NHS 10 Year Plan - What Does It Mean For GPs?
The recent release of the NHS 10 Year Plan moves on from the Five Year Forward View - what impact will it have on the healthcare sector?
In this article, we have selected some key themes which we think will be of particular interest and importance to GPs.
Money
Probably the biggest issue in the plan is money - and the headline figure is that spending on primary and community care will be £4.5bn higher in 5 years' time. However, whether this will lead to an increase in profits for GP partners remains to be seen.
Will funds be put into the global sum to make partners' pay rise faster than inflation?
Two things suggest not:
- First, there may well be a continuation of the recent trend for making new money available via CCGs for "pet projects" rather than simply using it to reverse the decline in profits that most partnerships have seen over the past decade.
- Secondly, the plan talks of the need to move work out of secondary care and into primary care. We have heard that plenty of times before of course - but if the £4.5bn attaches to this, then it will just be more money for more work - rather than making primary care more profitable. However this remains to be seen - the plan does not specify in detail exactly how the money will be spent. There will, inevitably, be adjustments to QOF although it remains to be seen whether QOF will become more valuable overall.
The plan sets out various ways of addressing the shortage of new GPs. We accept that money is not the sole root of the problem, but it does seem to us that money plays a large part in it. Making partnerships more financially rewarding would encourage more to accept the additional responsibility that goes with it. But more importantly, if partners had more money per session they could afford to pay more employees to do the additional work rather than having to do it themselves and burning out. The increase in workload that all practices have seen has not just been about an increase in work overall - it has been about not being able to pay more people to do that extra work.
The NHS is also looking to increase funding to widen job roles in primary care such as the number of clinical pharmacists within general practice teams, with the aim to reduce pressure on GPs.
Structure of Practices
The plan envisages practices operating in networks of 30-50,000. This continues the ambition seen in the Five Year Forward View for working at greater scale, but the ten year plan appears to see this as the vehicle to tie primary and community care together - i.e. money will be made available via these networks. We do not yet know what these network contracts will look like, and they are the subject of negotiations between the Department of Health (DoH) and the General Practitioners Committee (GPC). It may be that the money is handed out (at network level) on the terms of the NHS standard contract, as is currently the case for Local Enhanced Services (LESs) and Directed Enhanced Services (DESs). It appears that the network contracts will be set up in such a way as to enable practices to offer services to patients who are registered with other practices in their network - which is an issue currently causing difficulties.
From a legal perspective if practices are going to be relying on other practices in the network to "do their bit" and ensure that everyone gets paid, then there really ought to be contracts in place between all members of the network. It remains to be seen whether this will be covered by network agreements or whether groups will need to make their own arrangements. For example, it appears that savings from any reductions in A&E admissions will be handed to the network. In such a case, if one practice's patients are attending A&E in high numbers, the others would presumably want some element of control over that practice, or to know that any savings made would not go to that practice.
Digital
The intention appears to be that the way practices offer appointments will change, or at least will need to "interface" with other parts of the NHS. NHS111 is to have a feature enabling appointments to be booked directly, as will the NHS App. Patients are going to be encouraged to expect digital consultations - which means that practices will have to be able to offer them themselves, or their patients will be directed to "digital providers" - and presumably some financial implications will flow from that. For practices that do roll this out, there will be issues to consider around data security (particularly in the light of GDPR).
In addition, practices will need to adhere to the essential list of interventions which all NHS organisations delivering health services will be required to adopt e.g. implement electronic prescribing systems and use e-rostering/e-job plan to deploy workforce.
Integrated Care Systems (ICSs)
The Five Year Forward View set out its vision for the integration of primary and secondary care leading to opportunities for GP providers to combine with a range of other providers as multispeciality providers and beyond as part of an accountable care system now called an integrated care system, to take responsibility for a population budget for a wider area. There is wide variance geographically in the progress towards developing integrated care systems but the ten year plan reinforces and builds on this strategy setting out how this will be implemented nationally and locally over a specified timeframe.
Primary care is at the heart of an ICS and so the development of sustainable ICSs will be a key driver towards the development of practice networks, primary care at scale organisations and corporate GP joint ventures. The development of an integrated care contract is still ongoing having been through several consultations and legal challenges, but the ten year plan envisages that this contract will be available in 2019 for use where an ICS is best structured around a single lead provider.
Procurement
Breaking down the boundaries of primary and secondary care has sometimes proven difficult under the current regulatory regime. To allow plans to be achieved more rapidly, the ten year plan has signalled that the existing procurement regime will be relaxed in respect of healthcare contracting to be replaced with statutory guidance. The new centralised NHS procurement organisation, Supply Chain Coordination Limited (SCCL), will be using national purchasing power to get better deals and deliver high quality affordable care, mainly through extending the number of nationally contracted products, doubling volume of products bought through SCCL to 80%, and standardising procurement specifications. How this guidance will effectively balance these new flexibilities against maintaining the principles of fairness, equality and transparency and strengthening patient choice remains to be seen.
As with any collaboration, the key message will be ensuring that at every layer of collaboration, there is strong governance in place to ensure stability, fair decision making and buy-in from all parties.
Of course, the fact that many questions remain unanswered here is not a criticism - there is always uncertainty about the future. And the ten year plan offers a welcome insight into the direction of travel for the sector, and at least gives us some "known unknowns".