RESOURCING GENERAL PRACTICE TO IMPROVE PATIENT CARE ANDD ENSURE A SUSTAINABLE NHS: RCGP SUBMISSION FOR THE 2015 SPENDINGG REVIEW A year ago, NHS England together with a range of other agencies published the Five Year Forward View. This set out a vision for how the NHS in England can be sustainable into the future, and has been widely welcomed, including by the current Government. At the heart of the Five Year Forward View iss the recognition of the need n for a new deal for general practice, to stabilise the service, cut waiting times for patients to seee a GP and provide more care closer to home. As the Government considers its spending plans for the NHS up to 2019/20, it is imperative this new deal is given the highest priority in order to secure the future of not only general practice but also the NHS itself. In this document, we summarise the case for additional investment in general practice and set out the additional funding that we believee is needed, including to implement the recommendations of the recent Primary Care Workforce Commission. The case for additional investment General practice carries out 90% of contactss in today s NHS, yet receives just a little over 8% of the NHS budget. By investing in general practice, we can care for more people p at lower cost in the community, saving the NHS money by reducing the need for expensive hospital treatment. Independent research produced for the RCGP by Deloitte 1 shows that increased spending on general practice across the UK could lead to short term savings of up to 447m annually,, comprising: 133.9m per year, through divertingg up to 1.7m patients away from A&EE 143.3m per year, through reducingg the number of unnecessary ambulance call outss 170.1m per year, through reducingg the length of hospital stays for patients aged over 65, by providing greater primary care support at home. When medium term savings from better management of people with long term conditions iss factored in, this could rise by a further 333m across the UK, to reach 780m by the end of 2019/200 2. At the same time, additional funding is urgently required in order to shore up thee existing general practice service in the face of the unprecedented pressures it is under. For example: In 2015, patients will have to wait a week or more to see a GP G or practicee nurse on an estimated 67m occasions, accordingg to RCGP analysis based on the GP Patient Survey 3. Between 2008/09 and 2013/14, the number of GP consultations in England rose from 303m to an estimated 361m, an increase of 19% 4. 1 Deloitte (2014) Spend to Save: The Economic case forr improving access to general practice. Accessible at: http://www.rcgp.org.uk/ /campaign home/~/media/files/ppf/2014 RCGP Spend to Save Deloitte report.ashx term savings and 280 million annually in medium term savings from better management of people with long term conditions, giving a total of 656 million savings annually 2 The equivalent figures for England aree 376 million annually in short by 2019/20. 3 New league table reveals GP shortages across England, RCGP press release February 2015. Accessible at: http://www.rcgp.org.uk/ /news/2015/february/new league table reveals gp shortages across england.aspx 4 Deloitte (2014) Under pressure: The funding of patient care in general practice. Accessible at: http://www.rcgp.org.uk/ /campaign home/~/media/files/ppf/deloitte%20report_under%20pressure.ashx 1
In a recent survey of 1,192 GPs in central England 5, 82% of respondents stated that they intend to leave general practice, take a career break and/or reduce clinical hours of work within the next five years, with workload intensity and volume being the most important factors driving this. By 2025, the number of people in the UK living with more than one serious long term condition is forecast to increase by nearly one million, from 8.2m to 9.1m. This is expected to cost an additional 1.2bn over the next decade. Without additional funding to enable general practice to cope with these pressures, we risk a vicious cycle, with an increasing number of GPs leaving the profession, and more and more patients attending hospital because they are unable to get the access they need to general practice. This would lead to a meltdown in general practice and rapidly escalating costs that would threaten the sustainability of the NHS. Additional funding requirements The Government has announced an additional 8bn of additional funding for the NHS in England by 2020/21 to enable the implementation of the Five Year Forward View. It is essential that a significant share of this is invested in general practice, to place it on a sustainable financial footing; to provide a platform for it to offer a greater range of services in the community; and allow it to provide a sustainable future for the NHS. The RCGP has called for 11% of the NHS budget to be invested in general practice, restoring it to the proportion of funding that it received a decade ago. To get to this level would mean that, by April 2020, general practice across the UK needs to be receiving 3.8bn per year more than it currently does, and general practice in England 3.1bn per year more. For general practice to be fit for the future with a growing and ageing population and the growth in multiple serious long term conditions it will need an expanded and more diverse workforce. Only through a reformed model will general practice be able to meet the soaring demand caused by ongoing demographic change. The Primary Care Workforce Commission, announced a year ago at RCGP s Annual Conference by Jeremy Hunt, has set out what the future workforce mix in general practice will need to look like to deliver the new models of care envisaged in the Five Year Forward View. The Commission s conclusions are strongly supported by the RCGP but will not happen without funding, so it is important that their financial implications are factored into the Government s NHS costings for the next few years. Having examined the Commission s recommendations, the College has assessed that the cost of implementing the them can be accommodated within the overall funding increase of 3.8bn per year that is necessary to save general practice and ensure the NHS remains sustainable. The College calculates that implementing the Commission s recommendations will cost an additional 1.66bn in general practice annually by 2019/20 in inflation adjusted terms, together with a further 709m for community nursing services (see Technical Annex for details). This would deliver an 5 Retaining the general practitioner workforce in England: what matters to GPs? A cross sectional study. Dale et al. BMC Family Practice (2015) 16:140. 2
additional 5,000 GPs, 5,000 medical assistants, 4,300 practice based pharmacists, 1,000 physician associates, 2,275 practice nurses and 9,469 community nurses. TECHNICAL ANNEX: COSTS OF IMPLEMENTING THE RECOMMENDATIONS OF THE PRIMARY CARE WORKFORCE COMMISSION Summary: total costs within general practice Role Additional staff by 2020 (FTE) Additional cost in 2019/20 (inflation GP 5,000 1,092,121,333 Medical assistant 5,000 129,977,793 Practice based pharmacist 4,300 273,326,560 Physician associate 1,000 63,118,514 Practice nurse 2,275 95,758,097 Total annual cost in 2019/20 (inflation : 1,654,302,297 Summary: total costs outside general practice Role Additional staff by 2020 (FTE) Additional cost in 2019/20 (inflation Community nurse (including district nurse) 9,469 708,558,868 Total annual cost in 2019/20 (inflation : 708,558,868 Costings by professional group General practitioners The Commission called for the rapid implementation of the Government s commitment to recruiting 5,000 additional GPs in England (Section 2.2.1). In 2013/14, the annual unit cost of a GP, including admin and clerical staff, office and business costs, premises, travel and ongoing training, but excluding qualifications and direct care staff, was 197,943 (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Salary figure based on average income before tax for GPMS contractor GPs. Number of GPs by 2020 (FTE) Total additional cost in 2019/20 (inflation 5,000 1,092,121,333 3
Medical assistants The Commission noted that medical assistants, as employed in family medicine in the US, could substantially reduce the administrative burden on GPs and nurses, and recommended that this role should be developed and evaluated. (Section 2.2.4) The number of medical assistants required was not quantified by the Commission, but a figure of 5,000 is assumed, which is roughly equivalent to 0.6 per practice. As a new role, cost figures for medical assistants do not exist, but it is assumed to be equivalent to a clinical support community nurse employed at Agenda for Change Band 2. The wage/salary cost for this role in 2013/14 was 16,282, which correlates closely to the salary of a healthcare assistant (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Taking into account salary on costs, and management and administration staff overheads, but excluding non staff overheads such as office, telephone and utilities, as well as capital costs and travel, the annual cost of such a role in 2013/14, was 23,558. (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Number of Medical Assistants by 2020 (FTE) Total additional cost in 2019/20 (inflation 5,000 129,977,793 Pharmacists The Commission recommended that there should be greater involvement of clinical pharmacists, including prescribing pharmacists, in the management of people on long term medication and people in care homes, adding that this role is best carried out in the GP practice. (Section 2.2.3). No figure was put forward by the Commission on the number of additional practice based pharmacists that should be taken on by 2020. Work by the Centre for Workforce Intelligence to model the supply and demand of pharmacists predicted the emergence of an oversupply of pharmacists of between 11,000 and 18,000 over the period 2012 2040 (CfWI, A strategic review of the future pharmacist workforce informing pharmacist student intakes, September 2013). Taking the mid point of this range and assuming a linear trend (consistent with the scenarios posited that involve a broadening role for pharmacists) suggests an excess supply of approximately 4,300 pharmacists by 2020. Costings are assumed to be equivalent to those for a community pharmacist, including wages, salary on cost, and management and administration staff overheads, but excluding non staff overheads, training costs, capital overheads and travel. (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Number of additional practice based pharmacists Total additional cost in 2019/20 (inflation by 2020 (FTE) 4,300 273,326,560 4
Physician associates The Commission concluded that there are substantial potential benefits from a range of new approaches to staffing in general practices, including the wider use of physician associates (Section 2.2.4). In June 2015, the Secretary of State for Health announced that there would be 1,000 physician associates available to work in general practice by 2020. According to the Faculty of Physician Associates, the newly qualified Physician Associate post has been evaluated under Agenda for Change at Band 7. Costings are assumed to be equivalent to those for an advanced community based nurse earning the mean salary for Agenda for Change Band 7, and include wages, salary on cost, and management and administration staff overheads, but exclude non staff overheads, qualification costs, and capital overheads. (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Number of additional physician associates by Total additional cost in 2019/20 (inflation 2020 (FTE) 1,000 63,118,514 Practice and community nurses The Commission recommended that the number of general practice and community nurses needed to increase in order to address both current shortfalls and the number of nurses due to retire in the next 5 10 years. (Section 2.2.2.) Modelling by the Centre for Workforce Intelligence indicates the emergence of a gap in the nursing workforce between supply and demand of 47,545 between 2010 and 2016 (Centre for Workforce Intelligence, Future Nursing Workforce Projections: Starting the Discussion, June 2013.) Assuming that this shortfall is spread across the NHS in the same proportions as the distribution of the current nursing workforce, this implies a shortfall in the number of practice nurses over this period of 1,711 and a shortfall in the number of community nurses of 6,965. In addition to increasing the number of GPs, the Government and HEE have committed to expanding the number of other clinical professional working in primary and community care by 5,000 by 2020, to meet the needs of patients under the transforming primary care policy. As part of this Health Education England s Workforce Plan proposes increases in the number of training commissions in 2015/16 of 141 for practice nurses, 71 for district nurses and 555 for adult nurses in primary and community care 6. Assuming that these levels of increase are sustained an increase over the period 2016 20 of 564 in the number of practice nurses, 284 in the number of district nurses, and 2,220 in the number of adult nurses in community/primary care. 6 It is not clear from HEE s published plans how many of these posts are to replace retiring staff: to the extent that they are, this may bring the overall number of additional FTE equivalents required down. 5
Adding together the above elements for 2010 16 and 2016 20 gives the following figures: Number of practice nurses Number of community nurses (including district nurses) 2,275 9,469 In 2013/14, the annual cost of a practice nurse including, wages, salary on costs, and management and administration staff overheads, but excluding non staff overheads, qualification costs, capital overheads, and travel, was 38,143. (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Number of practice nurses Total additional costs in 2019/20 (inflation 2,275 95,758,097 In 2013/14, the annual costs of a community nurse, excluding qualification costs but including (given the non practice context in which this role would be expected to operate) all other elements, was 67,814. (Personal Social Services Research Unit, Unit Costs of Health and Social Care 2014). Number of community nurses (including district Total additional costs in 2019/20 (inflation nurses) 9,469 708,558,868 6