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The General Practice Forward View – All Meat and No Bones?

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A few weeks ago, buried among the political debates surrounding Brexit and the Junior Doctors’ dispute, England NHS published (on the Queen’s birthday) its General Practice Forward View, a national strategy document and “multi-billion plan designed to get general practice back on its feet, improve patient care and access, and invest in new ways of providing primary care.”

Sometimes a hearty meal has to be given time to be digested. And certainly, at 60 pages long this NHS England tome is hearty. However, after giving ourselves some breathing space to digest each of its five courses (covering investment, workforce, workload, infrastructure, and care design), it’s clear that some of the NHS’s cogitations are less nourishing than one would have hoped.

Is this the new NHS mission statement for the GP practice?

Reading the contents page of the strategy plan puts us in mind of a handily headed mission statement, with NHS England stating the support it plans to offer practices in handy bitesize chunks:

- Investment – “We will accelerate funding of primary care”

- Workforce – “We will expand and support GP and wider primary care staffing”

- Workload – “We will reduce practice burdens and help release time”

- Practice Infrastructure – “We will develop the primary care estate and invest in better technology”

- Care redesign – “We will provide a major programme of improvement support to practices”

Taking each of these laudable objectives in turn, and spending some time contemplating the considerable volume of words dedicated to each within the strategy plan, it’s clear that a great deal more emphasis is placed upon the financial questions rather than actually planning for change and how to enable the changes that NHS England would like to see occurring in the future. In truth, the document adds little to information, strategies, and plans that are already in the public domain.

All bones and no meat?

On funding and investment…

There are plenty of statements about extra finance being made available. For example, £500 million in extra funding for a ‘turnaround package’. This is on top of the £2.4 billion per annum increase expected by 2020/21. It is suggested that this money will enable investment in staff, technology, and premises.

On workforce…

On staffing issues, objectives include extra funding for training, recruitment, retention, and return-to-practice. The aim is to increase GP numbers by 5,000 over the next five years (already in the Government’s General Election manifesto), and add more than 4,000 other medical professionals such as mental health therapists (fully funded by GP practices) and co-funded clinical pharmacists.

Yet the thrust of its strategy appears to be oriented toward advertising medical profession opportunities in GP practices, although it does state that a scheme will be launched to offer bursaries up to £20,000 to attract GP trainees to regions where they are most needed. Again, a laudable objective, but with the number of bursaries available capped at 109 a measure that promises to fall well short of real requirements.

Perhaps highlighting the government’s futility in GP recruitment, it was announced on 27th April that GP numbers fell by 2% last year. This means that to meet recruitment targets, not 5,000 but 5,657 GPs will need to be hired into England’s GP practices.

On workload…

When discussing workload, a new automated process that will ease the burden of care planning is promised to be in place by 2017/18, and hospitals will no longer be able to use blanket policies to refer patients back to GPs when patients fail to attend an appointment.

These are steps in the right direction, as is NHS England’s assertion that CQC oversight will be streamlined. In recent weeks we have discussed the way that GP practices lose out in the financial battle between government and CQC. We also made a suggestion about How the GP practice can reduce the stress and cost of CQC Inspections. Sadly, this new policy document fails to take this discussion any further, though on inspection costs issues it does promise that “NHS England will discuss with the GPC how best to recognise any further fee increases and will ensure practices are appropriately compensated”. Read into this what you will.

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On practice infrastructure…

The policy document expends a fair amount of ink when discussing funding for premises and capital investment. It is inviting CCGs to put forward recommendations for investment in primary care infrastructure, and has set aside £900 million for premises and technology upgrades over the next five years. It wants to see better online tools, appointment, consultation, and workload management systems developed and employed. It wants to see better record sharing capabilities, but does not promise to work toward a national database that would truly allow this.

Care redesign…

Only in the very last section of the document is the question raised of what wider community care will look like in the future and how the GP practice will integrate into this. The government’s intention for national access to GP services has been watered down to being based on “locally determined demand.”

NHS England says that it will proved £171 million to help GP practices transform how they work, but there is scant discussion about MCP models or portfolio practices and salaried GPs. The document talks about the expansion of primary care services through initiatives such as the growth of Federations, but does little to tackle the inconsistency of how much these federations are doing to improve primary care.

What do GPs think?

It would be easy for us to say that the paper is more bluster than substance, and we might be called to question for doing so by GPC chair Dr Chaand Nagpul who said, “The General Practice Forward View represents a significant and comprehensive package of proposals to support general practice both in the immediate and longer term, the most that we have seen since 2004.”

The RCGP chair, Dr Maureen Baker is also bullish of the report, saying, “The publication of NHS England’s GP Forward View is perhaps the most significant piece of news for our profession since the 1960s – and a clear recognition of the value of general practice for patients and the NHS. In one fell swoop, we are being promised much of the funding and support for general practice that the College has been calling for.”

However, GPs themselves are far more skeptical. On the Pulse site, reaction includes:

- “Nothing significant or untried to address the major structural failings of our speciality.”

- “Forget announcements of intent - we need kpi free money NOW.”

- “Too little, too late!”

- “Absolutely nothing in this to stop me from retiring at 56.”

- “It's hot. I'm thirsty. But in the distance I can see a shimmering pool of water. I hope I can make it that far.”

- “This is an acknowledgement of problems in general practice. A departure from ‘there is no crisis’.”

- “Great confidence booster for the future - it took NHSE/DoH 10 years to realise they had made a balls of it! Pity they didn't think to ask a GP.”

Overall, then, the General Practice Forward View is a step in the right direction. It perhaps sets a strategic framework for the future. If only it had some meat on those bones…

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