The primary care ship lurched significantly in early March with the arrival of the new NHS England (NHSE) GP contract
Dr David Attwood is Deputy Honorary Secretary of the BGS, and a GP with a specialist interest in Older People, particularly in change management surrounding their proactive and unplanned care. He tweets @DavidAttwood12
Titled “Investment and Evolution” and sporting the NHS flagship blue and white livery it made many bold statements. First up, the extortionate premiums in indemnity coverage that GPs face will end, thanks to state backed indemnity. Nice.
Next up, GP surgeries will form up into ‘Primary Care Networks (PCN).’ To qualify, practices need to work together to cover a minimum population of 30,000 people. Once done and the contract with NHSE is signed, then the network gets 70% of the salary of a pharmacist and all the salary of a social prescriber paid. There are additional financial incentives to do this and there will be more remuneration for other skilled professionals such as physiotherapists and paramedics in the next few years. Not bad.
There is another ace kicker here; each Primary Care Network will have a GP Clinical Director that is funded for a couple of sessions. Their goal is to ensure excellent care in the network and also align with community health services.
In turn community health services have been instructed to change their geographical footprints so that they are aligned to the Primary Care Network footprint and from 2020 PCNs must collaborate with non-GP providers. The implication here is obvious; primary care and community health services have to integrate. This is potentially very exciting if you are looking to support older people in the community and mass produce Comprehensive Geriatric Assessments (CGAs) for older people living with moderate or severe frailty.
In other headlines, 175 QOF points (outcome measures for which primary care are financially remunerated) have been retired and rejigged into other conditions such as diabetes. QOF also now features a Personalised Care Adjustment; there is evidence that stringently treating to QOF targets can be detrimental to the health and wellbeing of older people living with moderate and severe frailty and the ability to modify targets to take account of this is great news.
Two QOF quality improvement (QI) modules have also been opened up and come under the titles:
- Medications optimisation
- Advance care planning
GP surgeries will have to complete these QI modules and demonstrate an improvement in care. Depending on their success it is likely that further QI modules will be brought out in the next five years.
So, we have PCNs with grass roots leaders (Clinical Directors), integrating with Community Health Services, new QI modules, and extra funding/staff. How does this feed into the big picture? The hope is that PCNs will become a fundamental building block of Integrated Care Systems (ICS), which by 2021 will cover the whole of the country.
All ICSs will be accountable for implementing the NHS Long Term Plan and seven workstreams (National Service Specifications) have been identified, of which the first four are directly relevant to older people living with dementia, multimorbidity and frailty:
- Medications optimisation
- Enhanced Health in Care Homes
- Anticipatory Care Planning
- Personalised Care
NHSE has yet to finalise outcomes, processes, and evaluation of these areas so it’s still an open book.
How do GPs feel about this? It depends on your starting point. If you are in a surgery that already has the minimum of 30,000 patients then you are in a pretty sweet place right now. Similarly, if your PCN has good working relations with Community and Acute Health Services then you are in an even better situation.
If you do not exist in this eutopic nirvana then there is quite a bit of work to do. General Practice is a bit of a tribal world; some neighbouring practices have good working relationships, for others things are (shall we say) a little more ‘strained’. Greater problems often exist between primary care and Acute/Community Providers. The pessimists will tell you that Clinical Director for PCN’s will have quite a bit of work to do here. The optimists will point to the fact that creating new leaders will change the locality’s political landscape, which in turn will drive change.
Another issue with the new contract is that PCNs have to provide out of hours coverage. NHS 111 will soon be able to book into GP evening slots in PCNs. However, there is a national shortage of GPs and no amount of remuneration will change this fact. If you are a 50,000 strong PCN you need to provide 25 hours of extra clinical time per week. It might be that creating a multi-professional and multi-skilled team could bridge some of this gap but we will need to see how this goes. The good news is that NHSE have said they are going to keep this under review.
Whilst the GP contract has other offers in the next few years from the NHSE mothership, a few primary care clinicians are wary. Some feel that NHSE has a history of incentivising primary care to do something and then chipping away at the amazing initial offer with added work. The end result is working harder and earning the same or less. Other GPs have a more positive outlook; the contract is fixed for five years, offering unprecedented stability and funding clarity.
Leaving GP views aside and focusing on the health population management of older people we have already named heaps of positives. However, one area that does require further development is screening for older people living with frailty.
The new contract makes a polite nod to the old 2017-2019 GP contract where the Electronic Frailty Index (EFI) was used as a screening tool for moderate and severe frailty. However, there were a lot of challenges with implementing this in primary care (a discussion for another blog), which are best summarised by saying that there will be wild fluctuations in prevalence of frailty for reasons that are not solely due to demographic variations.
NHSE could rectify this by incentivising primary care networks to do a QI Module for identification of frailty based on the screening of patients who had any of the following criteria and then using Rockwood Clinical Frailty Scale to make the diagnosis:
- Age >90
- Diagnosis of dementia
- Living in care homes
- EFI severe
Part of that QI Module may be some support or training in the recognition of frailty, management of long term conditions with co-existing frailty, and medications de-prescribing.
On a final and much brighter note, the NHSE boffins may have cracked a massive barrier to delivering excellent, joined up care for older people; information governance and specifically data sharing.
Here’s the problem: older people with complex needs require the skills of a medley of health and social care professionals, who are employed by different providers, with siloed patient records, resulting in multiple fragmented accounts of the patient story. It has long been appreciated that to articulate the needs of the patient so that they genuinely tell their story only once, this NHS orchestra of professionals requires a shared IT solution. However, there is a lot of anxiety in the NHS about information sharing and patient confidentiality which maintains the fragmented status quo.
Now here is where it gets interesting. The clever folk in NHSE realised that if they wanted to get smaller practices to work in Primary Care Networks, a key challenge would be data sharing and information governance. As a result they will be publishing a model national data sharing template for use. This is a potential game changer for older people with complex needs; by having and information sharing agreement between primary care networks and community health services, the foundations are set for a shared IT solution, meaning that patients will finally be able to tell their story only once.
So will we be entering into a brave new world in primary care? It depends on where your starting point is. There will be quite a few GP surgeries in the UK that already cover a population of more than 30,000. They are in a great place. Smaller practices and GP federations will be less excited by the proposal. Whilst there are going to be some workforce challenges, this is under regular review by the powers that be. There are certainly a lot of positives, with some great potential for improving the health of older people and if NHSE do decide to crack frailty screening and identification then we can make some deep inroads.
A key strength of primary care has always been its nimbleness in the face of change. Ultimately success will be determined by the individuals in a network, working relationships with community teams, and what changes NHSE make to the contract in the next five years.