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February 2024

New contract risks practice nurse job losses

General practice leaders have greeted the publication of the new GP contract with dismay, warning that it will lead to more staff losses and practice closures

The Department of Health and Social Care (DHSC) and NHS England (NHSE) have informed the BMA’s GP Committee (GPC) of GMS contract changes for 2024/25, which include a 1.9% increase for practice funding (for staff and expenses) and a 2.1% pay award for GPs.

The 2024/25 contract will allow enhanced nurses to be included in the Additional Roles Reimbursement Scheme; an enhanced nurses is one working at an enhanced level of practice and holding a postgraduate certification or diploma in one or more specialist areas of care (level seven or above). As a new role, this will initially be capped at one per PCN (two where the list size is 100,000 or over).

The contract does not include any of the improvements that the GPC had requested, and which the GPC has described as unacceptable.

Most notably, the committee believes the well below-inflation 1.9% baseline practice contract funding uplift is ‘nowhere near what is needed to prevent practices from reducing staffing and services or closing altogether’.

Without a marked increase to baseline funding, GPC England believes that significant numbers of practices will have no choice but to make staff redundant and freeze recruitment, severely impacting patient access and ultimately reducing quality of care.

The committee also fears that rising numbers of GP contractors and partnerships will be left with ‘no option’ other than to hand in their notice, leading to a rash of practice closures.

Writing to practices to announce the contract details, NHS England acknowledged ‘General practice is central to the NHS, and the hard work of GPs and primary care staff is hugely valued and appreciated.’ But GPC England chair Dr Katie Bramall-Stainer, said: ‘Actions speak louder than words, and GPs will see another year of cuts to their total practice income per patient which itself has only risen by £15 in over a decade, despite 1000 practices being lost, 2000 fewer GPs and over 6,000,000 more patients registered with practices across England. For this contract to match 2019/20 funding, it would need an 8.7% uplift. Instead it’s another effective cut of 1.9% and a third consecutive imposition.

‘We know that the Department of Health and Social Care did not approach the Treasury to increase funding beyond 1.9%. They know as well as we do, that can only mean practice closures, staff redundancies, loss of the GP workforce, fewer GP nurses, reduced activity, reduced access and an unacceptable experience for our patients.’

RCGP chair Professor Kamila Hawthorne has written to Health and Social Care Secretary Victoria Atkins, to express her dismay: ‘The core practice contract financial uplift of just 1.9% amounts to a real terms funding cut, which will make it even harder for GPs to deliver the care our patients need at a time when general practice is already in crisis. General practice is providing care for more patients than ever before, delivering on the Government’s pledge to increase the number of appointments offered by 50 million a year. In December 2023, general practice delivered 7% more appointments than December 2019, with 2.9% fewer fully qualified GPs.    

‘GPs can't keep doing more with less. This derisory funding plan for general practice will have real life consequences for the profession, the service we provide and, most importantly, for our patients.’

The RCGP said the contract reflected an ‘ongoing trend of neglecting primary care’, with the Government’s own figures showing the proportion of Integrated Care Board direct commissioning spend on primary medical care has fallen to 8.4% in 2023/24 – a smaller share than in any of the previous eight years.

‘Practices will not notice any real benefit from the small amounts of flexibility being introduced by the contract whilst the service as a whole remains starved of funding.  It is hugely disappointing that the Government has failed to heed the calls by the RCGP, the BMA and others to remove the restrictions attached to the additional roles reimbursement scheme to allow practices to use this funding to recruit more, much needed, GPs,’ Professor Hawthorne said.  

She added: ‘In addition to correcting this funding cut the Government must urgently come up with a plan to secure the future of general practice.’

Announcing the new contract, the DHSC and NHSE said that now the terms of the five-year framework had elapsed, there would be a return to the pay review body process (Doctors and Dentists Review Body, DDRB) as the established process for determining pay uplifts for public sector workers, when workforces are not in multi-year deals.

As the DDRB has not yet made recommendations for 2024/25, the contract includes a planning assumption of 2% for pay growth in the GP contract, with the promise of a further uplift depending on the Government’s response to the DDRB report.

There will be an overall increase in investment of £259m taking overall contract investment to £11,864m in 2024/25. This includes:

  • A planning assumption of 2% pay growth for contractor gps, salaried gps, and other practice staff.
  • A planning assumption of 2% pay growth uplift to the overall Additional Roles Reimbursement Scheme (ARRS).
  • 1.68% inflation, in line with the Government’s November 2023 GDP deflator.
  • 0.38% ONS population growth.

The contract promises to:

  • Cut bureaucracy for practices by suspending and income protecting 32 out of the 76 Quality and Outcomes Framework (QOF) indicators. These indicators account for 212 of the 635 points that can be earned through the QOF scheme. For the income protected indicators, practices will be awarded QOF points based on their performance in previous years, while points for the remaining live indicators remain conditional on their performance in 2024/25.
  • Help practices with cash flow and increase financial flexibilities by raising the QOF aspiration payment from 70% to 80% in 2024/25
  • Give Primary Care Networks (PCNs) more staffing flexibility by including enhanced nurses* in the Additional Roles Reimbursement Scheme (ARRS), and giving PCNs and GPs more flexibility by removing all caps on all other direct patient care roles.
  • Support practices and PCNs to improve outcomes by simplifying the Directed Enhanced Service (DES) requirements.
  • Improve patient experience of access by reviewing the data that digital telephony systems generate to better understand overall demand on general practice in advance of winter. In 2024/25 the GP Contract will be amended to require practices to provide data on eight metrics through a national data extraction, for use by PCN Clinical Directors, ICBs and NHS England.

These eight metrics are:

1. call volumes

2. calls abandoned

3. call times to answer

4. missed call volumes

5. wait time before call abandoned

6. call backs requested

7. call backs made

8. average call length time

In order to highlight the importance of continuity of care, whilst ensuring practices have flexibility to deliver services to best meet the needs of their patient population, the provisions in the GP Contract Regulations will be amended to explicitly require continuity of care to be considered when determining the appropriate response when a patient contacts their practice.

*Enhanced practice nurses will be included in the roles eligible for reimbursement. This will allow nurses working at an enhanced level of practice and holding a (level seven or above) postgraduate certification or diploma in one or more specialist areas of care to be recruited via ARRS. As a new role, this will initially be capped at one per PCN (two where the list size is 100,000 or over).

Practice Nurse 2024;50(2): online first