalised care – that were to be delivered in April 2020, have been delayed until April 2021.
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 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 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.
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.
From April 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 £40.5 million in 2020/21 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
The new contract has been widely welcomed and represents a welcome step change in recognising and addressing the capacity crisis in general practice. It brings in around £1.4 billion of additional new money into general practice compared to the original contract framework and resets the immediate demands on PCNs.
It is also clear that improving access is now an explicit expectation from the government, as is delivery of the NHS long-term plan, and this new money is intended to support this. Challenges remain – even if PCNs can find new staff to recruit, these new teams will also need time, capacity and support to develop effective ways of teamworking and expanded premises to house them. While more GPs are being trained than ever before, issues around retention mean overall numbers have not been increasing in recent years. Reducing GP workload will be fundamental to improving retention, and this will rely on the successful introduction of the new staff.
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.
This does not promise me home visits which are currently not offered by my practice.Nor does it even glance at the elephant in the room ie social care.
I agree with the previous comment. My surgery spends time texting me requesting: how much alcohol do you drink in a day, how many cigarettes do you smoke in a day, but i could not get an Appointment to see my GP. It talks about a lot of extra money for GP's but has not mentioned the word 'integration' once. Carers have become invisible and 'safeguarding' a serious issue, again not mentioned. Preoccupied with Health, this is pointless if Social Care is not given the same priority, including Carers contact information, if EMERGENCY, CRISIS contact is required. SUMMARY 24 Hour Contact via email or phone is a NECESSITY.
The costs associated with 'dementia care' far exceed that connected with cancer and heart disease. Two thirds of people living with dementia live in the community. Their carers are under enormous stress and the social care system fails them absolutely where any amount of self funding is available. Respite for carers or their family member with dementia is extremely scarce, so carers become isolated, ill and depressed. Putting a limit on the amount of 'private' money having to be used to pay exorbitantly high care home fees has been repeatedly ignored since the Care Act supposedly came into being in 2014. Social care is seriously broken, dementia is overlooked because it's such an enormous problem, and the needs of carers completely overlooked.
We are currently engaging with community OT services under a pilot scheme to provide a more rapid and effective patient journey through the grant funded home adaptations route. Prevention of admission to hospital and enabling swift patient discharge back into the community is key in maintaining independence. Working together rather than in isolation. We are looking forward to our local GP's continuing to engage with us.
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