The new chief executive of NHS England Simon Stevens speaks to Victoria Vaughan about the pressures facing general practice
The fact that life is tough at the coalface of the NHS is being shouted from the often rickety practice rafters, but for the first time the head of the service has publicly agreed the situation is not good.
NHS England chief executive, Simon Stevens, has been in the post for a year and is currently pushing forward his vision for the NHS detailed in the easy-read Five Year Forward View published in October 2014.This sets out much about new ways of integration between primary, secondary and social care.
Alongside this he has not been quiet about his support of general practices or the funding imbalance between primary care and hospitals.
“The reality is that general practice continues to be the bedrock of the National Health Service and you see this in the fact that, although there are pressures on A&E departments over the winter, there are 370 million GP consultations a year so [that’s] about 16 GP consultations for every one A&E attendance. That is a hugely important part of the working NHS.
“The reality is that, in my opinion at least, there has been a relative underinvestment in general practice compared to secondary care over at least the last decade,” says Stevens.
This is evidenced by the fact that the number of hospital consultants has gone up three times faster than GPs.
An independent review of numbers, carried out on behalf of the Department of Health and published a year ago highlighted the workforce issue.
It showed that despite the long-standing Department of Health policy to increase GP training numbers in England to 3,250 a year, actual recruitment figures had remained at 2,700 a year, for the last four years. It made several recommendations to reach this target to include a professionally-led marketing campaign.
Stevens says: “The Forward View basically said, ‘It is time to call a spade a spade’. We cannot carry on with that trend if we are going to have the kinds of services that, actually, the patients need and the public want.”
He pointed to the £1 billion primary care infrastructure fund announced in December 2014 as NHS England’s commitment to general practices. The four-year “fighting fund” aims to improve GP premises and infrastructure as well as supporting the 10‑point recruitment retention, return to work scheme agreed with the Royal College of General Practitioners (RCGP) and the General Practice Committee.
“I think we are taking an ‘all of the above’ approach to doing everything we can to pull out the stops for general practice,” he says.
Stevens is very much in favour of leaving practices to evolve into the structures that work for them.
He says that federations “clearly go with the grain of what a number of practices are wanting to do”.
The RCGP has been in the forefront of calling for more federated arrangements respecting practice sovereignty and the choices that individual GPs make about how to arrange their services, subject to meeting the standards that the NHS overall expects.
“I think one of the great strengths of general practice in this country has been its ability to adapt and evolve. I do not think being prescriptive about precisely what the shape of general practice should look like in every part of the country makes any sense at all,” he says.
More broadly his Forward View has triggered changes in primary care. More than 260 health organisations rushed to sign up to his vision by volunteering to become vanguards of which 29 have been selected for the first wave, announced in March. And many of these projects are being headed-up by clinical commissioning groups (CCGs). Mansfield and Ashfield and Newark and Sherwood CCGs, Hampshire and Farnham CCG and Harrogate and Rural District CCG are all setting up integrated primary and acute care systems (PACs) – joining up GP, hospital, community and mental health services. While NHS Sunderland CCG and NHS Dudley CCG are working on creating multispecialty community providers (MCPs) – moving specialist care out of hospitals into the community.
Stevens says NHS England will work to link areas that have similar circumstances rather than working along geographic locations as has traditionally happened. “We have often thought that if it is something that needs to take place at a bigger scale than your immediate town or locality then go find three next door neighbours to do it together. However, actually it turns out that, and we have seen this with the vanguards, what they wanted to do in Harrogate and what they wanted to do in Yeovil has got more in common than Harrogate versus what they wanted to do in Stockport.”
Stevens confirmed that the vanguards will be matched in this way, with areas that have similar priorities working together regardless of location, and that NHS England is in talks with Monitor, the Trust Development Authority (TDA) and the Care Quality Commission (CQC) about how it could work.
Critics argued the vanguards are just another NHS fad, destined to go nowhere. But Stevens gives four reasons why this time it’ll be different. “This was not a bid for money. We will make some investment using some of the £200 million funding we have got available for next year in these vanguards. However, we deliberately did not include a box saying, ‘And tell us what share of the £200 million you think you need’. Secondly, the reality now is that, frankly, in many places people can see they do not really have a choice. The availability of more and more money to fund increasing volumes on the old model is under challenge in many parts of the country. The third reason is that it does genuinely go with the grain of what front-line clinicians want to do. It is not managerially deposed… The fourth thing is that it is not just the usual suspects. Actually, Morecambe Bay is one of the 29 vanguards, so some places are parts of the country with long-standing and deep-seated issues that they have got to confront.”
The ultimate aim is that, if Stevens’ plans are successful, in five to 10 years time healthcare currently delivered in outpatients departments will be available in the community through MCPs. Those forming the first MCPs envisage they will take funding responsibility for their population, using the GP registered list as the basis.
Another new care model outlined in the Forward View is the PACs, where hospitals employ GPs, something that will trouble those struggling to manage spending in hospitals. The Forward View mentions “safeguards” to stop costs spiraling out of control. Stevens elaborates: “Hospitals that are in a partnership of equals with their GPs are coming together to form integrated health systems, they will have to take on responsibility for the fair shares population funding for the people that they are responsible for. For the people of Harrogate, the Harrogate PACs will have to take responsibility for managing health service resources within that total [budget].”
The challenges faced by general practices are many and profound. Be it premises, recruitment or workload there is no shortage of voices shouting about the problems. And it now seems they are being heard right at the top.
This interview took place in early March.