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Wednesday 26 October 2016
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Mind the GP gap

The Tories pledged a seven-day NHS but what will this mean for general practice, how will it be funded and staffed?

The election’s long past and the shock of an outright Conservative win is sinking in. The Tories now have unambiguous control for the next five years, with none of the compromises of a coalition. Jeremy Hunt as secretary of state for health is a known and familiar figure. The financial regime and service specifications for 2015-16 are in place.
For NHS practice managers, then, back to business as usual?
Yes and no. At national level policy direction remains broadly the same, while the financial environment hasn’t changed. And yet the clear election result brings both a mandate for implementing manifesto pledges, and an expectation that promises will be honoured. (And then there’s the small matter of the economy, to which we’ll return.)

Seven-day access
In primary care the immediate pressure lies in expectations for patient access. The Conservative manifesto commitment to “ensure you can see a GP and receive the hospital care you need, seven days a week by 2020”, coupled with access to same-day appointments for anyone over 75 who needs one, will not be negotiable. Politically there’s now a lot of credibility at stake.
And as challenges go, it’s a big one. Leaving aside the question of whether patients actually want to attend an appointment on a Sunday afternoon, and hence whether it makes business sense for a practice to open and staff itself for such clinics, there’s a pressing and severely practical question. Where would we find the doctors?
The Tory manifesto lacked the overt health staffing ambitions of some of its rivals – more GPs, more nurses and so on – yet extending patient access implies having more people to deliver the service. It’s not unreasonable to assume they will expect to be paid. In the commercial world, one might increase wage rates to lure staff from competitors; or one might aim at a completely new group of people, employ them and train them appropriately. That strategy was, for instance, used by some supermarkets when first contemplating Sunday opening. But there is no pool of potential staff waiting to be enticed into the pressured world of healthcare delivery. Years of pay freezes and political sniping have taken their toll. Word on the street is that working for the NHS is often not the route to work-life balance, job satisfaction or material wealth. Even the pension isn’t what it used to be. New recruits to GP training are scarce and growing scarcer, and the same is true of most clinical professions.

The private sector
The NHS would do well to invest in retaining its existing staff.
Heavy reliance upon training is no longer the option it was a decade ago, if only because of the time it takes to train someone to the required level. For primary care practices, the immediate outlook is likely to be one of staffing difficulties coupled with mounting expenditure on locum and agency staff. NHS England’s response appears to be to blame the agencies for raising their rates – understandable, but unlikely to buck a labour market in which doctors, nurses and therapists sense the opportunity to earn more.
Just possibly, there’s an underlying belief that if primary care practices can’t somehow deliver, the market will provide. Invite tenders; tempt the big corporates into the primary care market. Perhaps Virgin Healthcare and Serco and Care UK and the like will view primary care as a greater business opportunity. Perhaps the days of independent primary care practices are numbered and they’ll go the way of the corner shop dwarfed by the supermarket.
Perhaps, but there’s little sign of enthusiasm from the corporates, and plenty of evidence they see publicly-funded health and social care as worth avoiding. The margins are too tight, potential profits are minimal, and the risks are too severe. Serco is withdrawing from the community care market, having struggled to make their Suffolk contract a springboard for expansion. Circle has handed back the keys of Hinchingbrooke Hospital. Commercial hospital providers have had a good sniff around NHS contracts, for instance when the Cambridgeshire commissioners put services for the elderly out to tender, and by and large they didn’t like what they smelt. The private sector cavalry doesn’t look likely to charge to the government’s aid.
Conclusion? It may be an expensive time to initiate weekend clinics.

Money, money, money
Ah yes. The money.
Asked about the most important change within the English NHS during the last five years, many would point to restructuring under the Health and Social Care Act 2012. For GP practices, the immediate NHS context changed totally. Goodbye primary care trusts, hello clinical commissioning groups.
But others maintain an even bigger change from the Blair/Brown years has been financial. No growth worthy of the name, instead pay freezes, and the insidious drip-drip-drip of cost improvement targets, typically 4% or more each year.
Financially, the story of the NHS over the last five years has been the bumpy road from surplus to deficit. For practices, it’s been an increasingly tough struggle to somehow keep afloat.
Where is the promised reinvestment in frontline services? The ‘Nicholson challenge’ (the
quality, innovation, productivity and prevention initiative) wasn’t just about saving £20 billion: it envisaged cost improvement savings being
used to address three key cost pressures. Population growth, people living longer, and the cost of introducing new drugs and treatments. One would reasonably expect primary care to receive the lion’s share of the first two, and no small proportion of the third.
So where did the money go? Billions were returned to HM Treasury to help with the national deficit. And, as times grew tighter, billions more have been slushed to struggling acute hospitals in largely unstructured bail-outs.
For primary care practices, like all NHS providers, “business as usual” is financially no longer viable. Last autumn’s Five Year Forward View from NHS England recognised this reality, seeking an extra £8 billion from politicians. It’s the sum belatedly and reluctantly pledged by George Osborne during the election campaign.
Belatedly, in that it formed no part of the pre-election budget. Reluctantly, because Osborne’s wider ambition is to eliminate the nation’s fiscal deficit by 2018-19, mainly by cutting public expenditure. Boosting the NHS budget is unlikely to have been part of the Treasury’s plan. Suspicious sceptics wonder about the phasing of the extra £8 billion. Will it arrive quickly enough to forestall the financial crisis projected for the coming autumn and winter? Will there be strings attached?
Remember too that the Five Year Forward View also expects an ambitious £22 billion more savings from within the NHS. Together with Osborne’s promise, that’s £30 billion – enough to keep the wolf from the door, but never intended to meet the growth aspirations beloved of politicians.

The challenge ahead
How might the NHS achieve such daunting efficiency gains? That’s the underlying strategic challenge.
Great hopes are being placed upon “integration” in its various forms; great expectations are being pinned upon primary care. And yes, closer, more co-operative working can greatly improve the user experience. But will it reduce demand at the key pressure points: the accident and emergency department, the ambulance control room, the GP surgery?
As for what’s expected of primary care: most flattering, but please. Where are we to find the GPs?

Noel Plumridge is a finance columnist.