The new five-year contract for general practice is the biggest reform to GP services in 15 years. But what will it mean in practice and what do GPs need to think about right now? Here are our views and a handy guide to the 6 key points for GPs and 6 key points for PCNs.
Overall the plan brings some positive news around new investment, indemnity and new roles being created and funded via the network. However it warns that GP recruitment is still failing to meet targets set a few years ago and, whilst the focus on other healthcare workers is welcome, it has perhaps come too late to turn around the recruitment shortages.
There will be challenges around enabling Primary Care Networks (PCNs) and particularly how they fit around already scaled-up operations such as Federations and Super Practices. There is also a considerable change in QoF – whereas many hoped it would have been relaxed, the reality is it’s here to stay in yet another form.
The changes to indemnity are welcome. It will mean that retiring GPs and nurses can continue with some primary care work without significant initial costs. GPs can also change sessions without the need to worry about how many they are covered for. The one unknown is the impact on locums – they are covered by the scheme and therefore it could make it even more attractive to go down this route rather than take on permanent roles.
There are positives in that both NHS England and the BMA have taken on board the damaging impact of the pension savings tax regime on staff retention. We at Hall Liddy have long argued this through our role in AISMA and we hope to continue to work alongside it to push through meaningful change.
The 6 key points for GPs
The proposal is to allow GP’s to pension only 50% of their income to reduce pension and tax costs. This is based on an existing local government scheme.
We are not convinced this will allow enough flexibility to remove punitive levels of tax and we will continue to lobby on this.
The document states that General Practice will not have to bear any of the proposed rise in employer pension costs from 14.3% to 20.6%, though the mechanism to deal with this has not been announced.
This will require adequate funding put into the system to deal with the increased cost.
From April 2019 a new state-backed scheme will allow costs to be met centrally for all GP’s and other staff delivering primary medical services including out of hours cover.
GPs will need to take care with existing arrangements during the transition. Continued cover will be needed in some form for non-NHS work and regulatory aspects and some insurers may require run-off cover as well. Practices will need to ensure all staff have adequate protection during this period to avoid uninsured claims.
175 points across 28 indicators are being retired.
101 points are being recycled into 15 ‘more clinically appropriate’ indicators
74 points will be used to create two Quality Improvement modules covering prescribing safety and end of life care.
Exception reporting will change to give confirmation of why someone is being excluded.
Practices will need to get to grips with the many changes coming through so they are well prepared.
4. URGENT CARE AND EXTENDED HOURS
The current Extended Hours Access DES will draw to a close in June 2019. Funding will stop at practice level and transfer to the Network DES, with the expectation that 100% of patients in a PCN will be covered. Each PCN of 50,000 patients would be expected to provide 25 hours’ extended access across the network per week. In future the Extended Access Service funding will also transfer to the PCN.
We suspect that work may still need to be subcontracted back to other organisations such as Federations or Out of Hours Providers who would need to work at scale to provide the level of service required for the funding available.
5. STAFF PAY
GPC England recommends that practice staff including salaried GPs receive at least a 2% increase in 2019/20.
Practices must take care to recognise minimum wage levels as well as local employment factors. They should also consider how indemnity funding is currently given, particularly for salaried GPs. It may not be appropriate to give them a 2% increase if at present they pay their own medical defence out of their salary.
6. OTHER CHANGES
The rurality index will be amended to apply to patients living within a practice catchment area only. This should not impact on many practices but removes an anomaly in the system for digital providers. In addition a review of the out of area registration arrangements will be performed.
The review of the temporary resident system will be carried out and guidance given to local commissioners.
This is long overdue and will be welcomed in areas with high tourism which have long argued that a frozen level of TR funding fails to meet demand. We brought these issues to the attention of NHS England and the BMA when working with practices in the Lake District and are delighted that they have been recognised.
Every GP earning above £150,000 will be listed by name and earnings in a national publication from 2019/20.
There must be clarify about the definition of ‘earnings’ before any further advice can be given. We also hope that the need to publicise earnings at a practice level is removed from the contract.
The Premises review will be published in March 2019.
The 6 key points for Primary Care Networks
1. NEW FUNDING
Significant new funding will go into primary care networks to develop teams at the network level.
New Additional Roles Reimbursement Scheme – In year 1 it is not capitation based but each network will receive funding to cover 100% of the costs of a social prescribing link worker and 70% of a clinical pharmacist. These must be new roles, not existing ones. From year 2 this will be on a weighted capitation level, although the basis needs to be confirmed.
It will be interesting to see if roles currently funded by CCG’s already supporting practices will continue or whether the new network funding will simply replace current roles with no increased capacity.
Network Support – there will be a £1.50 per head payment plus contribution towards a 0.25 WTE Clinical Director as a minimum. Each PCN will have a GP Clinical Director lead.
The concern is that this takes more GPs away from patient-facing roles at a time where there is already a shortage.
Access – the Extended Hours Access DES will transfer to the PCN in July 2019. Enhanced Access £6 per head commissioned monies will follow at a later date with the aim of combining access requirements from 2021/22.
This will remain challenging while workforce shortages continue but hopefully at least there will be local flexibility around managing access.
New fund – there will also be a new Investment and Impact Fund.
2. LOCAL ENHANCED SERVICES
The agreement covers only national contract funding. CCGs have been asked to review LES funding and it may be that these move from practice to PCN level.
Care must be taken to avoid destabilising practices at local level. LES funding is a core part of GP practice funding and removing it will cause problems as many practices have fixed costs.
3. NETWORK CONTRACT DES
The overarching change will be that the DES will go live from 1 July 2019. The network and constituent practices will need to complete registration by 15 May 2019 including appointing the named Clinical Director and the single practice / provider that will receive money on behalf of the PCNs.
Start work now on establishing your PCN and how it will operate (please see section 5 below).
4. NETWORK LIST SIZE
Whilst the desired number is 30,000 to 50,000, the document acknowledges that some practices already exceed this and could, if it meets registration requirements, serve as one PCN. Likewise, it accepts that reaching this size may be an issue for some rural practices.
Sense will therefore prevail when working out what size the network will be alongside discussions with the CCG.
5. AGREEMENTS AND LEGAL FORMATION
All constituent GP practices of a PCN must sign a network agreement, which is being jointly developed by NHS and the GPC and will be available by March 2019. This will include patient data-sharing requirements plus other compliance aspects.
Only individual GMS, PMS and APMS contract holders have the legal right to sign up to the DES but it is the PCN which will deliver it. A CCG cannot be a PCN.
Each will appoint a Clinical Director as its named, accountable leader. Each PCN will have a host practice or provider that will receive the funding on behalf of the network.
This raises a few issues in the short term:
- Practices should not rush into the formation of a PCN as VAT and NHS Pension issues could arise if an incorrect legal organisation is formed. We recommend that practices wait until the documentation is available in March 2019.
- However time is of the essence and PCNs need to start considering who will host the funding and who the Clinical Director will be. It would seem sensible that PCN funding is ring-fenced from practice funding, so the host practice may want to consider setting up a new bank account once the documentation is available from NHSE/GPC.
- The PCN DES does not start officially until 1 July 2019 so there is time to sort this if you are organised. We hope the documentation to be issued will confirm that the Network will not have any VAT issues with the supply of staff from one practice to another – but until documentation exists, it may be sensible that the host practice is not VAT registered in case VAT is an issue. We also hope that staff employed under the PCN will have access to the NHS Pension Scheme, and that the documentation includes a memorandum of understanding to protect the host practice from any liabilities arising under contracts (principally of employment) held on behalf of the PCN.
6. NEW STAFF ROLES
2019/20 – PCNs will have funding to employ a Social Prescribing Link Worker and a Clinical Pharmacist.
2020/21 – PCNs will have funding to employ Advanced Practice Physiotherapists and Physician Associates.
2021/22 – PCNs will have funding to employ Advanced Paramedic Practitioners.
This won’t prevent PCNs employing other staff or staff for these roles at an earlier date, however there will be no additional funding for this and it will need to be met by the constituent practices.
Remember this is funding for new roles only and not existing staff. Some CCGs already fund some of these roles through Pilot schemes – whether this existing funding will continue under PCNs is questionable.
This summary is provided for information only and does not represent financial advice.