General Practice Forward View

Version number:      1

First published:     April 2016:

Classification:      Official

Gateway publication reference: 05116

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General Practice Forward View   3


Introduction: Simon Stevens                                 4
GP services for the future: Dr Arvind Madan                 6
Chapter 1: Investment                                     10
We will accelerate funding of primary care
Chapter 2: Workforce                                      16
We will expand and support GP and
wider primary care staffing
Chapter 3: Workload                                       26
We will reduce practice burdens and
help release time
Chapter 4: Practice infrastructure                        36
We will develop the primary care estate
and invest in better technology
Chapter 5: Care redesign                                  46
We will provide a major programme of
improvement support to practices
Conclusion                                                56

44 General Practice Forward View


   There is arguably no more              “ The strength of British
   important job in modern                 general practice is its
   Britain than that of the family
                                           personal response to a
                                           dedicated patient list; its
   GPs are by far the largest              weakness is its failure to
   branch of British medicine. A           develop consistent systems
   growing and ageing population,          that free up time and
   with complex multiple health            resources to devote to
   conditions, means that personal                                               On workforce: pulling out all
   and population-orientated
                                           improving care for patients.          the stops to try to double the
   primary care is central to any          The current shift towards             growth rate in GPs, through
   country’s health system. As a           groups of practices working           new incentives for training,
   recent British Medical Journal          together offers a major               recruitment, retention and return
   headline put it – “if general           opportunity to tackle the             to practice. Having taken the
   practice fails, the whole NHS                                                 past 10 years to achieve a net
                                           frustrations that so many
   fails”.                                                                       increase of around 5,000 full
                                           people feel in accessing care         time equivalent GPs, aiming to
   So if anyone ten years ago had          in general practice.”                 add a further 5,000 net in just
   said: “Here’s what the NHS                                                    the next five years. Plus 3,000
   should now do - cut the share                                                 new fully funded practice-
   of funding for primary care and         So rather than ignore these real      based mental health therapists,
   grow the number of hospital             pressures, the NHS has at last        an extra 1,500 co-funded
   specialists three times faster than     begun openly acknowledging            practice clinical pharmacists,
   GPs”, they’d have been laughed          them. We need to act. This            and nationally funded support
   out of court. But looking back          document sets out exactly             for practice nurses, physician
   over a decade, that’s exactly           how. It contains specific,            associates, practice managers
   what’s happened. Which is why           practical and funded steps – on       and receptionists.
   it’s no great surprise that a recent    investment, workforce, workload,
   international survey revealed           infrastructure and care redesign.     On workload: a new practice
   British GPs are under far greater                                             resilience programme to support
   pressure than their counterparts,       On investment: by 2020/21             struggling practices, changes
   with rising workload matched by         recurrent funding to increase by      to streamline the Care Quality
   growing patient concerns about          an estimated £2.4 billion a year,     Commission inspection regime,
   convenient access.                      decisively growing the share          support for GPs suffering
                                           of spend on general practice          from burnout and stress, cuts
   A recent report on GP workload          services, and coupled with a          in redtape, legal limits on
   pressures by the Primary Care           ‘turnaround’ package of a further     administrative burdens at the
   Foundation and NHS Alliance said        £500 million. Investments in staff,   hospital/GP interface, and action
   this:                                   technology and premises, and          to cut demand on general
                                           action on indemnity and redtape.      practice.

General Practice Forward View   5

On infrastructure: new rules to          Thanks go to the many GPs,
allow up to 100% reimbursement           other NHS professionals and
of premises developments, direct         patient groups who’ve helped
practice investment tech to              shape this urgent ‘to do’ list
support better online tools and          - including particularly our
appointment, consultation and            partners at the Royal College
workload management systems,             of General Practitioners, the
better record sharing to support         British Medical Association’s
team work across practices.              General Practitioners Committee,
                                         Department of Health, Health
On care redesign: support                Education England, the National
for individual practices                 Association of Primary Care,
and for federations and                  NHS Alliance, the Family Doctors
superpartnerships; direct funding        Association and in local CCGs
for improved in hours and out of         and Local Medical Committees
hours access, including clinical         right across England.
hubs and reformed urgent care;
and a new voluntary contract             Looking back over nearly seventy
supporting integrated primary            years, there have been key
and community health services.           moments in NHS history when
                                         the health service has stepped
One of the great strengths of            up to support and strengthen
general practice in this country         general practice and wider
has been its diversity across            primary care. Think: the New
geographies and its adaptability         Deal for GPs in 1966. Think:
over time. So one size will not fit      new contractual models in the
all when it comes to the future          1990s and 2000s. If properly
shape and work of primary care.          implemented, the wide-ranging
But in the round, this support           measures in this document may
package is likely to herald a            perhaps come to be seen as a
‘triple reinvention’ - of the clinical   similar inflexion point.
model, the career model, and the
business model at the heart of           But be that as it may, the vital
general practice. In his preface         thing is to roll our sleeves up, get
to this document Arvind Madan            practical, and together begin to
describes what this could mean           make a tangible difference, now,
from the practice and the patient        for practices and for our patients.

                                         Simon Stevens
                                         Chief Executive, NHS England

66 General Practice Forward View

   GP services for the future:
   Dr Arvind Madan
   The public relies on general         Running the practice or having
   practice services for the health     a meaningful conversation
   and wellbeing of themselves          with staff is relegated to the
   and their family. It is one of       edges of the day. Almost every
   the great strengths of the           practice is struggling to balance
   NHS, and is recognised time          rising workload within tighter
   and again in international           financial constraints. Add to
   comparisons.                         this the strain of recruitment
                                        issues and it becomes easy to
   Over my 20 years as a GP             see why morale is so challenged.      to the wider sustainability of
   demand for appointments, and         Clinicians increasingly feel unable   the NHS. Secondly, there is
   particularly their complexity, has   to provide the care they want         acknowledgement of historic
   increased beyond recognition.        to give, and understandable           underfunding in general
                                        resentment of working under this      practice and the need for this
   There has been a steady rise         pressure is growing.                  to be reversed. Thirdly, practices
   in patient expectations, a                                                 themselves seem more open to
   target driven culture and a          Yet patients rightly expect and       new ways of working than at
   growing requirement for GPs to       deserve high quality care from        any time I can recall. As much
   accommodate work previously          a familiar team of healthcare         because we want patient care
   undertaken in hospitals, or in       professionals they know               to improve, as we recognise our
   social care. This has resulted       and trust. We know these              survival depends on it.
   in unprecedented pressure on         relationships rest at the heart
   practices, which impacts on staff    of how every general practice         Most observers now agree that
   and patients. Small changes          functions. They are fundamental       the solution lies in a combination
   in general practice capacity         to what we do, namely person-         of investment and reform.
   have a big impact on demand          centred coordinated care of           It requires action from NHS
   for hospital care, so the need       complex physical, mental and          England, clinical commissioning
   to support general practice in       social issues, within the context     groups (CCGs), health and care
   underpinning the whole NHS has       of the individual, their families     organisations, and practices
   never been greater.                  and the wider community.              themselves. We know there is
                                                                              no single cause for the issues we
   However, a typical morning           I joined NHS England at the end       face, and that no single part of
   in general practice currently        of last year, in part driven by       the system acting in isolation can
   comprises a long arduous             my frustration with how I felt        fix it either. We need a concerted
   struggle through appointments,       high quality primary care for         approach of initiatives, involving
   phone calls, repeat prescriptions,   patients was being undervalued.       all stakeholders, across a number
   results, letters and home visits.    Since starting I have made three      of key areas.
   Before you get time to look          observations. Firstly, there is
   up, much less take a break,          a deep-seated recognition of
   it is the afternoon and you          how a strengthened version
   have to start all over again.        of general practice is essential

General Practice Forward View           7

The General Practice Forward          The GP is an expert medical
View represents a step change         generalist and must be properly
in the level of investment and        valued as the provider of
support for general practice.         holistic, person-centred care
It includes help for struggling       for undifferentiated illness,
practices, plans to reduce            across time within a continuous
workload, expansion of a wider        relationship. These are core
workforce, investment in              strengths of general practice
technology and estates and a          and must be preserved within
national development                  any change. However, patient
programme to accelerate               demand and GP shortages
transformation of services. NHS       mean that we no longer have
England is committing to an           the time to use our expertise on
increase in investment to support     patient issues that can be safely
general practice over the next five   and competently managed by
years. Furthermore this will be       others. Wider members of the
supplemented by GP-led CCGs as        practice-based team will play
they act to transform local care      an increasing role in providing
systems. This transformation will     day-to-day coordination and
be built around patients, around      delivery of care. Greater use of
the wider workforce, around the       skill mix will be key to releasing    initiatives (including the voluntary
redesign of our workload and          capacity, if we are to offer          sector) and pharmacy minor
organisation of care, and creating    patients with complex or multiple     ailment schemes. Pharmacists
a satisfying and rewarding career     long-term conditions longer GP        remain one of the most
for everyone working in general       consultations.                        underutilised professional
practice.                                                                   resources in the system and we
                                      In the way we currently view          must bring their considerable
Some patients want to be              practice nurses as an integral        skills in to play more fully.
partners in their own care. They      part of the practice team, the
want the knowledge, skills            GP Access Fund schemes are            We all accept that we have
and confidence to take more           already showing how a broad           a long way to go to hit the
responsibility for their health       range of healthcare professionals     ambitious recruitment targets set
and feel more in control of their     can contribute to providing           for primary care, but we must use
outcomes. Channelling this            care, for example advanced            every effort to try, as this will be
growing patient appetite for          nurse practitioners, clinical         necessary for much of the reform
services that help patients to help   pharmacists, physician associates,    required. NHS England, alongside
themselves unlocks both a better      physiotherapists and paramedics.      Health Education England and
patient experience and a way to       Staff are navigating patients to      CCGs, will support a series of
alleviate practice workload. No       a wider range of alternative          initiatives to grow and train the
amount of reform of the existing      services such as primary care         workforce in response to this
system will work unless we also       access hubs, social prescribing       challenge.
partner with our patients to
manage demand more efficiently.

88 General Practice Forward View

   A common reason for poor
   morale is the daily struggle with
   growing workload. Much of this
   is generated by a fragmented
   system, over which practices feel
   they have little influence. Our
   first and most pressing priority
   must be to alleviate this wasteful
   burden, which takes away from
   direct patient care. We know
   we cannot work any harder, so
   we have to find ways to work
   differently. A key requirement
   for wider system change is the
   urgent need to identify and
   eliminate needless workload.

   But this is a challenge when it      Teams need support and               We will also develop different
   is difficult to find time to look    space if they are to adopt new       ways of managing clinical
   up from the day job. For GPs to      ways of working. This is why         demand. In addition to increasing
   believe in a better future we must   NHS England plans to invest          self-care, use of different
   first start to feel the impact of    in a national development            triage methods and a broader
   changes now. Some of the new         programme at individual, practice    workforce sharing the burden,
   measures within this document        and network or federation            we also need to grow capacity
   are specifically designed to         level. I have been struck by how     through a network of locality
   provide immediate relief to          positively received the recent NHS   primary care access Hubs (as seen
   existing pressures. We need to       England and BMA roadshows            in the GP Access Fund areas) and
   tackle issues such as irrelevant     on releasing capacity have been.     increase clinical personnel behind
   communications, duplicate            However, this should be viewed       services such as 111, for example,
   reporting, unwieldy payment          as the start of a journey in         nurses, pharmacists and dentists.
   systems and streamline oversight     supporting practices to build the
   and regulation.                      capacity and capabilities required
                                        within our teams. We must and
                                        will go much further.

General Practice Forward View         9

It is becoming increasingly            GPs’ core role will be to provide
normal for general practices           first contact care to patients
to work together at scale, and         with undifferentiated problems,
already over half the country          provide continuity of care where
have formed into networks              this is needed, and act as leaders
or federations of practices. In        within larger multi-disciplinary
the future there will be greater       teams with greater links to
opportunities for practices to         hospital, community and social
work collaboratively in larger         care specialists.
groupings for the benefit of
more sizeable populations, yet         Primary care professionals will
maintain their unique identity         increasingly work at different
and relationship with their own        organisational levels, for
patients. Larger organisational        example, their own practice, a
forms will enable greater              neighbourhood of practices and
opportunities for practices to         across the local health economy.          The General Practice Forward
increase their flexibility to shape,   This will open up opportunities           View will not solve all the issues
buy or build additional services,      in pathway design, service                we face immediately, but it
working from a more effective          leadership, education, training           does set a new direction and
platform with other local health       and research, or developing areas         opportunity to demonstrate what
and care providers, including          of clinical interest. Specialists will    a strengthened model of general
community health services, social      develop more community facing             practice can provide to patients,
care and voluntary organisations.      roles, supporting primary care            those who work in the service,
                                       colleagues in developing case             and for the sustainability of the
GPs must feel confident in the         management expertise, both in             wider NHS. General practice has
vision of where general practice       person and remotely. There will           risen to challenges in the past
could go and how it will feel          be greater use of technology to           and, with support from leaders
to be a GP in the future. A            connect primary care with others,         across the system, it will again.
significant proportion of demand       for the sharing of best practice
must be managed through                and sourcing of timely advice.
helping patients to stay well, self-   These changes will develop a
care and navigate to other team        more unified team approach,
members, or alternate services.        in a variety of career structures,
                                       with satisfying and rewarding
                                       opportunities for both clinicians         Dr Arvind Madan
                                       and non-clinicians, and a more            GP, Director of Primary Care,
                                       coordinated experience of care            NHS England
                                       for patients.

1010 General Practice Forward View

    Chapter 1: Investment
    We will accelerate funding of primary care

           We will increase the levels of
           investment in primary care:
           • By investing a further £2.4 billion a year by
             2020/21 into general practice services. This means
             that investment will rise from £9.6 billion a year
             in 2015/16 to over £12 billion a year by 2020/21.
           • Represents a 14 percent real terms increase,
             almost double the 8 percent real terms increase
             for the rest of the NHS.
           • This is the expected increase nationally.
             Investment is likely to grow even further as CCGs
             build community services and new care models,
             in line with the Five Year Forward View.
           • This includes capital investment amounting to
             £900 million over the next five years.
           • Will be supplemented by a Sustainability and
             Transformation package, totalling over half
             a billion pounds over the next five years, to
             support struggling practices, further develop the
             workforce, tackle workload and stimulate care
           • A new funding formula to better reflect practice
             workload, including deprivation and rurality.
           • Consult the profession and others on proposals
             to tackle indemnity costs in general practice by
             July 2016.

General Practice Forward View   11

The Five Year Forward View         Since the creation of NHS
recognised that primary care has   England in 2013, each year there
been underfunded compared          have been real term increases
to secondary care, and that        in primary care funding. On the
this must change. The historic     back of the Spending Review,
strength of general practice is    which committed £10 billion a
being weakened by the relative     year more above inflation for the
under-investment in general        NHS by 2020 to back the Five
practice that has occurred over    Year Forward View, we know we
the past decade.                   need to sustain and accelerate
                                   growth in investment.

1212 General Practice Forward View

    Package of investment in                         Plus local investment                        This package will include:
    general practice1                                For the first time, the Planning
    We are committed to increasing                   Guidance for the NHS has made                • £56 million, to include a new
    the proportion of investment                     securing the sustainability of                 practice resilience programme
    going into general practice                      general practice, and in particular            starting in 2016/17, and the
    services. This should reach over                 addressing workforce and                       offer of specialist services to
    10 percent by 2020/21, and will                  workload issues, one of nine                   GPs suffering from burn out
    rise further as CCG investment                   national ‘must dos’. Every part                and stress (see chapter 3)
    in general practice rises also.                  of England has been asked to                 • £206 million for workforce
    Overall investment to support                    produce a Sustainability and                   measures to grow the medical
    general practice services will rise              Transformation Plan (STP), which               and non-medical workforce (see
    by a minimum of £2.4 billion a                   will include plans to secure                   chapter 2)
    year by 2020/21. This represents                 and support general practice,                • £246 million to support
    a 14 percent real terms increase,                and enable it to play its part in              practices in redesigning services,
    significantly more than that                     more integrated primary and                    including a requirement on
    anticipated for CCG allocations.                 community services. These plans                CCGs to provide around
                                                     will be completed by July 2016.                £171 million of practice
    The additional investment we                     National actions on their own will             transformational support and
    are making in introducing new                    not be enough – local leadership               a new national £30 million
    care models will benefit general                 and investment will be vital.                  development programme for
    practice too – and this will ensure                                                             general practice (see chapter 5).
    investment rises at least in line                Plus a five year general
    with the plans set out above, and                practice Sustainability and                  We will also continue to support
    potentially even more.                           Transformation package                       capital investment in general
                                                     We have created a national £508              practice through a programme
    For 2016/17, NHS England has                     million five year Sustainability             of investment estimated to reach
    allocated an additional £322                     and Transformation package                   over £900 million over the next
    million in primary medical care                  for general practice to help                 five years.
    allocations, providing for an                    further support struggling
    immediate increase in funding of                 practices in the interim, develop            Fairer distribution of funding
    4.4 percent.                                     the workforce, stimulate care                The Carr-Hill formula applies a
                                                     redesign and tackle workload.                weighting (to General Medical
                                                                                                  Services (GMS) contracts only) to
                                                                                                  reflect the comparative workload
                                                                                                  associated with different patient

        As part of agreed devolution arrangements, Greater Manchester has been allocated a
        transformation fund which includes an appropriate share of NHS England funding for
        primary medical care initiatives. It will be for Greater Manchester to determine how it
        is spent in the local area.

General Practice Forward View          13

Many believe that the Carr-Hill       Tackling rising costs of               • working with the medical
formula is now out of date and        indemnity                                defence organisations and
needs to be revised to reflect        Indemnity costs have risen in the        indemnity insurers to meet
changes in the population             NHS in England significantly in          the needs of new ways of
and the impact of this on             recent years. This is the result of      delivering care. For example,
comparative workload. NHS             the rising number of claims, and         through products that treat
England is working with the           the rising level of awards made          the delivery of services across
BMA to review the Carr-Hill           by the courts, with the cost of          practices outside of core hours
formula to specifically examine       care packages doubling every             (with shared access to patient
the impact of deprivation, age        seven years. This is despite the         records) as similar to in-hours
and other factors that influence      fact that on objective measures,         working, rather than charging
practice workload. This work          the quality and safety of care           the out of hours rate. This is
will be concluded in the summer       provided by GPs has never been           in recognition of access to the
of 2016, and form the basis of        higher. GPs tell us that these           patient record.
discussion with the BMA about         costs are distorting decisions
changes that might be needed.         about whether to remain in work        Some GPs have called for
                                      (particularly for those choosing to    general practice to have Crown
A minority of practices are yet       work part-time), whether to work       indemnity. This would mean it is
to undergo their PMS contract         in GP out of hours and urgent          not possible to sue for damages
reviews. We are committed             care services for non NHS trust        and that the small minority of
to ensuring this process is           providers, and whether to deploy       patients who had suffered harm
completed in the interest of          the wider clinical workforce           as a result of clinical negligence
equity across all practices.          (where costs for nurse indemnity       would not have recourse to any
However, in the interests of          can be the equivalent of medical       financial compensation. We do
stability, these changes are being    indemnity).                            not believe that this is the intent
phased over a minimum of four                                                of the profession, and this form
years, ensuring there is a water      NHS England has taken initial          of immunity does not apply to
tight reinvestment plan for all       steps to alleviate these pressures     other health services.
savings in local general practices,   through:
and engaging in individual                                                   Rather, we believe that the
conversations with practices that     • the establishment in 2014/15         shared aim of all those working
are particularly challenged.            and 2015/16 of a £2.5 million        in the NHS is to bring down
                                        ‘winter indemnity’ scheme to         the overall costs associated
CCG plans for reinvestment              help with the costs of those         with negligence claims in an
must be published before the            working out of hours                 appropriate fashion, and ensure
full impact of Personal Medical       • taking into account increases in     that the way that those costs are
Services (PMS) reviews are              indemnity costs, amongst other       borne does not dis-incentivise
implemented for individual              factors, in agreeing funding for     excellent clinical staff from
practices.                              the 2016/17 GP contract.             working in the NHS or restrict
                                                                             access to justice.

1414 General Practice Forward View

    The Department of Health will         The Department of Health             In principle, GPs should be no
    be consulting shortly on the          and NHS England will instead         more exposed to the rising costs
    options for introducing a Fixed       bring forward proposals in July      of indemnity than our hospital
    Recoverable Cost scheme to cap        2016 for discussion with the         doctors, and any solution will
    the level of recoverable costs        profession, medical defence          need to address this.
    for claimant lawyers on clinical      organisations, the commercial
    negligence claims. The aim is         insurance industry and the NHS       Taken together, this represents a
    to make the cost of claimant          Litigation Authority. This will      significant programme of work
    lawyers more proportionate to         consider potential solutions,        to reform indemnity in general
    damages and defence costs.            including considering:               practice, addressing some short-
                                                                               term pressures whilst looking to
    We and the Department of              • how personal costs of              bring down the overall costs to
    Health are also committed to            indemnity and clinical insurance   the system.
    reviewing the way in which              can be contained, provided
    costs are funded. Any changes           certain clinical governance
    would have a bearing on                 standards are met – with the
    historical claims and handling          objective of reducing the
    of past liabilities. This is            overall costs to the individual;
    complex with the potential to         • reducing indemnity costs
    create unintended financial             for individuals in particular
    consequences if mishandled.             circumstances, such as GPs
    The Clinical Negligence Scheme          who wish to remain in the
    for Trusts (CNST) is a risk-pooling     workforce on a part-time basis
    arrangement for trusts, and             past a certain age; and
    requires every organisation to        • enable new models of
    contribute funds. The rising costs      care such as Multispeciality
    of CNST has been an issue for           Community Providers (MCPs)
    providers in other sectors, and to      to take on corporate indemnity,
    date, we have not seen evidence         freeing up individuals working
    that access to CNST would bring         in those new models from the
    down the costs for practice             burden of personal indemnity
    partnerships. There would be            costs.
    significant implications for the
    treatment of historical claims, for
    the insurance market in general,
    and it might increase costs to
    practices. So this is not a simple

General Practice Forward View   15

Better Care Fund
The Better Care Fund (BCF)            CASE STUDY
requires CCGs and local authorities
to pool budgets and to agree an
integrated spending plan for how         Wider integration of health and social
they will use their BCF allocation.      care - Sunderland (MCP vanguard)
In 2016/17, the minimum size of
the BCF has been increased to            Through the Better Care Fund all of Sunderland’s
£3.9 billion.                            resources for out-of-hospital care from both the
                                         CCG and local authority are now contained within
From April 2016, CCGs, local             a single pooled budget of over £160 million. From
authorities and NHS England will         April 2015, a Provider Management Board took on
be able to pool budgets to jointly       the leadership for redesigning existing services and
commission expanded services,            investing new funds in additional GP and nursing
including:                               sessions in integrated teams and a 24/7 Recovery at
                                         Home service.
• additional nurses in GP settings
  to provide a coordination role         Co-located multidisciplinary teams, working
  for patients with long term            across several practices, provide an enhanced
  conditions;                            level of care to patients with complex needs.
• GPs providing services in care         These are often frail older people and/or people
  and nursing home settings;             with multiple co-morbidities both at home and
• providing a mental health              in supported housing, including care homes,
  professional in a GP setting; and      identified via a risk stratification approach.
• hosting a social worker in a GP

1616 General Practice Forward View

    Chapter 2: Workforce
    We will expand and support GPs and
    wider primary care staffing

           The General Practice Forward View cannot be delivered without sufficient
           recruitment and workforce expansion. Therefore NHS England and Health Education
           England (HEE) have set ambitious targets to expand the workforce, backed with
           an extra £206 million as part of the Sustainability and Transformation package. We
           will also support the development of capability within the current workforce and
           support the health and wellbeing of staff.

           Expansion of workforce capacity
           Plans to double the rate of growth of the medical workforce to create an extra 5,000
           additional doctors working in general practice by 2020. This five year programme
           • Increase in GP training recruitment to 3,250 a year to support overall net growth of
             5,000 extra doctors by 2020 (compared with 2014).
           • Major recruitment campaign in England to attract doctors to become GPs,
             supported by 35 national ambassadors and advocates promoting the GP role.
           • Major new international recruitment campaign to attract up to an extra 500
             appropriately trained and qualified doctors from overseas.
           • Targeted £20,000 bursaries in the areas that have found it hardest to recruit into
             GP training.
           • 250 new post-certificate of completion of training (CCT) fellowships to provide
             further training opportunities in areas of poorest GP recruitment.
           • Attract and retain at least an extra 500 GPs back into English general practice,
             • simplifying the return to work routes further, with new portfolio
               route, and other measures to reduce the length of time.
             • launch of targeted financial incentives to return to work in areas of
               greatest need.
           A minimum of 5,000 other staff working in general practice by 2020/21. This five
           year programme will include:
           • Investment in an extra 3,000 mental health therapists to work in primary care by
             2020, which is an average of a full time therapist for every 2-3 typical sized GP
           • Current investment of £31 million to pilot 470 clinical pharmacists in over 700
             practices to be supplemented by new central investment of £112 million to extend
             the programme by a pharmacist per 30,000 population for all practices not in the
             initial pilot – leading to a further 1,500 pharmacists in general practice by 2020.
           • Introduction of a new Pharmacy Integration Fund.

General Practice Forward View   17

        • A general practice nurse development strategy, with an extra minimum £15 million
          national investment including improving training capacity in general practice,
          increases in the number of pre-registration nurse placements, measures to improve
          retention of the existing nursing workforce and support for return to work schemes
          for practice nurses.
        • National investment of £45 million benefitting every practice to support the
          training of current reception and clerical staff to play a greater role in navigation
          of patients and handling clinical paperwork to free up GP time.
        • Investment by HEE in the training of 1,000 physician associates to support general
        • Introduction of pilots of new medical assistant roles that help support doctors, as
          recommended by the RCGP.
        • £6 million investment in practice manager development, alongside access for
          practice managers to the new national development programme.
        • £3.5 million investment in multi-disciplinary training hubs in every part of England
          to support the development of the wider workforce within general practice.

        Health and wellbeing
        £16 million extra investment in specialist mental health services to support GPs
        suffering with burn out and stress, and support retention of GPs, in addition to the
        £3.5 million already announced.

Over the past decade, the
number of GPs (full time
equivalents) working in general
practice has risen by over 5,000.

But we know that many practices
now face recruitment issues
and are increasingly reliant on
temporary staff. Moreover, a
higher proportion of older GPs
are signalling that they are
considering leaving the workforce

1818 General Practice Forward View

    We aim to double the rate of
    growth in the primary care
    medical workforce over the
    next five years, to create an
    extra 5,000 doctors working in
    general practice. This needs
    to be supported by growth in
    the non-medical workforce
    – a minimum of 5,000 extra
    staff – nurses, pharmacists,
    physician associates, mental
    health workers and others.

    Work to date                        Last year, NHS England, HEE,          Through the 10 point action plan,
    The Primary Care Workforce          Royal College of General              together we have:
    Commission, set up by HEE and       Practitioners (RCGP) and the
    chaired by Professor Martin         General Practitioners Committee       • delivered a marketing campaign
    Roland, called for a broader        (GPC) developed an initial 10           to encourage foundation year
    range of staff to be involved in    point action plan – Building            2 doctors who are applying
    providing care. Their report, The   the Workforce a new Deal for            for specialty training to choose
    future of primary care creating     General Practice - to kick start        general practice;
    teams for tomorrow, set out         initiatives to improve recruitment,   • launched a scheme to offer up
    how we can better deploy the        retention and return to practice.       to £20,000 bursaries for 109
    talents of the wider workforce to   Now that there is significant new       GP trainees to attract doctors
    reduce the workload burden on       investment for general practice,        to parts of the country where
    GPs, meet patients’ needs and       we will be working together             there have been consistent
    to free GPs up to do what they      – and with other professional           shortages of trainees;
    do best. The report also set out    bodies, such as the RCN,              • established new post-CCT
    recommendations to increase         Queen’s Nursing Institute, Royal        fellowships to provide further
    the role of nursing, advanced       Pharmaceutical Society, National        training opportunities in areas
    clinical practitioners, medical     Association of Primary Care and         of poorest GP recruitment that
    assistants, practice pharmacists    NHS Clinical Commissioners              encourage new CCT holders
    and physician associates along      to step up actions to grow the          to work as GPs in those areas,
    with stronger partnerships with     workforce and stimulate a more          whilst pursuing special interests
    the voluntary sector and better     diverse range of workforce              and meeting local need such
    use of technology.                  models within primary care.             as urgent care and learning
                                                                                disability care;

General Practice Forward View        19

• committed to invest £3.5
  million in 13 new multi­
  disciplinary training hubs
  (Community Provider Education
  Networks) across the country
  to support the development
  of the wider workforce within
  general practice, including
  placements in general practices,
  development for current staff
  and workforce planning;
• created a national induction
  and refresher (returner)
  scheme, offering a new £2,300
  per month bursary to doctors
  looking to return to general
  practice to help with costs
  and improving entry routes –
  leading to an increase in the
  number of applicants and           are developing a strategy for         This represents a welcome
  improving coverage, given          supporting the practice nursing       increase of around 7 percent
  previous local variation;          workforce.                            on last year’s first round of
• invested an extra £1.75 million                                          recruitment.
  nationally to support practice     Building the workforce
  nurse development;                 for 2020                              HEE will in partnership with
• invested in leadership             To double the rate of growth          the RCGP, and the profession
  development and coaching for       of the medical workforce, and         continue refining and developing
  individual GPs; and                accelerate use of the wider           GP specialty training to provide
• piloted new ways of working        workforce, we set out below           greater career flexibility while
  including the development          the new programmes of work            maintaining standards in order to
  of Primary Care Physician          that will be needed. This will be     maximise recruitment.
  Associates.                        backed by an extra £206 million
                                     over the next five years on top of
For the wider workforce, we          previously announced initiatives.
agreed a major £31 million
scheme to pilot the deployment       Recruiting doctors into
of over 470 clinical pharmacists     general practice
in just over 700 practices over      HEE has increased GP training
the next three years, helping        capacity and increased
practices with the costs of          recruitment to 3,250 doctors
employment and training. We          per annum recurrently. In the
have published a practice and        first round recruitment for 2016,
community nursing education          2,296 posts - 70 percent - have
and career framework, and            already been filled.

2020 General Practice Forward View

    We know we need to improve            in the community and their                 Already, the new induction and
    the number of medical school          patients’ care. HEE has recruited          refresher (returner) scheme has
    graduates choosing to join            and trained 35 campaign                    seen:
    general practice. There is a strong   ambassadors and advocates to
    correlation between training          support and promote national               • the end to multiple different
    placements in general practice        and regional activities including            policies, with one single
    and eventually working in general     attendance at recruitment events             national policy, supported by
    practice. HEE is currently working    and through social media.                    single website, a consistent
    with the Medical Schools Council,                                                  set of written guidance to
    higher education institutions, the    We will supplement this                      applicants, and a new single
    RCGP and the GPC to increase          with a major international                   point of contact;
    the profile of general practice       recruitment drive, to attract up           • a significant increase in NHS
    in medical schools and in their       to 500 appropriately trained and             England bursaries for the
    curricula.                            qualified doctors – and possibly             period of time that the doctor
                                          more - from overseas over the                is in a supervised placement -
    A working group, chaired by           next five years.                             £2,300 per month – up from a
    Professor Valerie Wass OBE, will                                                   range of £0 to £500 per month
    publish recommendations in            Working with HEE we will                     previously depending on which
    summer 2016 about recruitment         evaluate its £20,000 bursary                 part of the country you are in;
    and selection, finance and            scheme to attract trainees into            • the end to requiring doctors
    curriculum and the promotion of       hard to fill areas and identify if           working overseas to return to
    general practice as a speciality.     more needs to be done.                       England to start the application
                                                                                       process, with the ability to
    The recommendations will              HEE will roll out a total of 250             hold interviews now via Skype
    improve the medical school            post CCT fellowships by                      and sit initial assessments in
    experience of general practice        summer 2017 to offer wider                   countries all round the world;
    through greater exposure to the       and more varied training                     and
    diverse and stimulating reality of    opportunities in areas of poorest          • a review of the appropriate
    general practice professionally       GP recruitment.                              and relevant content of all
    and personally. More graduates                                                     assessments, leading to a
    will be encouraged to make a          Retaining the current medical                doubling of pass rates in the
    positive choice of general practice   workforce                                    last nine months.
    as a career.                          One of the strengths of general
                                          practice as a career is its flexibility,
    HEE and the RCGP will                 with the chance to work part-
    continue to develop the current       time or combine general practice
    recruitment campaign to raise         with work in other settings. We
    the profile of general practice       want to make it easier and more
    as a career. The campaign             attractive for GPs to return to
    showcases the variety of different    work in English general practice.
    opportunities and the flexibility
    of the specialty, as well as
    the central role that GPs play

General Practice Forward View          21

As a direct result, we have seen     • create a central contact point
a significant rise in the number       for any doctor wishing to
of doctors applying to return to       return to work in English
work in general practice, with         general practice, so that
an increase of 40 percent in the       doctors are supported in
number of doctors booking to           navigating any regulatory issues
sit the multiple-choice questions      and to support and guide them
(MCQ), one of the routes for           through the process;
returning to practice, in 2015/16    • address delays in securing
compared to 2014/15.                   Disclosure and Barring Service
                                       checks – taking several weeks
We need to accelerate this             and sometimes months –
further so that we can attract         and sort out information
at least an extra 500 doctors          governance issues to enable
over the next five years back into     checks to be valid across
general practice. The RCGP has         different parts of the system;
sought feedback on some of           • increase the financial
the main barriers experienced by       compensation available
returning doctors, and this has        through the current GP
formed the basis of our action         retainer scheme from 1 May
plan for improvement. Our aim          2016; and introduce a new GP         In addition, we will invest further
is to start measuring the time         retainer scheme more fit for         in leadership development,
it takes for a doctor to return        purpose from 1 April 2017; and       coaching and mentoring skills for
to work, and halve the average       • offer targeted financial             experienced doctors – enabling
time.                                  incentives to GPs from May           them to build on their skills and
                                       2016 for returning to work           offer the value of their experience
We will build on the                   in areas of greatest need.           to younger doctors. We will take
improvements to establish a                                                 stock of the findings of evidence
straightforward route for doctors    We also need to find ways to           on retention, and address any
to return to work in England.        attract GPs to remain in practice      further issues identified.
                                     towards the end of their career.
In addition, we will:                The published evidence on
                                     retention suggests that the single
• from April 2016, introduce a       biggest enabler would be to
  new Portfolio Route (2016)         address concerns over workload,
  for GPs with previous UK           and create a greater sense of
  experience, continuing to          ‘status’ for general practice
  work in equivalent primary         within society. The totality of the
  care roles outside the UK,         General Practice Forward View
  removing the need for them to      is aimed at addressing these
  sit the current exams to return    fundamental issues.
  to practice;

2222 General Practice Forward View

                                                                                • introduce a Pharmacy
                                                                                  Integration Fund, worth £20
                                                                                  million in 2016/17 and rising by
                                                                                  a further £20 million each year,
                                                                                  to help further transform how
                                                                                  pharmacists, their teams and
                                                                                  community pharmacy work
                                                                                  as part of wider NHS services in
                                                                                  their area. Subject to a separate
                                                                                  consultation, our proposals
                                                                                  include better support for GP
                                                                                  practices, for care homes and
                                                                                  for urgent care for the use of
                                                                                  the fund;
    Building the wider workforce            pre-registration nurse              • invest in an extra 3000
    The success of general practice         placements and other measures         mental health therapists to
    in the future will also rely on         to improve retention;                 be working in primary care by
    the expansion of the wider            • extend the clinical pharmacists       2020 to support localities to
    non-medical workforce –                 programme with a new £112             expand the Improving Access to
    including investment in nurses,         million offer to enable               Psychological Therapies (IAPT)
    pharmacists, practice managers,         every practice to access a            programme;
    administrative staff and the            clinical pharmacist across          • provide £45 million extra
    introduction of new roles such as       a minimum population on               funding nationally over five
    physician associates and medical        average of 30,000 - leading           years so that every practice
    assistants.                             to an extra 1,500 pharmacists         in the country can help their
                                            in general practice. Appetite         reception and clerical staff
    Our ambition is to use some of          for the original pilot scheme         play a greater role in care
    the extra investment going into         was high. We will need to             navigation, signposting
    general practice to support the         learn more from the evaluation        patients and handling clinical
    employment of a minimum of              but early indications suggest         paperwork to free up GP
    5,000 extra staff.                      clinical pharmacists may              time. This builds on successful
                                            have a role in streamlining           pilots tested through the
    To achieve this, at a national          practice prescription processes,      Prime Minister’s GP Access
    level, NHS England and HEE, over        medicines optimisation, minor         Fund schemes and vanguard
    the next five years, will:              ailments and long term                sites where the majority of
                                            conditions management. We             clinical correspondence can be
    • invest an extra £15 million           will roll this out further across     managed through trained staff;
      nationally in general                 the country over the next five      • pilot new medical assistant
      practice nurse development,           years, so that every practice can     roles that help support doctors;
      including support for return          benefit. We will also open up       • pilot the role of primary care
      to work schemes, improving            the clinical pharmacist training      physiotherapy services;
      training capacity in general          programme to practices that
      practice for nurses, increases in     have directly funded a clinical
      the number of                         pharmacist;

General Practice Forward View         23

• invest an extra £6 million        The vanguard sites that are            First, we will work with the
  in practice manager               testing new integrated models          profession to introduce
  development;                      of care and the GP Access Fund         new measures entitling GPs
• roll out the recently published   schemes are already developing         who want flexible working
  HEE Community (District)          many different ways of using the       but who can commit to
  and General Practice Nursing      wider workforce, and proving           working in a practice or an
  Service Education and             that this can be better for            area for a period of time,
  Career Framework and the          patients and free up GP time.          additional benefits relative to
  accompanying HEE Education                                               undertaking a rolling series
  and Career Framework;             A balanced GP workforce                of short term locum roles. In
• implement the Queen’s Nursing     The model of independent               other words, while continuing
  Institute Voluntary Education     contractor status and partnership      to incentivise partnerships
  and Practice Standards for        has proved a valuable foundation       and salaried commitments to
  District and General Practice     for general practice. Partners         practices on the one hand,
  Nursing; and                      provide leadership and continuity,     we also want to create an
• work with general practice to     and in recent years this has been      alternative to day-by-day or
  ensure general practice nurses    invaluable as general practice has     week-by-week locuming for
  have access to mentorship         come under pressure.                   those at a point in their career
  training.                                                                or family life who need more
                                    We also recognise that a more          flexibility.
This also needs to be               flexible workforce better enables
supplemented at a local level,      practices to secure short-term         Second, NHS England will set
and for the first time - through    support to cover sick leave,           indicative rates for locums and
the Planning Guidance – the NHS     parental leave or transition           will ask practices to indicate
locally has been asked to produce   periods between leavers and            in the annual e-declaration
plans to address workforce issues   joiners. However many practices        information where they are
in general practice. We will        now report that a shift to reliance    having to pay above those rates.
review these plans in the summer,   on locums is undermining service       This is to understand the scale
and identify any further actions    continuity and stable team             of the issues practices are facing
that need to be taken or ideas      working.                               and help plan how we can target
that can be spread nationally to                                           workforce support to areas facing
accelerate the growth, retention    It is therefore in the interests of    the greatest pressures.
and development of the general      GPs and practices to improve the
practice workforce.                 relative attractiveness of partner     Third, we envisage ‘at scale’
                                    and salaried positions versus          working in larger practice
                                    a shift to a more unstable and         groupings will create
                                    short term workforce.                  opportunities to embed a more
                                                                           locally focused team based
                                                                           approach which incorporates

2424 General Practice Forward View

    Promoting health and
    wellbeing to combat burnout           CASE STUDY
    A new national service is
    being established to improve
    GPs’ access to mental health             Multidisciplinary workforce - West
    support. Support for GPs                 Wakefield Multispecialty Community
    suffering mental health problems
                                             Provider (MCP)
    is part of NHS England’s plans
    to retain a healthy workforce.           West Wakefield Health and Wellbeing Ltd is a GP
    NHS England has already                  Federation in West Yorkshire serving a population
    committed to spend up to £3.5            of 65,000 and is a wave one GP Access Fund site.
    million in this new service,             It is now leading one of the new care models
    and will now increase that               MCP vanguard sites with two other GP networks
    investment by a further £16              covering a total population of 152,000 people.
    million. The procurement will
    start in June 2016 and the service       Among a series of initiatives designed to relieve
    is expected to be available across       pressure on GPs, they are training care navigators
    England from December 2016.              to break down the automatic assumption that a
    This means all GPs will be able          GP appointment is the best first place to go for
    to access free, confidential local       any problem.
    support and treatment for mental
    health issues, supporting GPs            As well as reduce the number of patients needing
    who are at risk of suffering stress      to access their GP, care navigators are able to
    or burnout.                              ‘queue bust’ at reception by offering patients who
                                             arrive at the practice advice to signpost them to
    Implementation                           the most appropriate solution for their needs.
    We will establish a new
    Workforce 2020 oversight                 Over 70 staff have received training on available
    advisory group, with                     resources, services and innovations within the
    representation from national             practice and MCP programme, and in the wider
    bodies, to steer the delivery of         voluntary and third sector.
    this ambitious programme, and
    review where further actions
    need to be taken in light of
    progress nationally and locally
    over the next five years.

General Practice Forward View   25

2626 General Practice Forward View

    Chapter 3: Workload
    We will reduce practice burdens
    and help release time
                                                                Workload was identified by the
                                                                2015 BMA survey as the single
                                                                biggest issue of concern to GPs
           Support for general practice with the                and their staff. Latest research,
           management of demand, diversion                      published in the Lancet, suggests
                                                                that there has been an average
           of unnecessary work, an overall                      increase in workload in general
           reduction in bureaucracy and more                    practice of around 2.5 percent
           integration with the wider health and                a year since 2007/8, taking
           care system including:                               account of both volume and
                                                                acuity. Whilst some of this rise
           • Major £30 million ‘Releasing Time for Patients’    can be addressed by increasing
             development programme to help release              the workforce, we also want to
             capacity within general practice (see also         support practices in moderating
             Chapter 5).                                        demand and reforming how we
           • New standard contract measures for hospitals       support and organise services.
             to stop work shifting at the hospital/general
             practice interface.                                The Primary Care Foundation
           • New four year £40 million practice resilience      and NHS Alliance have identified
             programme, starting in 2016.                       the changes that will have the
           • Move to maximum interval of five yearly CQC        biggest impact in reducing
             inspections for good and outstanding practices.    bureaucracy and reshaping
           • Introduction of a simplified system across NHS     demand. Their report, Making
             England, CQC and GMC.                              Time in General Practice,
           • Streamlining of payment processes for practices,   identified a number of practical,
             and automation of common tasks.                    high-impact ways to remove
                                                                unnecessary pressures on general
                                                                practice and free up time for
                                                                patient care.

                                                                The report found that the top
                                                                three sources of bureaucracy
                                                                experienced in general practice
                                                                are: the processes used to make
                                                                and claim payments; keeping up
                                                                to date with information from
                                                                commissioners and national
                                                                bodies, and reporting for contract
                                                                monitoring or regulation.

General Practice Forward View        27

The report also estimated
that around 27 percent                 Potentially avoidable GP appointments
of appointments could
potentially be avoided if there
was more coordinated working
between GPs and hospitals, wider
use of primary care staff, better
use of technology to streamline
administrative burdens, and
wider system changes.

NHS England is therefore taking
immediate action in the following

Managing demand more
NHS England is investing in a
major new £30 million ‘Releasing
Time for Patients’ development
programme to support practices
release time (see Chapter 5).

Practices have identified that
one way of doing this is to assist
patients in managing a greater       In addition, by September              in general practice. We will
proportion of their minor self-      2016, we will have launched a          design this in conjunction with
limiting illnesses for themselves.   national programme to help             the wider national development
We will therefore use some of        practices support people living        programme for general practice.
the funding for workforce and        with long term conditions
technology, outlined elsewhere       to self-care. Practices will be        GPs can also influence the
in this document, to support         offered tailored support to offer      commissioning of local pathways
practices in doing so.               high quality care planning to          for community pharmacy to help
                                     patients who have low levels of        patients with self-care and minor
                                     knowledge, skills and confidence       ailments. The developments
                                     to manage their own health and         in digital interoperability and
                                     wellbeing. The aim is to equip         access to a shared primary care
                                     the workforce with the tools and       record provide practices with
                                     skills to do this. This should help    an opportunity to harness this
                                     improve patient outcomes, and          potential for reducing demand
                                     over time, reduce the demand           for urgent appointments.

2828 General Practice Forward View

    Alongside a reformed 111               In addition, a further £40 million    • Onward referral: unless a
    service, we will also work with        will now be committed to                CCG requests otherwise, for a
    CCGs to ensure they institute          develop a practice resilience           non-urgent condition related
    plans to address patient flows in      programme, starting with a £16          to the original referral, onward
    their area using tried and tested      million boost in 2016/17. We            referral to another professional
    ideas such as access hubs, social      will work with the RCGP and the         within the same hospital is
    prescribing and evidence based         BMA to develop this programme           permitted, and there is no
    minor ailment schemes.                 as quickly as possible, and             requirement to refer back
                                           consider introducing practice           to the GP. Re-referral for GP
    Building practice resilience           resilience teams.                       approval is only required for
    In 2015, NHS England                                                           onward referral of non-urgent,
    committed to invest £10 million        New standards for outpatient            unrelated conditions.
    to support vulnerable practices.       appointments and interactions         • Discharge summaries:
    Eligible criteria for accessing this   with other providers                    hospitals will be required to
    additional support was developed       We have introduced a number             send discharge summaries
    with NHS Clinical Commissioners        of new legal requirements in            by direct electronic or email
    and other national stakeholders,       the NHS Standard Contract               transmission for inpatient, day
    with around 800 practices              for hospitals in relation to the        case or A&E care within 24
    identified as meeting the criteria.    hospital/general practice interface     hours, with local standards
                                           from April 2016. These should           being set for discharge
    This support is designed to            relieve some of the administrative      summaries from other settings.
    build resilience in primary care       burden on practices.                    Furthermore, the hospital
    and to support delivery of new                                                 should provide summaries in
    models of care. RCGP support           The changes include:                    the standardised format agreed
    for inadequate rated practices                                                 by the Academy of Medical
    will continue as part of this          • Local access policies: hospitals      Royal Colleges, so GPs can find
    programme. A multi-supplier              will not be able to adopt             key information in the summary
    (call off) framework will be             blanket policies under which          more easily.
    available to commissioners from          patients who do not attend an       • Outpatient clinic letters:
    September 2016 to support                outpatient clinic appointment         hospitals to communicate
    the programme. This is likely            are automatically discharged          clearly and promptly with GPs
    to include a range of local and          back to their GP for re-referral.     following outpatient clinic
    national providers and may be            Also a new requirement on             attendance, where there is
    expanded over time. In order             hospitals to publish local access     information that the GP needs
    to maximise the impact of this           policies and evidence of having       quickly in order to manage
    support, from April 2016, NHS            taken account of GP feedback          a patient’s care (certainly no
    England will offer support to            when considering service              later than 14 days after the
    eligible practices that are willing      development and redesign.             appointment). For 2017/18,
    to match fund this additional                                                  the intention is to strengthen
    support, or offer the equivalent                                               this by requiring electronic
    resources commitment ‘in kind’.                                                transmission of clinic letters
                                                                                   within 24 hours.

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