Imposed contract offers little relief to hard-pressed practices

For the second consecutive year, the Government has imposed a new contract on GPs – and despite strong arguments, it places tough new requirements for patient access while doing nothing to address capacity or the effects of inflation on practice costs

General practice nurses may be as dismayed by the new GP contract, which came into effect on 1 April 2023, as their GP employers. Certainly, any prospects of a pay rise seem remote.

Despite the best attempts of GPs’ representatives, the Government has refused to increase funding beyond that set out in the 2019-24 five-year contract framework or to consider alternative policies that would help to protect practices from having to reduce staffing because of rising practice costs and staffing expenses.¹

This means that financial uplifts will be kept at 2.1%, to cover pay increases for practice staff, increases in practice expenses, and a pay award for GPs themselves, despite the extreme change in economic circumstances that have seen a massive inflationary spike over the last 12 months, and significant increases in workload since the pandemic.

A statement from the BMA’s GP committee for England (GPCE) says: ‘It is extremely disappointing that the Government has refused to allow NHS England to substantially improve its offer, especially in terms of providing adequate support to practices in the face of the dire straits many find themselves in, with ever-increasing demand and continuing workforce and funding shortages.’

GPCE adds: ‘Despite it being a priority for practices, GPs will note that the 2023/24 contract changes do not include any additional investment to urgently counter the damaging impact of soaring inflation on practice costs and staffing expenses. This means nothing to cover astronomically rising energy bills, fair and reasonable cost-of-living staff pay increases, supplies and equipment. GPCE believes the contract changes mean the safety of anxious patients and burnt-out staff will continue to be at risk, jeopardising the existence of some community practices and will cause even more GPs and surgery staff to reduce their hours or leave general practice altogether. This comes at a time when patients need them most.’

In February 2023, the most recent period for which figures are available, general practice delivered 1.37 million appointments each day – 10% more than the same month pre-pandemic – with nearly seven in ten of these delivered face-to-face. The average number of patients each GP is responsible for has increased by 18% since 2015, and now stands at 2,286.2

Ruth Rankine, director of primary care at the NHS Confederation, said: ‘Demand remains high and general practice continues to go above and beyond. The proportion of same day appointments fell very slightly from the previous month, which might be down to patients having less severe complaints as we move out of winter.’ She added that while the Government’s focus on access – as explained below – was right, ‘overworked staff can only do so much’.

ACCESS ON DEMAND

The key change for this year is that the contract will be updated to make it clear that patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time.¹

GPCE states: ‘These contract changes wilfully ignore the reality on the ground. Patients need their practices to have more capacity, to provide better continuity, and for the backlog of unmet care to be rapidly reduced . However, our existing and exhausted GPs and surgery workforce cannot do any more than they already are without additional help. In the context of a service that is under intolerable pressure, simply trying to force practices to do more with unhelpful and unnecessary bureaucratic workload and legislative changes is only going to end in disaster.

‘We have been clear that the continued focus on access, instead of looking at capacity, workload and continuity – at a time when we are seeing more patients than ever – will further impact GP morale and retention.’

The regulations will now say:

• The GP practice must take steps to ensure that an appropriate response is provided to a patient who contacts the practice:
• By attendance at the contractor’s practice premises
• By telephone
• Through the practice’s online consultation system or
• Through any other available online system.
• The appropriate responses the practice must offer are:
• Invite the patient for an appointment, either to attend the contractor’s practice premises or to participate in a telephone or video consultation, at a time which is appropriate and reasonable having regard to all the circumstances
• Provide appropriate advice or care to the patient by another method
• Invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves.
• Communicate with the patient, to request further information, to convey when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances.
• If the contact is made out of core hours, it must be dealt with during the following core hours (8am-6.30pm Monday to Friday), but any contact during normal surgery hours must be dealt with during the surgery period in which the contact is made.

The appropriate response must:

• Not jeopardise the patient’s health
• Be based on the clinical needs of the patient
• Take into account the preferences of the patient where appropriate.

Although the BMA agrees with the ‘aspiration of this amended regulation’, it warns: ‘This requirement is not achievable for many practices with current resource and workforce. With GP numbers decreasing, consultation numbers higher than ever, and general practice being under-resourced, we think this government-imposed contract will push practices to the brink of their existence, within the NHS. For this and other reasons GPCE rejected the contract changes. The Government has made it clear that this contract, rejected by the profession, will come into force on 1 April 2023.’

The decision whether to offer an appointment or signpost the patient to another source of advice or assistance must be ‘based on the clinical needs of the patient’.

GPCE states: ‘Some practices may be able to achieve this requirement as a function of having adequate care navigation capacity or by utilising total-triage systems; however, many practices will not be able to do this as demand outstrips capacity.

‘Many practices do not have enough adequately trained care navigators or other clinicians to make this assessment of clinical need. Patients also may find the use of care navigators by their practice challenging, and there is need for Government to educate patients about the role of care navigators.’

Practices where care navigation is used to allocate patients to appropriate services have various possible options available to them. They could:

• Offer on-the-day assessment by another clinician for cases perceived to be urgent
• Offer assessment at another time by a clinician for cases relating to longer-term and non-urgent conditions
• Signpost to another service where another service is appropriate e.g. mental health support, community services, community pharmacy
• Signpost to 111, Urgent Treatment Centre (UTC), or overflow hub when capacity in the practice is reached
• Request further information – for example via digital tools available to the practice.

GPCE sees the use of care navigation as a potential solution to this imposed contract stipulation, but practices may have other innovative ways of managing this issue such as total triage. ‘We do not advocate a move back to duty doctor or other systems which place an unnecessary and unsafe burden’ on clinicians,’ the GPCE said.

The revised contract does not stipulate the time frame in which a further assessment or appointment has to be offered, it says ‘at a time which is appropriate and reasonable having regard to all the circumstances’. However, QOF and Investment and Impact Fund (IIF) targets aim to have patients seen within 14 days of contacting the practice. Some practices will be able to achieve this, but if practices cannot, this is not a breach of the contract.

Although the contract requires practices respond to contacts ‘outside core hours’ in the core hours following the contact, practices can choose to turn off online consulting methods outside core hours which will enable more capacity to respond to in-hours contacts.¹

SAFE WORKING

Practices who attempt to achieve the requirements may do so at the expense of clinician wellbeing and patient safety. GPCE safe working guidance recommends that clinicians have no more than 35 clinical contacts per day. More contacts than this can lead to decision fatigue, clinical errors and patient harm, and clinician burn out.³

GPCE therefore advises practices to protect patients and clinical staff from these risks by limiting clinical contacts to no more than 35 per day for each clinician, and any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or UTCs. This is permitted within the contract, which says that patients should be offered assessment of need or be signposted to an appropriate service.

Most importantly, the new requirements do not enable practices to ask patients to call back another time, so when safe clinical capacity is reached, patients should be signposted to other settings.

Integrated care boards/systems (ICBs) should ensure that there is a formal escalation route for practices that have reached safe capacity.

GPCE says: ‘Investment is required to recruit care navigators, develop care navigation systems, and provide premises and infrastructure to enable all practices to make the mandated assessment. We recommend that practices write to their ICB requesting this investment to enable them to achieve these requirements safely.’

OTHER CORE CHANGES

Access to records

The deadline for full implementation of prospective patient online access to their records will be extended to 31 October.

Cloud-based telephony

A requirement will be introduced for practices to procure their telephony solutions only from an NHS framework once their current telephony contracts expire.

Funding

‘Investment and Evolution: A five year Framework for GP contract reform’ sets out the expected"¯funding arrangements. It specifies agreed funding to provide pay uplifts in line with predicted inflation (as at April 2019). This year the funding provides for a 2.1% pay uplift for all GPs, practice staff and practice expenses.

GPCE sought additional funding in line with the current rate of inflation. Despite presenting significant evidence, including findings from a representative survey of practices and a series of case studies highlighting the extreme pressure practices are facing, the case for additional funding was rejected by Government ministers.

Vaccination and Immunisations

Vaccinations and immunisations requirements will be amended to reflect updated JCVI guidance. This includes changes to the Human Papillomavirus (HPV) and Shingles programmes.

Childhood Immunisations

There will be a number of changes to the childhood Vaccination and Immunisation (V&I) programme. These include:

• Removal of the V&I repayment mechanism if a practice achieves under 80% coverage
• Changes to the childhood V&I QOF thresholds, so that lower thresholds are reduced to 81% – 89% (dependent on indicator) and the upper thresholds raised to 96%
• Clarification of the wording in the General Practice Statement of Financial Entitlement (SFE) that an Item of Service fee will be payable for vaccinations for medical reasons and incomplete or unknown vaccination status (‘evergreen offer’).

QOF (Quality and outcomes framework)

All disease register indicators will be income protected for the year, with funding paid to practices based on 2022/23 performance monthly once the 2022/23 QOF outturn is finalised.

Two new cholesterol indicators (worth 30 points ~£36m) will be added to QOF along with a new overarching mental health indicator. These will be funded by retiring indicator RA002 (the percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months) and reducing the value of DEM004 (annual dementia review).

Indicator AF007 will be retired and replaced with the former IIF indicator CVD-05. The Quality Improvement (QI) modules for 2023/24 will focus on workforce wellbeing and optimising demand and capacity.

There will also be other small changes to indicator wordings and values in 2023/24.

PCN DES (Primary Care Network Directed Enhanced Service)

Practices are reminded that the PCN DES and all it entails (services, IIF, access requirements etc) are optional.

Practices may decide that they can no longer viably participate in the PCN DES and as such that their patients would be better supported and their practice operated more effectively and safely outside of their PCN, they are able to opt-out during the next opt-out window. The next opt-out period will commence when the contract is updated on 1 April, running until 30 April 2023.

Weight Management DES

The Weight Management Enhanced Service will continue into 2023/24, retaining the £11.50 referral payment.

ARRS (Additional Roles Reimbursement Scheme)

There will be a number of changes to the ARRS. These include:

1. Increasing the cap on Advanced Practitioners from two to three per PCN where the PCN’s list size numbers less than 100,000, and from three to six where the PCN’s list size numbers 100,000 or over

2. Reimbursing PCNs for the time that First Contact Practitioners spend out of practice undertaking education and training to become Advanced Practitioners including Advanced Clinical Practitioner Nurses in the roles eligible for reimbursement as Advanced Practitioners (APs)

3. Introducing apprentice Physician Associates (PAs) as a reimbursable role

4. Removing all existing recruitment caps on Mental Health Practitioners, and clarifying that they are able to support some first contact activity

5. Amending the Clinical Pharmacist role description to clarify that Clinical Pharmacists can be supervised by Advanced Practice Pharmacists.

REFERENCES

1. BMA. GP access: meeting the reasonable needs of patients; 6 April 2023. https://www.bma.org.uk/advice-and-support/gp-practices/gp-service-provision/gp-access-meeting-the-reasonable-needs-of-patients

2. BMA. Pressures in general practice data analysis; 30 March 2023. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice-data-analysis

3. BMA. Safe working in general practice; 2 March 2023. https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-in-general-practice