Is investment in GP services increasing?

Beccy Baird writing at the Kings Fund: Last year we published a report highlighting the crisis in general practice. There are strong signs that general practice continues to be under increasing strain, including a rise in complaints about GPs, surveys showing patient satisfaction – particularly with access – is declining, and reports of all GPs in an area closing their registered lists as they feel unable to take on more patients.

The government and the national NHS bodies have made attempts to recognise and address the issues facing general practice. In April 2016, NHS England published the General practice forward view, which outlined a range of initiatives and investment for general practice. Among the measures it introduced were a programme to address some of the administrative burdens placed on GPs, initiatives to improve mental health support for GPs and support to deal with rising indemnity costs. Many of the measures focused on recruitment, both through training more GPs and by recruiting from abroad, although figures so far suggest that the government’s target of 5,000 more GPs by 2021 will not be met.

Financial investment in general practice is mind-bogglingly hard to track, and there isn’t any published data that fully profiles promised investments over the period covered by the General practice forward viewNew figures from NHS Digital show that spending in general practice increased in real terms in 2016/17 compared to 2015/16 (though by less than the increase between 2014/15 and 2015/16), but it is still unclear how much of this increased investment is actually reaching frontline services. This is particularly true for the money GPs receive outside their core contract. For example, the overall increase shown in NHS Digital’s figures includes financial flows which don’t reach GP practices directly, particularly payments for information management and technology, which accounted for about 29 per cent of the overall growth in investment.

King's Fund

NHS England has indicated that in future significant additional funds for general practice will have to come from local commissioners, particularly the Sustainability and Transformation Fund. However, it’s highly unlikely that much, if any, of this spend will materialise in the near future as the Sustainability and Transformation Fund is used to offset deficits in other parts of the system, especially acute hospitals. In the past, NHS England has also suggested that as clinical commissioning groups build new care models in line with the NHS five year forward view that investment in general practice would grow even further. However, NHS England’s latest annual accounts show commissioners underspent the budget for primary care and secondary dental care by about 2.3 per cent in 2016/17, suggesting that this increased flow of money to general practice is not happening.

Overall the money does seem to be going up, but by exactly how much and whether it’s in line with the promises made in the General practice forward view (namely to increase spend by 14 per cent in real terms between 2015/16 and 2020/21) is unclear. There’s also no way of knowing whether this money is enough to meet the rising demands placed on GPs. We’ve talked endlessly about the lack of good-quality national data which means it’s hard to know how much extra investment is needed. NHS England is working hard to address this, but it will be a long and complex process to address the lack of national data.

But there is good news. Last week the Care Quality Commission published its first report on the state of general practice. There was much to celebrate in the report, with the majority of general practices found to be providing safe and high-quality care despite the ongoing challenges of rising demand. What particularly struck me was how strongly correlated communication and relationships were with good-quality care. Practices where clinicians were connected to others, within the practice, in their community and in wider professional networks performed better than those that were insular and inward looking. These better practices have been developing innovative ways to deliver care and there are many examples of creative thinking, including the primary care home models, community-based models and new ways of reaching specific population groups. This needs to be the way forward. There could be a focus solely on delivering more of the current model, faster, by finding more GPs, adopting new technologies and improving the understanding and management of patient flow. But the realities of recruitment and retention challenges mean significantly greater numbers of GPs are unlikely and the changing health needs of the population, with growing numbers of people with complex long-term conditions, mean these approaches alone are unlikely to meet patient needs.

The Fund is launching a new project to look at innovative delivery models in general practice from the UK and internationally, seeing if we can distil from these a set of design principles that might guide practices developing new ways of working. We’d love to hear from GPs who are innovating in this way – please get in touch.

Source: The Kings Fund

The NHS Five Year Forward View – Summary

The NHS Five Year Forward View was published on 23 October 2014 and sets out a new shared vision for the future of the NHS based around the new models of care. It has been developed by the partner organisations that deliver and oversee health and care services including Care Quality Commission, Public Health England and NHS Improvement (previously Monitor and National Trust Development Authority).

Summary

  1. The NHS has dramatically improved over the past fifteen years. Cancer and cardiac outcomes are better; waits are shorter; patient satisfaction much higher. Progress has continued even during global recession and austerity thanks to protected funding and the commitment of NHS staff. But quality of care can be variable, preventable illness is widespread, health inequalities deep-rooted. Our patients’ needs are changing, new treatment options are emerging, and we face particular challenges in areas such as mental health, cancer and support for frail older patients. Service pressures are building.
  2. Fortunately there is now quite broad consensus on what a better future should be. This ‘Forward View’ sets out a clear direction for the NHS – showing why change is needed and what it will look like. Some of what is needed can be brought about by the NHS itself. Other actions require new  partnerships with local communities, local authorities and employers. Some critical decisions – for example on investment, on various public health measures, and on local service changes – will need explicit support from the next government.
  3. The first argument we make in this Forward View is that the future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgradein prevention and public health. Twelve years ago Derek Wanless’ health review warned that unless the country took prevention seriously we would be faced with a sharply rising burden of avoidable illness. That warning has not been heeded – and the NHS is on the hook for the consequences.
  4. The NHS will therefore now back hard-hitting national action on obesity, smoking, alcohol and other major health risks. We will help develop and support new workplace incentives to promote employee health and cut sickness-related unemployment. And we will advocate for stronger public health-related powers for local government and elected mayors.
  5. Second, when people do need health services, patients will gain far greater control of their own care – including the option of shared budgets combining health and social care. The 1.4 million full time unpaid carers in England will get new support, and the NHS will become a better partner with voluntary organisations and local communities.
  6. Third, the NHS will take decisive steps to break down the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally but with some services in specialist centres, organised to support people with multiple health conditions, not just single diseases.
  7. England is too diverse for a ‘one size fits all’ care model to apply everywhere. But nor is the answer simply to let ‘a thousand flowers bloom’. Different local health communities will instead be supported by the NHS’ national leadership to choose from amongst a small number of radical new care delivery options, and then given the resources and support to implement them where that makes sense.
  8. One new option will permit groups of GPs to combine with nurses, other community health services, hospital specialists and perhaps mental health and social care to create integrated out-of-hospital care – the Multispecialty Community Provider. Early versions of these models are emerging in different parts of the country, but they generally do not yet employ hospital consultants, have admitting rights to hospital beds, run community hospitals or take delegated control of the NHS budget.
  9. A further new option will be the integrated hospital and primary care provider – Primary and Acute Care Systems – combining for the first time general practice and hospital services, similar to the Accountable Care Organisations now developing in other countries too.
  10. Across the NHS, urgent and emergency care services will be redesigned to integrate between A&E departments, GP out-of-hours services, urgent care centres, NHS 111, and ambulance services. Smaller hospitals will have new options to help them remain viable, including forming partnerships with other hospitals further afield, and partnering with specialist hospitals to provide more local services. Midwives will have new options to take charge of the maternity services they offer. The NHS will provide more support for frail older people living in care homes.
  11. The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services. The number of GPs in training needs to be increased as fast as possible, with new options to encourage retention.
  12. In order to support these changes, the national leadership of the NHS will need to act coherently together, and provide meaningful local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied. We will back diverse solutions and local leadership, in place of the distraction of further national structural reorganisation. We will invest in new options for our workforce, and raise our game on health technology – radically improving patients’ experience of interacting with the NHS. We will improve the NHS’ ability to undertake research and apply innovation – including by developing new ‘test bed’ sites for worldwide innovators, and new ‘green field’ sites where completely new NHS services will be designed from scratch.
  13. In order to provide the comprehensive and high quality care the people of England clearly want, Monitor, NHS England and independent analysts have previously calculated that a combination of growing demand if met by no further annual efficiencies and flat real terms funding would produce a mismatch between resources and patient needs of nearly £30 billion a year by 2020/21. So to sustain a comprehensive high-quality NHS, action will be needed on all three fronts – demand, efficiency and funding. Less impact on any one of them will require compensating action on the other two.
  14. The NHS’ long run performance has been efficiency of 0.8% annually, but nearer to 1.5%-2% in recent years. For the NHS repeatedly to achieve an extra 2% net efficiency/demand saving across its whole funding base each year for the rest of the decade would represent a strong performance – compared with the NHS’ own past, compared with the wider UK economy, and with other countries’ health systems. We believe it is possible – perhaps rising to as high as 3% by the end of the period – provided we take action on prevention, invest in new care models, sustain social care services, and over time see a bigger share of the efficiency coming from wider system improvements.
  15. On funding scenarios, flat real terms NHS spending overall would represent a continuation of current budget protection. Flat real terms NHS spending per person would take account of population growth. Flat NHS spending as a share of GDP would differ from the long term trend in which health spending in industrialised countries tends to rise as a share of national income.
  16. Depending on the combined efficiency and funding option pursued, the effect is to close the £30 billion gap by one third, one half, or all the way. Delivering on the transformational changes set out in this Forward View and the resulting annual efficiencies could – if matched by staged funding increases as the economy allows – close the £30 billion gap by 2020/21. Decisions on these options will be for the next Parliament and government, and will need to be updated and adjusted over the course of the five year period. However nothing in the analysis above suggests that continuing with a comprehensive taxfunded NHS is intrinsically un-doable. Instead it suggests that there are viable options for sustaining and improving the NHS over the next five years, provided that the NHS does its part, allied with the support of government, and of our other partners, both national and local.

“It suggests there are winners and losers using NHS services. We can only hope the new models of care makes more winners”