ving General Practice: livering a sustainable

Transcription

1 ving General Practice: livering a sustainable ure ard Vautrey ir, BMA GP committee England

2 ecognition of the problem HS Five Year Forward View October 2014 eneral practice, with its registered list and everyone ving access to a family doctor, is one of the great rengths of the NHS, but it is under severe strain rimary care services have been under-resourced mpared to hospitals. So over the next five years we ill invest more in primary care

3 unding

4 nderfunding of healthcare in the UK Health spend across leading EU countries (2015) Health spend as a % of GDP Germany Sweden France Netherlands Denmark Austria Belgium Average (not incl. UK) UK Finland Ireland Italy

5 P Forward View - Published April 2016 bn by 2020/21 From 9.6 billion in 2015/16 to over 12 billion by 20/21; 14% real terms increase compared to 8% for rest of NHS Includes 500m for extending GP access 8 million for 5 year Sustainability and Transformation package. 56m for practice resilience programme for GPs suffering burnout and stress 206m to grow medical and non-medical workforce 171m to support practices develop working at scale 0m for capital investment on to tackle indemnity costs

6 re of NHS funding invested in general practice (England) ar % total investment % excluding dispensed drugs 04/5 10.0% N/A 05/6 10.4% N/A 06/7 9.8% N/A 07/8 9.2% N/A 08/9 8.7% 8.0% 09/10 8.5% 7.8% 10/11 8.3% 7.7% 11/12 8.2% 7.6% 12/13 8.0% 7.5% 13/14 8.0% 7.4% 14/15 8.1% 7.5% 15/16 8.3% 7.7% 16/17 8.5% 7.9% S budget TDEL, source PESA. GP investment, source CIC

7 P share of NHS budget projected change % % % 9.6% % % 9.0% % % % 8.4% 8.0% 7.8% 7.7% 7.6% 7.5% 7.4% 7.5% 7.7% 7.9% 8.1% 8.2% 8.3% 8.4% % % % 2005/ / / / / / / / / / / / / / / /21 Actual Projected

8 unding gap to reach 11% investment target vestment in general practice (excluding drug reimbursement) billion / / / / /21 Actual investment Investment needed to reach target Projected investment

9 ayments to practices in England 2016/17 er weighted patient) GMS (5301 practices) PMS (2127 practices) APMS (279 practices) Average payment Average payment for non-dispensing practice = 57p per day

10 orkforce

11 P Forward View - workforce 5,000 extra doctors working in general practice by 2020/21 Increase GP training recruitment to 3,250 a year 500 GPs returning through improving Retainer Scheme and Induction and Refresher (I&R) Scheme 112m (in addition to the existing 31 million) for clinical pharmacists, leading to a further 1500 pharmacists in addition to the current 470 in general practice by 2020 (one pharmacist per 30,000 population). 3,000 practice-based mental health therapists by 2020 therapist for every 2-3 typically sized practices 15m for practice nurse development, over 50m reception, admin staff and practice manager development 1000 physician associates in primary care settings by 2020

12 P workforce ndon trainee survey 2017 Factors affecting job choice xt career choice: Salaried GP 47% Short-term locum 19% Long-term locum 18% Other 12% Partner 4%

13 P Workforce more GPs? Current reality (excluding locums): March 2017 Sept ,002 GPs, a decrease of 558 (-1.4%) from 39,660 32,272 FTE GPs, a decrease of 700 (-2.2%) from 32,972 March 2016 Sept 2017 Number of FTE GPs fell by 1953 (-5.7%) to Number of FTE consultants rose by 881 (2.0%) to Number of doctors in training rose by 843 (1.7% )to 50,969

14 P workforce numbers Sep-15 Mar-16 Sep-16 Mar-17 Sep-17 GP headcount ,324 GP FTE , GP headcount GP FTE

15 hanging workforce Number of Full Time Equivalent GPs in England since the introduction of the (primary care) Workforce Minimum Dataset (2015) 0 5,000 10,000 15,000 20,000 25,000 30,000 3 GP Providers Salaried/Other GPs GP Retainers GP Locums /18 15

16 orkforce expansion strategy, recurrently funded oblem: FTE GPs declining, GPs reducing time commitment or leaving, increased role bstitution rather than expansion, time-limited funding pact: Longer appointment waits, practices unable to recruit, closing lists to new gistrations or closing altogether lution: Genuine workforce expansion strategy, recurrently funded, flexible working tiatives, international GP recruitment, training grants, better use of funded MDT, omoting general practice positively ogress: Medical school expansion with GP focus; 256 x 20k targeted enhanced cruitment scheme; improved induction/refresher and retainer schemes; recruiting ernationally; clinical pharmacist scheme (520 WTE pharmacists in 1790 practices)

17 ther GPFV workforce commitments tice manager development 6m over 3 years NHS England providing funding to support o o o subscriptions to the Practice Manager Network development of best practice resources for GP practice management peer appraisals o coaching and mentoring Networking events have been held around the country LMCs involved in planning and delivery eption and clerical staff Training in active signposting and management of clinical correspondence 45 million over five years - 5 million allocated in September 2017, followed by 10 million in July 2018

18 orkload

19 anaging and reducing workload e UK population is projected to reach 70 million by mid In m people aged 65+ and 1.5m aged By 2020 increased by 1.1 million 65+, over 300, By 2039 increased by 9.9 million 75+, 3.6 million 85+ nificant increases in NHS activity across the UK: - Consultation rates for GPs in England rose by 13.6% between 2007 and 2014 (Oxford University, 2016). - Consultations numbers increased by more than 15% between 2010/11 and 2014/15 (Kings Fund 2016). - In Scotland consultations rose by 3.9% from 15.6 million to 16.2 million between 2003 and 2013 (ISD, 20 - In Northern Ireland, total general practice consultations rose from 7.2 million in 2003/04 to 12.7 million 2013/14 (BMA, 2015). here has been no routine public reporting of GP activity data and no standardised national dataset to date ne S England data collections are currently in progress in England.

20 upporting GPs and practices in crisis actice resilience programme 16 million committed for 2016/17 > 17.2m spent on 1279 practices 8m available in 2017/18 Health Service Launched January 2017 Case load of 846 GP patients by end of September 2017

21 anaging and reducing workload: rimary-secondary care interface Changes to the standard hospital contract 2015/16 and 2017, for example: hospitals are responsible for providing patients with fit notes hospitals to provide discharge summaries within 24 hours Hospitals to stop asking GPs to re-refer DNA appointments Helping practices and LMCs hold CCGs and trusts to account, by providing template letters to report and push back on breaches Working with NHS England to communicate changes to trusts and patients (eg new patient facing leaflet)

22 anaging and reducing workload fe working in general practice and black alerts Define a safe workload and how GPs can alert the wider health and care system when workloads breach safe limits Create a map of hotspots to show frequency and location of breaches of safe working. ality first Expand the current suite of resources with renewed guidance templates resourced work Identify all routes of unresourced/unfunded workload to inform discussions on reducing this flow Explore developing a get a note from your doctor resource for GPs. lfcare and social prescribing Create an online resource featuring good practice examples of self-care and social prescribing.

23 ontracts

24 etain national core contract for general practice oblem: Threat of APMS and ACO contracts, doctors unwilling to commit to becoming partners e to uncertainty, impacting recruitment, retention and premises developments. pact: Threat to quality health service for patients, continuity of care and working with munities long-term, loss of independent advocate, risk of a costlier service that loses the port of the public lution: Ongoing commitment to the national contract and independent contractor status; atle models built on the foundation of registered lists and GMS contract; collaborative working oss local healthcare systems rather than single responsible body/employer; fully funded egrated urgent care service ogress: Investment in GMS contract through national negotiations; Secretary of State aking of commitment to partnership model; ACO contract guidance; government review of Os.

25 elivering new funding 16/17 contract Expenses funded and 1% pay uplift CQC fees - 15m Indemnity - 33m National Insurance contributions - 56m Superannuation - 14m Increase to V&I IoS fee from 7.64 to m Increased QOF point value (CPI adjustment) - 14m 220m - more than double 2015/16 investment and seven times 2014/15 Additional 102m for population growth and local schemes Overall total of 322m new funding (4.4% increase)

26 ontract changes 2017/18 Expenses funded and 1% pay uplift Indemnity rise paid ( 30m) CQC fees fully reimbursed Sickness payments guaranteed Superannuation 0.08% pension admin charge ( 3.8m) Overseas visitors changes admin workload ( 5m) Learning Disabilities ES - increase from 116 to 140 per health check Morbidly obese influenza vaccination programme ( 6.2m) Bagging and labelling records ( 2m) Workforce census ( 1.5m) Business improvement district levies reimbursement ( 1m) Increase to QOF point value in line with CPI adjustment ( 13m) Population growth funded ( 58.9m) 238m investment into GP contracts for 2017/18

27 remises, IT and admin support oblem: insufficient investment, deterioration in premises, out of date/not fit for rpose, slow IT networks, outsourcing NHS backroom function problems pact: practices unable to accommodate latest innovations, practices handing back ntracts because of premises, difficulties with data sharing, vulnerable to cyber-attack, tients at potential risk, destabilising practice finances, exacerbating workforce crisis lution: IT refresh; recurrent fully funded systems; end paper records; superfast data nnections; fully functioning PCSE/back office support systems; premises commission; reased recurrent investment in GP premises ogress: PCDs updated; challenging NHS PS and CHP; extension to STDL/VAT/legal fees gramme; discussions regarding the replacement of GPSoC; GP2GP implementation gressing

28 ontract negotiations - update Main issues facing General Practice not contractual and need to be addressed through other routes Minimal changes planned for 18/19 Current contract negotiations yet to be completed Pay uplift and expenses via DDRB, not direct agreement, due to lifting 1% pay No changes to QOF (apart from uplift for CPI) review for 2019/20 underway Seeking commitment to uplift vacs & imms IoS, sickness and paternity paymen NHS England opposed to practices providing their patients with private minor surgery for non-nhs commissioned services nuary,

29 ontract update - funding CCG allocation for 2018/19: 188m NHS England can only offer within current budget: 1% pay uplift and expenses uplift Population growth uplift Indemnity increase cover GPC cannot agree to another 1% uplift Approaching the DDRB for pay and expense uplift (in line with other healthcare professionals) BMA DDRB submission: GP pay Staff related expenses Other expenses SFE reimbursables (locum cover, study leave, retainer scheme etc) Guardians of safe working Cybersecurity measures GDPR DHSC DDRB submission: 1% budgeted for but need for more flexibility t address areas of skills shortage Acknowledged problems with GP recruitment and retention nuary,

30 ontract update - indemnity 30m uplift for indemnity for in-year rise in indemnity costs for 16/17 and 30m for 17/18 Paid to practices on a per patient basis and not weighted Practice should reimburse all GPs salaried and principals - in line with their individual payments Reimbursement to individual GPs should be to cover the indemnity increases for the last two years Locum GPs should ensure charges reflect their costs, including any increase in indemnity costs Guidance and template letters will be made available to salaried GPs and locums to help them make sure they get appropriate reimbursements Discussions started on state-backed indemnity scheme from April 2019 nuary,

31 ontract update premises cost directions Permit 100% improvement/development grants, with limited liability Explicit options for owner-occupiers who hand back core contract The Board can waive grant repayment for leaseholders who hand back core contract The Board can assign a lease to their designated property body for leaseholders who hand back core contract Lease terms will not be varied following a rent review Practices will not be at risk of being financially disadvantaged by agreeing to host a third party at the request of the commissioner Improved provisions for minimum standards reviews Focus on premises cost directions guidance document to be released alongside new directions GPC England calling for premises commission to look at wider issues and future arrangements nuary,

32 ontract update Electronic Referral System NHS Standard hospital contract changed such that from October 2018, hospitals will not be paid for referrals unless received through ERS GPC is seeking that: the ERS system will be fit for purpose appropriate bandwidth for use local contingency process if the system is not operational resources for training and implementation referral pathways developed as a result of ERS implementation agreed locally with GPs and LMCs appropriate referrals received by the hospital through a non-ers route will not be rejected on that basis, but processed internally hospitals must reply to the referring GP Joint guidance on ERS including how responsibility/liability flows through the system nuary,

33 ecent developments - GP at Hand London based practice-commissioned App for online consultations Available to any patient in England, but selective outside practice boundary Massive increase in patient registrations 4970 to 16,117 by January 2018 Patients not always clear they have left their current GP to access this service Undermines principle of registered list and current funding model Inappropriate use of out of area regulations Data protection issues and blurring lines between NHS and private services GPC written to and met with NHS England, requesting suspension of current registrations to allow full review to ensure patient safety and assess impact on other practices

34 ecent developments - PCSE Survey of GPs, practices and LMCs provides further evidence of failure of NHS England to hit December 2017 deadline with decline in services and need for resolution across the board Results and letter sent to Simon Stevens Legal template letters (statutory demands) for practices and GPs to use to recoup incorrect payments Exploring test cases on some service lines FOI to provide information as to extent of PCSE problems National Audit Office review of PCSE Subject access requests Writing to MPs and other political bodies

35 ecent developments - GDPR New data protection regulations from May 2018 Key changes for practices: Compliance must be actively demonstrated and documentation produced on reques More information is required in privacy notices for patients A legal requirement to report certain data breaches Significantly increased financial penalties for breaches as well as non-compliance Not charging patients for access to medical records Designation of Data Protection Officers NHS England and ICO very slow in assessing impact and practicalities on general practice and preparing guidance GPC guidance planned to be released early February

36 ccountable care systems & Accountable re organisations Accountable Whole population Single budget Competitive tender Salaried and managed service? e drivers: ecognition in England that current system et out in 2012 Health & Social Care Act isn t orking ould a population health approach deliver mproved care for patients? inancial constraints

37 irtually integrated ll contracts and accountabilities main in place, but overlaid with an lliance agreement outlining how ommissioners and providers will work gether to create better integration of rvices. nables providers to work in ollaboration under existing contracts. ssentially an ACS (accountable care stem) rather than an ACO ccountable care organisation). nuary,

38 artially integrated ngle contract held between the mmissioners and providers xcept core GP services). nder procurement rules this must e put out to tender. P contracts remain in place. rmal integration agreement etween the whole population rovider and GP practices to work gether. nuary,

39 ully integrated single contract between the hole population provider and the ommissioners. nder procurement rules this must e put out to tender. rovides or sub-contracts all rvices n end to GMS/PMS contract nuary,

40 CPs not the only game in town Aims of MCP/ACO model can be implemented without practices relinquishing their GMS/PMS contracts Build on the foundation of national GMS contract Need for recurrent management/administration costs funding orking at scale can be achieved through a variety of models: o o o o o o Formal or informal networks Federations Locality teams Collaborative partnerships between local health organisations Super partnerships Primary care home models

41 C ratings as at 31 July 2017

42 QC report State of Care in General Practice GPs provide the highest quality care (93% good or outstanding compared to 71% for acute trusts and 74% for NHS core mental health) Report warned that increased funding in general practice was vital to avoid a significant deterioration in services General practice is delivering over 90% of all patient contacts on just 7.9% of overall NHS budget

43 wards a healthier future for General Practice Sustained and significant funding investment More GPs, nurses, clinicians and support staff Building collaborative teams in each locality Manage workload enabling quality consultations Indemnity covered Premises and IT development Building on the foundation of a GMS contract Culture change in the NHS