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A Manifesto for General Practice 2021

 Introduction

Healthcare in the United Kingdom (UK) is delivered mostly by the National Health Service (NHS).  The NHS is a model of healthcare owned by the state with the aim of delivering universal health coverage (UHC).  UHC is the concept of providing health services to all without their suffering financial hardship as a result. 

The UK is wealthy with the 5th largest gross domestic product in the world.  In 2017, it spent $2989 per capita on healthcare with a budget of £114b.  The private healthcare market in the UK is small and covers 10.5% of the population.

Between 1990 and 2010, life expectancy in England increased by 4.2 years with improvements in reducing premature deaths from heart and circulatory diseases.  As such, people in the UK are living longer with more long-term conditions.  Over 15 million people in England now live with a long-term condition.  Most of this care is provided in the community by general practice and thus will be the focus of this paper.

For the UK to continue to provide UHC there are a number of challenges that need to be considered.  We will examine UHC in the UK in the context of primary care.

 

Governance and Leadership

Primary medical services in England are mostly delivered by self-employed contractors to the NHS.  These contractors provide services under three different types of contracts: the General Medical Services Contract (GMS), the Personal Medical Services Contract (PMS), or the Alternative Provider of Medical Services (APMS) Contract.  GMS and PMS contracts are granted in perpetuity to contractors who must be General Practitioners or in the case of the latter, employees within the NHS.  APMS contracts are time-limited and can be granted to anyone with the means of fulfilling the requirements of the contract.

The terms of the GMS contract are defined nationally by NHS England following annual negotiation with the General Practitioners Committee of the British Medical Association (BMA GPC).  The agenda for contractual negotiations is set by the Department of Health and Social Care (DoHSC) and the BMA GPC after consultation with relevant stakeholders.  PMS contracts are varied annually, mirroring the terms of GMS contract as a minimum, although additional features can be locally agreed upon.  APMS contracts are designed based upon local needs and are usually varied 5 yearly.

Quality of care provided by contractors to the NHS is closely monitored.  Individual clinicians working within the NHS must undergo annual appraisal and Doctors must undertake revalidation every 5 years.  Clinicians must be registered with their appropriate Professional Regulatory Body and contractors must register their services with the Care Quality Commission (CQC), who undertake regular assessments of those services.  The use of medicines and medical devices in the NHS is governed by the Medicines Healthcare Products Regulation Agency (MHRA), which is a UK Government agency.  Guidance of the use of medicines and technology in the NHS is created by the National Institute for Health and Care Excellence (NICE).  NICE is sponsored by the UK DoHSC.

This design allows for the state to maintain significant control of the healthcare agenda and of the quality of care provided whilst providing a mechanism of contractual flexibility to address local geographical needs.  In this way, it provides the basis of a core national healthcare offer with some local variations.  It also allows for organic variance of the private healthcare sector to address otherwise unmet needs.

Recommendation

  1. The systems in place to monitor quality of care creates a burden on providers which reduces their clinical availability and business growth. Reduce the burden of regulation to encourage variation and innovation.
  2. Mandate a broader range of stakeholders in contractual negotiations, ending the monopoly of the BMA.
  3. Transfer the duty of public health to NHSEI to ensure that wellness and illness establish parity as a minimum.
  4. The Secretary of State for Health and Social Care should be appointed the data controller for General Practice held patient data.

Services

Primary care contractors provide services under three different types of contracts.  In each of these contracts, fiscal resource follows patient registrations and achievement of patient outcome.  The consequence of adopting a range of contracting mechanisms and broad qualifying characteristics for potential contract holders is to reduce barriers for access to the primary medical services market.  This should result in the increased availability of independent providers to the market from which commissioners can exercise choice in the purchase of care. 

Whilst the resultant increase in contestability confers an element of market self-regulation, this particular market remains challenging to enter with a high degree of education and experience of industry being barriers to access.  Indeed, in 2018/19, only 2 per cent of practices held the most flexible and accessible of primary care contracts – the APMS contract.  As such, the aforementioned governance arrangements are necessary to manage dominant providers where low measurability of their outcomes exists.

Where the market voice does not result in a system that reflects the principle of UHC, state sponsored systems can be utilised to steer the healthcare provider market back to these ideals.

Recommendation

  1. Local authorities and NHS commissioners should establish provider organisations.
  2. NHS estates should be nationalised.
  3. The NHS should prioritise health over illness with a greater focus on establishing and maintaining wellness rather than treating illness.

 

Financing

The NHS is funded through three means; general taxation, national insurance contributions, and private fees for a small number of services.  Where income has dropped in the form of national insurance contributions and private fees, general taxation is used to ensure the NHS receives its budget.  In 2018/19 the budget for the NHS was £114b.  General taxation accounts for around 80% of the budget.

Utilising general taxation as the major source of funding is equitable due to the large-scale pooling of financial and health risks.  The use of this means is efficient with low administrative costs when compared to implementing dual or multiple systems and affords the state legitimate control over the healthcare agenda.

However, healthcare runs the risk of causing a financial burden to the government.  By definition, a tax-funded healthcare system depends upon a well-performing economy.  In such an instance where economic weakness could result in a reduced healthcare budget due to reduced tax revenue, plurality of financial income streams may be advantageous.

Currently, private fees provide only a small contribution to the UK healthcare budget.  The benefit of this is to limit exposure of patients to a market where eligibility is based upon risk selection and ability to pay.  Minimisation of this market also limits resource wastage in the form of excess management and administrative costs.  The minimisation of resource wastage reduces this barrier to the provision of universal healthcare.

Whilst there is no formula to address the funding needs of universal healthcare, plurality of income streams with majority funding by social means appears preferable.  With limited practical means to increase revenue with which to increase the NHS budget, effective resource allocation and usage is of paramount importance.  It seems sensible to ensure that the NHS continues to provide essential care with limited resources whilst the private healthcare market services those patients with the means to purchase non-essential care.

Recommendation

  1. Current funding is skewed to favour resourcing hospitals instead of community care, despite the latter being where more efficiencies are made, and most activity is provided. A larger portion of NHS funding should be committed to community care to realise the aim of health over illness.
  2. The NHS budget should be based upon need, rather than want. The funding formula should be adjusted to prioritise deprivation and under doctored areas.
  3. The UK healthcare market should be open to more purchasers or care creating a diversity of income streams that would limit the monopsony of the state and its financial vulnerability.
  4. The NHS should have greater flexibility to budget allocations. NHS organisations should be permitted to carry over profit from one financial year to the next without being taxed.  This provides an incentive to invest in services in the long term and to make decisions that result in savings and re-investment.
  5. Increase revenue for the NHS by increasing taxation on tobacco based products

 

Prioritising

NICE has the mandate to assess the evidence base of the cost-effectiveness of an intervention, service or programme, with the aim of helping decision-makers to maximise gains from limited resources.  In doing so, NICE undertake analyses of the existing evidence to estimate the impact of resource utilisation in relation to the benefits and harms of current of alternative courses of action.  NICE use a range of economic analysis methods to scrutinise resource impacts in terms of the additional cost or saving above that of current practice.  

In meeting the ideals of UHC, NICE factor into their considerations access to healthcare provision and the financial consequences of not providing an intervention, service or programme.  However, financial protection is not considered at an individual level by NICE and so healthcare market failure could go unnoticed unless the problem is endemic.

Recommendation

  1. NICE should have a duty to have regard for the private healthcare sector.
  2. State and private providers should share operational data to allow better prioritisation of resources and more strategic purchasing.
  3. The private sector should support NICE to meet its aims. Sharing operating infrastructure between the private and public sector would minimise resource wastage.

Strategic Purchasing

Providers of primary medical services receive financial resources via a core budget paid prospectively based upon a weighted practice level capitation.  This allows an element of predictability of income to ensure that services can operate without interruptions. Further payment comes from the Quality and Outcomes Framework (QoF).  QoF defines expected patient outcomes that result in increased payment if thresholds are met.  QoF is paid prospectively based upon predicted performance, and a reconciled figure at the year-end based upon actual performance.  If the provider is inefficient, there is a possibility that the organisation results in a year-end financial deficit.

This approach strikes a useful balance between provider stability and encouragement toward achieving designated outcomes, ensuring the needs of the purchaser are met.  It also provides financial controls that are important due to inflexible budget allocations. 

As the dominant purchaser of care in the UK, market failure is a risk to the state when taxation can no longer support stability in the healthcare market.  This has become increasingly evident in the last decade with reduced availability of some clinical procedures which some regard as a cost saving exercise.  However, efficiencies can be made through intelligent design of the workforce to minimise cuts to clinical services and maximise UHC.

 

Recommendation

  1. NHSEI should adopt long term contracts with primary care and minimise year to year variability. This will provide stability for commissioners and providers which will result in confidence for them to invest and innovate.
  2. Primary care should adopt the use of a single computer system.
  3. Resources should be allocated directly to providers, avoiding resource waste through third parties.
  4. Services should be commissioned at scale utilising as few contracts as possible to minimise the burden of managing multiple contracts.
  5. General Practices should be permitted to adopt Limited Company status to encourage innovation.

 

Human resources

Demand for general practice services has risen as the population has increased, and aged. There are now more patients who suffer from multiple chronic conditions.  In 2012, the DH estimated that people with long-term conditions accounted for 50% of general practice appointments.  Demand for GP consultations and prescriptions rose by 9% and 11.5% respectively between 2010 and 2018.

There was a 38% growth in the number of General Practice consultations between 1995 and 2008 and NHS Digital estimated a further 10% increase in consultations in the year ending in April 2019.  At the same time patients’ expectations of general practice have increased. 

Whilst the demand for GP services has increased over the years, the supply of GPs working in the NHS has fallen.  This has coincided with an increase in supply of allied healthcare professionals delivering services in primary care.  GP numbers fell after 2015 whilst the number of other staff working in general practice continued to increase.

Allied healthcare professionals are quicker and cheaper to train than GPs and have lower wages.  Due to the less rigorous academic demands of these roles, it is likely that they are also easier to recruit to training schemes.  This model of creating clinicians to supply the demands of the NHS affords quicker access to a larger, more diverse workforce that is cheaper to sustain in terms of wages.

With the increasing demand on primary care services yet diminutive resource allocation of around 7.1% of the total NHS budget, there is an urgent need to gain further efficiencies in the delivery of primary care services or to restrict what is being offered.  The move toward expanding allied healthcare professional competencies and responsibilities whilst minimising expansion of GP places makes fiscal sense.

However, there is unfinished debate over the quality of care provided by allied healthcare professionals when compared to their GP counterparts and the consequences that this might have downstream in the NHS.

Recommendation

  1. The importance of General Practitioners in supervising and training doctors and AHPs should be recognised.
  2. The NHS should recruit more General Practitioners, by
    • Providing
      • A change in title from General Practitioner to Consultant of Community Care
      • Flexible training
      • Flexible working
      • Mandatory GP rotations in Foundation and Speciality Training
      • Salaried employment
      • An increase to the cap on pension contributions
      • A national insurance contribution holiday
      • 100% tax relief on internet, telephone and automobile use
  1. Reflect commitment to the NHS workforce by adopt a NHS covenant based upon the armed forces covenant.

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