Ben was CEO of Nene CCG for 8 yrs. He was a Director of an acute trust and has run national improvement programmes. He is a founding director and Principal Consultant of Ockham Healthcare, which he describes as ‘a platform for change’.
On the surface the 5YFV looks positive for general practice, but on closer inspection it signals a significant threat to general practice as we know it. Can general practice survive?
On first reading the Five Year Forward View says highly supportive things about general practice. It states, ‘The foundation of NHS care will remain list-based primary care. Given the pressures they are under, we need a ‘new deal’ for GPs. Over the next 5 years the NHS will invest more in primary care.’ p11. So far so good.
But the overriding message of the report is that the NHS needs to change, and that one of the main ways it needs to change is to end the historic separation of GPs and hospital consultants. It says, ‘the traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS - is increasingly a barrier to the personalised and co-ordinated health services patients need’ (p16).
And it is clear that any investment and opportunity for general practice will come as a result of much greater integration with the rest of the NHS. The quote from page 11 (above) continues like this, ‘Over the next 5 years the NHS will invest more in primary care, whilst stabilising the core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services’.
So there will be no more funding for general practice other than that which they already have, other than that which CCGs can extract from hospitals, which in turn requires a significant change in the way general practice operates.
GPs are clear that they need more money. Their complaint comes because any new funding has a set of conditions, often requiring them to do a set of additional things that they do not have capacity to undertake. The new funding on offer has exactly these terms and conditions. For CCGs to release money from hospitals they will need primary and community care to reduce demand. This will require action. It will not be more money for doing exactly what GPs are doing now.
The further complication that any additional funding coming from CCGs is that it requires the CCGs to take on the co-commissioning agenda, which has its own set of challenges. If you reflect on the recent ‘£55-gate’ dementia diagnosis uproar, and then imagine what it would have been like if it had been GPs themselves awarding themselves this payment through the CCG under co-commissioning, you get a sense of what these challenges are likely to look like in practice!
The narrative in the 5 Year Forward View treads a delicate balance between the challenge and the opportunity for general practice. Playing it safe it says, ‘smaller independent GP practices will continue in their current form where patients and GPs want that.’ (p19). Bear in mind that carrying on in their current form also means operating with ‘stabilised’ core funding which, as the RCGP so frequently tell us, is not enough. This means that while this is technically possible, it is unlikely to remain financially possible in the medium term.
But the report goes on to say, ‘General practice is entering the next stage of its evolution… We will make it possible for extended group practices to form – either as federations, networks or single organisations. These Multispecialty Community Providers (MCPs) would become the focal point for a far wider range of care needed by their registered patients’ (p19). These MCPs will be able to do a whole range of things: employ consultants or take them on as partners; employ a wider range of staff; be where the majority of outpatient consultations take place; run the local community hospital; directly admit to hospital; and even take on a delegated budget for their registered patients.
So this is the big opportunity for general practice. The report clearly states how general practice can transform itself, drive a new integrated model of out of hospital care, and receive new investment. But can general practice respond quickly enough to make these new models a reality within relatively short timescales? The 5 Year Forward View, it seems, is ready for this.
Because, as if aware that this opportunity may not result in the scale and pace of change that is required, the report then offers another model – primary and acute care systems (PACS). And to make these possible, it is no longer only GPs practices that are able to deliver list-based services. The report says, ‘We will now permit a new variant of integrated care in some parts of England by allowing single organisations to provide NHS list-based GP and hospital services, together with mental health and community services’ (p20).
So there it is. GPs have the opportunity to drive the changes through the creation of MCPs, but if they don’t get them set up quickly acute and community trusts can set up PACS that can, amongst other things, deliver general practice. Remember the money is going to go to those organisations that manage the demand out of acute care, i.e. these new style organisations, and will not be going into core general practice. That funding will only be ‘stabilised’.
So the report is really saying general practice has to change, it has to change fundamentally by partnering with others and operating at much larger scale, and it has to change quickly. If it doesn’t, it will not only lose the chance to shape its own future, but will potentially be subsumed by the other large provider organisations that surround it.
Ben Gowland was Chief Executive of Nene CCG for nearly eight years. He left in April 2015 to set up Ockham Healthcare, a healthcare management consultancy he describes as a “platform for change”. Ben joined Nene as its CEO and first employee when it was first forming as a practice based commissioning (pbc) organisation. Within two years it had become the leading pbc organisation in England, and Ben went on to establish it as one of the largest CCGs in the country. Ben hosts RealityBites – The National Healthcare Conversation, a weekly online podcast.
This column was first published in The Information Daily
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