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

What do the manifestos mean for the NHS?

Chris Ham, Chief Executive writing at the Kings Fund:

There is more that unites the Conservative, Labour and Liberal Democrat manifestos on the NHS than divides them. All three parties reiterate their commitment to the enduring principles of the NHS. All promise to increase NHS funding during the next parliament. And all outline plans to improve care and to deliver key waiting time and other standards.

Family Fund is the UK’s largest charity providing grants for families raising disabled or seriously ill children and young people.

Where they exist, the differences between the three parties relate to the extent of these commitments, how they will be paid for, and which other issues each party sees to be important. On funding, for example, there are small but not trivial differences in the scale of increases planned, although comparisons are not helped by lack of detail on the commitments that have been made. From what we know, it appears that Labour’s plans are marginally more generous than those of the Conservatives and Liberal Democrats – at least in the early years of the parliament.

Labour and the Liberal Democrats plan to fund spending increases by raising more from taxes – on people earning over £80,000 a year in the case of Labour and by putting 1p on income tax in the case of the Liberal Democrats. The Conservatives plan to means test winter fuel payments and use the savings to increase spending on health and social care. Even with these commitments, spending under any future government will rise by only around 1 per cent per annum in real terms, well below the long-term annual trend of 4 per cent and less than the Office for Budget Responsibility has indicated is likely to be required.

Issues seen to be important to each party include giving priority to children’s health (Labour), exploring the possibility of a dedicated health and care tax (Liberal Democrats), and reviewing the operation of the NHS internal market (Conservatives). The Conservatives also plan to introduce legislation to create an independent health care safety investigations body, Labour makes a commitment to legislate on safe staffing levels, and the Liberal Democrats promise to establish an independent monitoring agency for health and social care, similar to the OBR.

The absence of any really radical plans for the NHS, in contrast to some of the proposals put forward for social care, has the benefit of creating a degree of certainty for NHS leaders. Readers of Labour’s commitment to repeal the Health and Social Care Act and reinstate the powers of the Health Secretary to have overall responsibility for the NHS might disagree with this assessment, but in truth the powers of the Health Secretary have never disappeared. Repealing the Act could also end up looking similar to the Conservatives’ commitment to consult on and if necessary make legislative changes to support delivery of NHS England’s plan.

Yet with certainty also comes anxiety. The prospect of five more years of austerity when the NHS is struggling to deliver current standards of care represents a huge challenge, and this will be accentuated by the risks associated with Brexit, especially in relation to retaining and recruiting EU staff, despite manifesto commitments to safeguard the rights of EU nationals working in the NHS. The absence of detail behind spending commitments will also raise concerns about the impact on budgets for public health and for education and training and the effect of social care pressures on the NHS.

NHS appointment

What is clear is that the NHS must use new resources to support reform and not just to prop up existing services. This means taking forward work that has started on sustainability and transformation plans – assuming that these are allowed to continue – and developing further the new care models that seek to achieve greater integration of care. The NHS five year forward view will now extend over eight years, creating more time – though no less urgency – to make the transformations of care required to meet the changing needs of the population. The spotlight will be on NHS leaders to demonstrate that the Forward View really can deliver transformation.

In some areas, changes will be needed to the provision of hospital services, for example by concentrating some services in fewer hospitals where there is evidence that this will improve outcomes for patients. Shortages of doctors, nurses and other frontline staff are making these changes more urgent because of the difficulty many hospitals are having in sustaining safe services. Where the clinical case for change has been made, politicians should not stand in the way of this, even in the face of public concern and the likelihood that some patients will need to travel further to access care.

Family Fund is the UK’s largest charity providing grants for families raising disabled or seriously ill children and young people.

The NHS must also make evolutionary and rapid organisational changes to tackle the complex and fragmented legacy of the Health and Social Care Act 2012. The most promising possibilities lie in the emergence of accountable care systems, in which providers collaborate to meet the needs of defined populations. If these systems are to succeed, the work of national regulators needs to be aligned and streamlined to enable leaders to build accountable care systems appropriate to their areas. Changes to the legal framework, as foreshadowed in the manifestos, could also help, provided that they do not herald a further damaging and distracting top-down reorganisation.