Paying GPs less will not increase numbers
David Mowat has a real stake in the future of general practice – two of his children are training to be doctors. ‘Hopefully, in time, this will be a contribution towards the extra 5, 000 [GPs promised by the Government], ’ he says.Until then, he has a lot on his plate. As the minister responsible for primary care in England, it is incumbent on him to make sure the GP Forward View delivers on all its promises, and to increase the GP workforce by 5, 000 by 2020 – or, should we say, 4, 998 plus the junior Mowats. Appointed in July, after the Brexit vote and the subsequent reshuffle, the minister speaks to Pulse as he is getting to grips with his new brief. Of course, for ministers, this often just means learning how to bat away questions. But he is willing to acknowledge that general practice is struggling, and the limitations of the Government’s plans to rectify the situation. The GP Forward View was announced with much fanfare, but GPs tell us they’re not feeling any benefit on the ground. What real benefits will they see, and when? Well, you’re right. My job, and that of others in NHS England, is to implement the GP Forward View over the next four years, and what that means is more of the NHS money being spent in primary practice. We’ve said there will be a 14% increase in funding for general practice – that is going to happen in real terms. But you’re right, GPs are a bit sceptical about it. If we were designing a health system today from scratch with a blank piece of paper, in which 70% of our spending was on long-term conditions and their management, we wouldn’t design it like we have, so much around acute hospitals and providers. We’d design it much more in the community. Now, we’re not starting from scratch, but we need to progress to get there. Many GPs would say they need a lifeline now, rather than the initiatives set out in the GP Forward View. Will they see some of the 14% increase you mention translated into their core funding? The indemnity funding [included in the uplift to the global sum from April 2016] is happening now. And changes to the formula [for practice funding] will be happening in a couple of years’ time. But things like more pharmacists being employed – that is happening too. There are actually more GPs being employed. The attrition rate is still too high, and one of the things I’d like to achieve is better retention of GPs. But even allowing for that, there are 100 more GP [trainees] than there were six months ago, and 300 more full-time equivalents. Those are quite big numbers and over time that’ll make a difference. There was a target to recruit 3, 250 GP trainees a year by 2015. When it was missed, it was moved back to 2016 – but it was missed again. What makes you confident that the Government can recruit 5, 000 extra GPs by 2020? You’re right – the 3, 000 GP trainees recruited this year is not 3, 250. But it’s the most we’ve ever done and it demonstrates a direction of travel. But in a sense, how confident we can be in that dynamic depends even more on some of the initiatives we’re taking around retention. The announcement to make it easier for GPs who want to step down a bit, want to work part time, was something that then RCGP chair Dr Maureen Baker suggested to me, and it was something I was pleased to work with NHS England to make happen. That’s part of the answer as well. I’m not saying it’s easy. Targets shouldn’t be easy. Am I saying that I’m willing to be judged on whether we make it or not? Yes, I am. Health secretary Jeremy Hunt recently said he wants practices to become ‘one-stop shops’, offering diabetes and renal care. How will the Government incentivise GPs to carry this out? In the end, that is done through the contract. I made the point earlier that 70% of NHS spending is on long-term conditions such as diabetes and dementia. But it must be the right answer to do much more of that without people going into acute hospitals and seeing specialists they don’t really need to see, through self-management and GP management. I visited a practice in Tower Hamlets [east London] that was promoting email communication between GPs and specialists, because the GP maybe just wanted to validate an opinion without necessarily sending a patient to an outpatient clinic, which is time-consuming for the patient as well. So the one-stop shop is the right answer. This will mean upgraded premises as well. It means more and more GPs working in bigger and better practice areas, not working in terraced houses as has historically sometimes been the case. Is there any move to include this kind of one-stop shop initiative in the next GP contract? The next round of contract negotiations is about to start, and it’s not something that’ll necessarily happen all in one go. But over time, that is the mechanism by which reimbursement happens. So will it be potentially done via an enhanced service that’s added onto the contract? Yes, potentially. There are lots of routes like that. I don’t know the exact answer to that question, but let’s be clear - we want GPs to do more, not less. There’s a big movement towards GP practices signposting patients to social care services. Again, how are you looking to commit funding to such schemes? Well, more and more CCGs are commissioning social prescribing. There’s a recognition, for example, that for diabetes, sometimes putting people in touch with other people who have got diabetes or telling them to join a sports team is part of the solution. That’s for the CCGs to commission in a sense. But it should be part of the GP’s armoury – looking at the whole person if you like. One of the things that’s always struck me coming into this job, I think, is more leadership positions in the health economy should be held by doctors than is currently the case. In my home area, I’ve visited the CCG recently, and there was a dynamic young chairman who was a GP, and there was a dynamic young chief executive who was a young GP, and it seems to me that’s a very big expression of faith in the GP profession in a sense, that we’ve put them in charge of commissioning in a way they never were before with the old PCTs and all of that. It seems the official evaluation of the seven-day pilots found Sunday opening of GP practices has not proved particularly popular. What will the Government do in light of that evidence? We still have a commitment in our manifesto to roll out access to GPs by 2020 and, speaking for myself, it’s not always possible to get to see a GP locally during working hours and that is something that I’m keen to be able to do. Now, of course, that shouldn’t mean all GPs have to be open all the time; it just means there should be a facility so that you can actually take advantage of that. In a 21st century healthcare system, that has to be the right way to go. In London, we’re hoping to have it rolled out by March 2018, and let’s see how that works – let’s see what difference that makes. We haven’t got the resources to do it yet anyway, but as we grow the resources, I think using them in this way is good. GPs are struggling to deal with demand at the moment, and they really need an increase in their core funding. What do practices have to do to get a share of the £2.4bn promised in the GP Forward View? If you’re asking ‘are all GPs going to get a pay rise, and is that what we’re going to use the money for?’ – that’s not directly the purpose of it. We look at the contract every year, and we try to make sure we know what’s right and fair. There has been a period of, let’s call it austerity. Not just for GPs, but everybody in the health system. That can’t last forever, and we do know we want to have more people being GPs and therefore paying them less isn’t usually a way of achieving that. So in directional terms, that takes you to saying that’s not something we can continue to do. Do we want GPs to do more? Yes, and that’s why we need to have 10, 000 more [GPs and practice staff] working in the profession with them. In terms of specific initiatives, as I said, we’ve started off with things like indemnity and initiatives to enable GPs to come back into work more quickly if they’ve been abroad or on maternity leave, or to step down a bit without retiring altogether. We need to start by doing better with those things. Put your questions to David Mowat at Pulse Live in London on 21-22 March.