After an exceedingly long and painful gestation the NHS 10 Year Plan has arrived. It has various targets in it, the longest being for 2040.
As an aside the plan was launched with lots of buzz and press releases without the actual document being shared with anyone (not even the press). This modus operandi was started by other recent governments, as it means that the only ‘story’ available is the government one, and they have full control of the narrative with no possibility of any challenge. I had hoped that this government would be more transparent but plus ca change.
There are other sources that are worth looking at to understand the content and potential effects:
I have read all 168 pages and am going to add my own summary and views. I do not cover everything in the plan, just the parts that I feel are most pertinent to general practice and other areas of interest. Overall, the plan is like the Curate’s Egg – good in parts.
As many of you know (newsletters passim) I have been around for a bit now – my first job in management in a Regional Health Authority was in 1993. General Practice has survived multiple reorganisations. The fundamental basics of a GP providing holistic longitudinal care with continuity to a registered list of patients has existed since the National Insurance Act 1911 (which also established Local Medical Committees). Indeed, I have heard independent contractor general practice being referred to as the Cockroach of UK Healthcare- does not matter what is thrown at it, it will continue to survive.
The plan is designed to deliver the three ‘shifts’ previous announced by the government:
- Shifting from hospital to community
- Shifting from analogue to digital
- Shifting from sickness to prevention
I will divide my commentary into:
- The Good
- The Bad
- The Ugly
- I never knew that
- What were you sniffing Wes?
THE GOOD
Decommissioning of poorly performing providers. You may think this is odd for an LMC to support, and this could also be included in the Ugly section. The context is crucial. If a practice is poorly performing, they have the ICB and CQC on their backs already. The latter has quite happily closed practices in LLR with minimal notice. However, regardless of how bad hospitals and individual departments are – when was the last time you heard of one being closed? When working for an RHA and then NHS E I was party to closing hospitals and services who were either persistently underperforming or so unsafe that they should not be allowed to continue. Currently the worst-case scenario is a slap on the wrist by CQC and perhaps a change in Chief Executive. The plan says there should be a lower threshold and quicker path to closing poor units. Of course, there is a risk that this is overused to eliminate smaller partner-run practices.
Carr- Hill formula. The plan recognises the inverse care law is still alive and kicking. It refers to the areas of highest need having the lowest number of GPs. It also recognises that the Carr-Hill Formula needs replacing. However, it does not join the dots in that the reason partnership is currently less attractive is due to ongoing underfunding and increased micromanagement and bureaucracy. What is needed is a reinvigorated GP contract increasing funding, respect, and job satisfaction. To quote from Field of dreams “If you build it, they will come.” Incidentally, the Health Foundation is inviting some practices to participate in an independent review of the local Health Equity payments. If approached, please consider taking part as this will not only be your chance to feedback your views of the local scheme, but the evaluation will feed into national discussions about the replacement of Carr-Hill.
A New Era for General Practice. The plan recognises the current patient dissatisfaction with GP services., It promises increased capacity with “thousands” more GPs, reduction in bureaucracy, and roll out of AI technology including scribes. It promises that those who need it “will get a digital or telephone consultation the same day.” What, of course, it does not say, is neither how are practices going to see increased funding so they can employ these additional GPs, nor how will the necessary increase in premises be funded.
The Plan recognises the significant importance of public health and social factors on health. For example, it proposes a ‘Start for Life’ programme for all communities and better partnerships with schools etc. It refers to the Tobacco and Vapes Bill which will mean that children turning 16 this year will never legally be sold tobacco.
Improved support for roll out and implementation of new technologies is promised. I hope that this will be implemented, as improvement in technologies too often has been due to GPs just doing it instead of central leadership. This should avoid a repeat of the current ‘wild west’ of IA scribes (newsletters passim) caused by lack of central leadership and support. Why is every practice having to develop their own DPIA, DCB0160 etc? The only response by the centre has been an unhelpful nannyish guide by NHS England and a letter from the national CCIO telling us all off.
Further development of the NHS App to be the single portal to hold patient information and to be able to order repeat medications and to request and arrange appointments will be helpful to patients and practices. This was how the App was originally envisage, although when I met the NHS App team in 2018 with a colleague (their team looked like they had an average age of 12), we had to dampen their enthusiasm and create a list of what was achievable then, and what would have to wait for, mainly secondary care, technology to catch up. But this will need the DHSC to mandate suppliers to enable the App to be used as planned (compare with the report in last month’s newsletter about how TPP decided that information from SystmOne practices would be displayed differently). The Plan then spoils it by claiming that the NHS App “will give everyone the knowledge they need … to ensure there are always 2 experts in every consulting room.”
Genomics. I was not sure which heading to put this under. There are plans to increase genomics for both newborns and adults. The advantages are better targeting of preventative and effective treatments. If badly handled the disadvantages will include people living under the cloud of high risk of a non-preventable serious illness all their life, significantly increased insurance premiums, unable to ever have a mortgage, and widening health inequalities.
Cherry picking. They state that they will not tolerate this (as happens at present) or other ‘gaming’ by independent providers.
Power. The plan states that power will be pushed out to local systems and providers. This would be good if it happens. However, the first negative Daily Fail or other headline is likely to cause politicians to reverse this.
CQC. The plan envisages that in future CQC visits will be determined by the outcome of AI driven data. If the indices are ones truly in the control of the practice, that it considers different demography, that the first contact will be to ask the practice whether they are aware of the cause the difference, if they have plans to rectify then this should be beneficial. As mentioned before (newsletters passim) you cannot inspect quality into a system. The only downside is that they plan to continue routine inspections every 3 to 5 years as well, but I hope that once the new system is embedded the routine visits are phased out as they will no longer be needed.
They promise to completely reform mandatory training. I would ask that one of the first to look at is the Oliver McGowan training which is OTT and unhelpful for most GPs.
Medical training is going to get an overhaul, they say they will learn from the Leng review about introducing other staff groups to clinical teams, and prioritise UK medical graduates for foundation year posts, and prioritise medical graduates together with other doctors who have worked in the NHS for a ‘significant period’ for specialist training posts.
Single National Formulary. If there is a strong/majority general practice voice when drawing this up nationally it will take away every area developing and maintaining their own local formularies which at times seem to be dependent upon how forceful secondary care colleagues can be in promoting a specific drug and trying to dump responsibility onto general practitioners because it is more convenient for them.
A review of the rising legal costs of clinical negligence claims. Having experienced the current scheme from both sides it only appears to work for the lawyers. I hope that the outcome may even be the adoption of a no-fault compensation scheme like that in current use in New Zealand (and even for some specialities in some parts of the USA).
THE BAD
The plan is extremely light on general practice. It regularly makes sweeping statements about the NHS where it actually means hospital and not general practice. When reading it I found myself shouting at the plan ‘not in general practice’s name.’ One example is that it repeatedly refers to productivity plummeting without any recognition that this does not apply to general practice which has demonstrated significantly increased productivity – for example the number of GP appointments in England increased by so much in May 2022 (15%) that it had a significant effect on Gross Domestic Product.
Personal Health Budgets. The plan envisages that by 2030, 1 million patients will have a PHB. In theory this places patients in the centre of their own care with more control. In reality the NHS is (should) be funded for the average cost of the care of a patient. With a PHB, if underspent patients will be looking at how to spend up to their budget. If overspent the NHS promises that no one will be without care so they will still provide care.
Contracts for Neighbourhood Providers (approx. 50k Population) and multi-Neighbourhood Providers (approx. 250k population). The NHS already has Neighbourhood providers – they are called general practices. If they reversed the starvation of investment and support, then once again, we could all host other services in our premises. These providers will also be able to hold contracts for general practices, which will be in competition and possibly undermine other local practices. This was tried before with PCTMS, PMS (with initial bribes), APMS etc, none of which have gained traction.
The concept of Neighbourhood Centres mirrors Alan Milburn’s previous dalliance with the same policy before (Darzi Centres) which failed due to poor understanding of general practice, patient wants, and willingness to invest the significant amount of money needed to pump prime them.
THE UGLY
A repeated idea is the development of a Single Patient Record (SPR). This is not the first government to have this brainwave, and in the past, when involved at a national level, we have been able to see it off.
You can see the attraction to patients (many of whom believe this is already the case), and managers. The reasons why it is a bad idea include:
- Curation. The reason everyone is so interested in general practice’s records is that we carefully curate them – constantly protect them from incorrect diagnoses, ensure important concepts are coded correctly etc. A few years ago, we had a sudden increase by a dozen in patients with SMI. Probably an indication of our flock, but this was because the prison system had changed their initial health consultation template, which added the code ‘psychotic illness’ with a free text of yes or no, and this was being written into our SystmOne Unit. Putting aside the incompetence of the person who had created the template, this caused significant additional work, contacting the prison service and asking them to correct each record individually. If there was a SPA, then who would be responsible for maintaining the record?
- Quality payments (QoF/IIF etc). If we are going to continue with any quality or performance related payments it is imperative that this is from information within the full control of the practice. It would be inappropriate for practices to lose funding due to incorrect data added by another organisation.
- Confidentiality. Patients will only provide GPs with their most private or embarrassing information if they have confidence that the information is only accessible to their GP. Once people know that their single record is accessible to Uncle Tom Cobley and all, they will withhold information that we need to do our jobs. If a struggling single-mum knows that their record could be accessed by Social Services, are they likely to still be as open with their GP about their problems?
- Data controller/Medicolegal. A unified record would require the status of Data Controller to move from the practice to someone else (probably the SoS). Although many practices would see this as being a positive move, my own personal view is that I want to retain ownership and control of my patients’ data. I do not want others having constant ability to change/update/delete the record. Whilst I would presume that an audit trail would apply, I suspect that patients and others will assume what they see when accessing the record is the whole truth.
- Wood for trees. This of us who are suffering from SystmOne sharing will know the disadvantage of having a record with large swathes of entries by community and other staff. Intermittent admissions requiring ITU stays could make it difficult to spot the background trends in eGFR etc.
- Patient safety. All the above result in reduced patient safety.
Although better designed software and the use of IA could ameliorate some of these problems, they will not overcome the ‘human factor’ with related errors. I hope that they will come to appreciate the many downsides to a truly single patient record. Their aims could also be achieved by improved interoperability with the ability to view different records in a combined view or alongside. This is the aim of the Local Health and Care Record programme which has been under development for almost a decade at significant cost to the NHS.
Patient Power Payments. The concept that funding for NHS organisations will be based at least in part on patient experience seems superficially attractive. For hospitals covering a large diverse area it may actually work as planned. However, if general practice was included it would result in downward spiralling of practices, particularly affecting those providing services to deprived populations. Practices in more deprived areas received lower levels of funding, and patients from more deprived areas tend to be more negative about their practices. We know from LLR data that there is a direct correlation between the amount of funding a practice receives and patient satisfaction. Combined with the proposal that CQC should have a lower threshold for closing failing practices this is likely to mean that young GPs are highly unlikely to join a partnership with an inner-city practice. Also, the ‘I pay your wages’ brigade may in the future be in the position of being able to actually reduce your income – so sick notes, antibiotics, benzodiazepines, and opiates for everyone!
Selling patient data. The plan openly says that they will gain ‘commercial value’ from access to anonymised data. At least this is more honest that the Care.Data programme when the DHSC was stating that data was not being sold at the same time as providing a ‘price list’ (which ‘someone’ very inconveniently shared with one or two journalists). The other issue about Care-Data was that the data was anonymised and not aggregated which meant that using a jigsaw approach knowing one or more health reference points you can identify individual records (for example a researcher on behalf of a newspaper was able to correctly identify Tony Blair’s complete medical record). The ability to protect data has improved, but the involvement of the company Palantir does noy instil confidence.
I NEVER KNEW THAT
More than a quarter of the population now have at least one long term condition and now account for 65% of NHS spending. We are aware from local data that the number of patients with multiple LTCs has increased by 14% since 2019.
The plan reports that approximately 1.5million people in England are purchasing Mounjaro or Ozempic privately (2.2% of the adult population)!
We all know that excessive alcohol consumption is harmful, but were you aware that the estimated societal cost of alcohol harm in England was £27.4 billion per year (1.2% of GDP) and that 4% of the population drink 30% of the total alcohol consumed?
WHAT WERE YOU SNIFFING WES?
Integrated Health organisations. This is one of the more ‘interesting’ ideas and the greatest risk to partnership based general practice. This is the proposal that an organisation (most likely an acute Trust like UHL) will hold the whole health budget for an area – so for secondary and primary care including general practice. Although the 10-year plan laughingly says that a GP could hold the contract, I am more likely to become the next Dalai Lama. The plan says this is based upon HMOs in the USA – a health system notorious for universality of care, developed primary medical health services, and cost effectiveness. The plan picks up on the Darzi report’s observation that the pendulum must swing to move funding from secondary to primary care. With Acute Trusts at the helm, it is extremely unlikely that any of this funding will come to general practice but will only be used for community services provided and run by the hospital.
Those of us who experienced the formation of NHS Trusts under the National Health Service and Community Care Act 1990, will understand how much of a terrible idea it is. Initially many Trusts combined acute secondary care services with mental health and community services. Acute hospitals always have been and always will be financial black holes sucking in all the resources available. The lived experience is that these combined trusts resulted in asset stripping of the mental health and community parts by the acute hospital services. Within a truly short time the centre required Trusts to divide into the separate components. Although general practices provide 90% of healthcare for 6% of the budget, hospital boards who spend most of the healthcare budget do not understand what we do, and most consultants have no respect for GPs. This uneven relationship will mean that unless DHSC require the majority of an IHO board to be GPs, the primary care budget will once again be stripped with a view that GPs should be subservient to the needs of the hospital.
Foundation Trusts. The plan re-envisages FTs. These were previously a bright idea of Alan Milburn in 2002 and created by the Health and Social Care (Community Health and Standards) Act 2003. The problem before was that to achieve the necessary financial balance, hospitals cut the only budget that they had easy control over – staffing. This directly led to scandals and patient harm. Although Mid-Staffs Hospital was the only one to achieve notoriety, many other Trusts were in a similar situation. So having failed spectacularly before, one of Wes’ bright ideas is to have another go. Those who had sight of draft copies of the NHS Plan advise that there was a final chapter written by Alan Milburn about how the plan would be implemented -this chapter and any reference to Milburn was expunged before the final version was published.
The plan claims that two thirds of hospital out-patient appointments can be replaced by “automated information, digital advice, direct input from specialists, and patient- initiated follow ups.” Whilst in total agreement that hospitals have much to learn from general practice about how to use information technology more efficiently, the reality is that this will no-where near reduce outpatients by 2/3rds let alone factoring in the cost of consultant time and related increased risk.
The NHS Plan complains that everything is 9 to 5. First this is an insult to our colleagues in general practice OOH and the hospital which provides 24 hours per day, seven days a week healthcare. Second, patients overall want routine care during normal ‘office hours.’ When I am doing Extended Hours in the evening or at a weekend the most common comment I get is why am I contacting them at an inconvenient time. From my own experience I do not want to work a long week and then must attend an outpatient appointment late at night or at a weekend when I need to rest.
The plan lulls you into a false sense of security about how improved digital technology can improve healthcare. It then comes out with the statement “as digital access becomes the norm many patients will get instant access to a clinician removing the need to wait for advice or carer.” Whilst I would love to be working in a system where we have so much capacity that we could have a clinician sitting around just waiting for a patient to call, without significant additional investment this is not going to happen.
SUMMARY
There is much good in the NHS 10year plan, but also many parts which I hope will be kicked into the long grass before permanent harm is caused to general practice.
Development of Neighbourhood Services should be positive for general practice, promoting flow of funding to primary care and general practice. But the risk that the project is dominated by UHL, and the thinly veiled threats to partner based general practices (particularly small organisations/those not working to scale) outweighs any theoretical benefit.
The plan is published at a time when Wes Streeting has also promised a revised general practice contract to be developed together with the profession and implemented prior to the end of this parliament. Without a more attractive/supportive contract for partner run practices, the NHS 10-year plan’s options for other bodies to run general practices are likely to happen, destabilising traditional general practices.
I hear that there is a cabinet reshuffle coming soon. Expect Wes to retain his position for now, as Keir Starmer will need to lay the blame on him when the 10-year plan does not deliver an improved NHS overnight, I understand that Liz Kendall is a front runner to replace him – so those GPs working or living in her area, please let her know your views.
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To listen to an audio version of the 10 year plan update, please click here