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Balancing act

Balancing act
13 November 2013

Funding for primary care is being further stretched as healthcare moves ever closer to the community

Funding for primary care is being further stretched as healthcare moves ever closer to the community
GPs have had a strained relationship with money over the last decade. There never seems to be enough of it – and when there briefly was in 2004, it led to an uproar over GPs’ pay that still lingers in the minds of the public. For all the talk of a GP-led NHS, expenditure on primary care as a proportion of overall NHS spending has fallen from 26% to 24% over the last decade (2003/04 to 2011/12) and spending on GP services has been static since 2005. 
But for the first time in years, GP leaders are confident that significant investment is on the way. On top of GPs’ new roles as commissioners, health secretary Jeremy Hunt wants to expand GP numbers by 2,000 and for primary care to take on huge amounts of extra work: more proactive care of vulnerable patients, a return to out-of-hours responsibility and more secondary care services performed in community settings. With the latest British Medical Association (BMA) workforce survey reporting GP morale and workload at its worst since 2001, there is seemingly no way any of this can be achieved without a significant shift of funding towards primary care.  
The question is: in what form and when will the money come, and what caveats will be attached? 
GPs hoping for a boost to their core practice income via the next GP contract may be dissapointed. NHS Employers has recommended yet another freeze for GPs in 2014/15, claiming that even a 1% rise would cost £500 million and be unaffordable. Even the BMA general practitioners’ committee (GPC), not known for talking down a pay rise, is cautious not to confuse the need to invest in primary care with GPs’ pay. 
“This isn’t about paying GPs more,” says GPC chairman Dr Chaand Nagpaul. “We need an explicit longer-term strategy to increase capacity: more GPs, more primary care estate, more nurses and staff, more buildings and staff for wraparound services.
“Some will come via clinical commissioning groups (CCGs), some via NHS England, and some via contract. But putting money into the contract clouds the issue and makes it about how much GPs are being paid.”
According to Nagpaul, general practice receives just 8% of the NHS budget. He’d like to see that rise by “at least 2%” as work incrementally moves out of secondary care and into primary care. “The only logical way the government can achieve what they want to is to invest in the infrastructure and capacity of general practice and its wraparound services.”
Immediate contract changes will aim to tackle the fact that “GPs are undoubtedly swamped by work and paralysed by bureaucracy,” he says. “We want to see the removal of all the unnecessary and bureaucratic aspects of the QOF and for that funding to move into core funding.” 
Cuts to the quality and outcomes framework (QOF) are pretty much a certainty, given that both the government and the GPC are keen to remove the most bureaucratic and burdensome indicators. As QOF expert Gavin Jamie puts it, “QOF has few friends at the moment – no-one is fighting hard to save it”.
The NHS Alliance’s Dr Mike Dixon says the framework – worth around 15-20% of an average practice’s income – will be “drastically” cut by at least a third and up to a half.
“This will give practices a bit of headroom for things like the accountable GP idea, where a named GP is responsible for vulnerable elderly patients,” he says. 
That means up to 450 QOF points’ worth of funding could be up for grabs. There is talk from within NHS England of new incentives for care of vulnerable older people, but the GPC will want the money to return to the global sum and there simply may not be time to design such indicators before the next contract is decided. 
Jamie suggests that QOF could return to its more focused, evidence-based origins (“I think the GPC would be quite happy to hark back to the original QOF from 2004”), allowing GPs to concentrate on seeing patients and more proactive work to reduce the burden on secondary care. 
“In an ideal world the money would go into the global sum because we are still going to do much of the work but perhaps not labouring over codes,” says Jamie. 
“In terms of new indicators – a lot of practices were surprised just how many points they got in the first year of the QOF, but it will always be tricky – it takes effort to change. The more difficult thing is whether GPs dismantle the administrative systems they have developed to do all that QOF work. It could be that GPs end up with a quantity framework rather than a quality framework if it becomes about taking work from secondary care.”
The idea of shifting services and workload from hospitals out into the community is not a new one. It has been a key message of all the myriad reforms of the last decade –but the money simply hasn’t been there to back it up: last year secondary care received 1.4% more funding than in the previous year, while primary care received 1.4% less. For years the NHS has talked up primary care’s role while simultaneously disinvesting in it. 
Medical accountant Bob Senior says GPs are concerned that amid falling profits, new work will land at their door and they will be expected to tackle it using their existing income streams. The health secretary has committed to reinvesting savings from reduced admissions back 
]into general practice, but so far offered no new cash. 
“You might be able to drop one enhanced service for another, I suppose. But GPs will need funding and new working capital to get any new services off the ground, which a bank will be happy to do if you can show them it is profitable. If the government says take on this and we’ll pay you the cost but nothing more, then that’s not going to happen.”
Premises funding is also a problem, 
says Senior – crucial to the expansion 
of community and ‘wraparound’ GP services is new buildings or expansion in existing ones. But the new NHS structure means decisions simply aren’t getting made, he says. 
“Premises funding was more straightforward when it was PCTs’ decision, but now those decisions are in somewhat of a hiatus as there is a lack of clarity over how commissioning groups do it. NHS England doesn’t seem to be doing it, and obviously there is a huge problem if your CCG is deciding which of the practices – which are all your competitors – should get nice new premises.”
Dixon says that once services move out of hospitals into the community, savings will be made quickly, which can be reinvested in primary care – but a cash injection will be needed to get such services off the ground. “We will of course create more resources as we treat more patients in general practice and away from expensive hospitals, but you need fuel to get where you want. Instead of this £500 million emergency fund for the crisis in A&E, which is really a quick fix, how about something like that as an investment to help GPs set up services?”
Unfortunately there is currently no commitment to anything like this, or the 2% annual investment the GPC are looking for. The worry is that the government will say GPs can use savings from their improved prescribing, referring and service design to reinvest in services, but the momentum to really drive change and shift budgets will never build.  
It’s easy to forget GPs are, technically, in charge of the where NHS money goes now. Could CCGs not simply shift money towards GP practices and away from hospitals themselves? Not exactly.  It will require some serious thinking to redesign the way hospitals are paid so that services are cash-limited; either tariffs need to be cut, or payment systems need to be “completely changed” to stop hospital costs spiralling, according to NHS England insiders. 
“We need to address the discrepancy in the way hospitals and primary care are paid – one by activity, the other per capita. Payment by activity is surely a busted flush,” says Dixon. “Another issue is the split in funding between NHS England and frontline commissioning groups, which seems unsustainable. You need to get funding moving between primary and secondary care.”
Other potential funding sources for the new services heading general practice’s way include the ‘transformation fund’, a £3.8 billion pooled budget for ‘transformational services,’ ie. those that span health and social care.  While an impressively vast figure, the ‘fund’ is essentially formed from 3% sliced off every CCGs’ budget, amounting for the average commissioning group to £10 million that they must spend in a certain way. Not exactly in line with the new principles of localised decision-making, and according to the GPC, already causing problems in certain areas by removing money from the health service.
So the overall picture is mixed: in the short term, GPs may get some relief from their least favourite QOF duties in order to free up time for more proactive work caring for the their most vulnerable patients and reducing A&E attendances; incentives will gradually be developed in line with the these priorities and out of hours.  In the longer term, there will be larger pots of cash available for GPs to expand their services, staff and premises – both new money and reinvested efficiency savings – although given the newness of the NHS management structure, accessing these funds is likely to be torturous. And beyond that, Jeremy Hunts’ aim to get half of all junior doctors becoming GPs (currently only 26% do) seems unlikely to ever be realised without a substantially more attractive remuneration package for the profession. 

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